It Takes a Village: An Interdisciplinary Approach to Preparing Internal Medicine Residents to Care for Patients at the Intersection of Women's Health,Gender-Affirming Care,and Health Disparities

Abstract

Objective:

To create an interdisciplinary curriculum to teach key topics at the intersection of women's health, gender-affirming care, and health disparities to internal medicine (IM) residents.

Materials and Methods:

A core team of faculty from IM, Obstetrics and Gynecology, and Surgery partnered with faculty and fellows from other disciplines and with community experts to design and deliver the curriculum. The resulting curriculum consisted of themed half-day modules, each consisting of three to four inter-related topics, updated and repeated on an ∼3-year cycle. Health equity was a focus of all topics. Module delivery used diverse interactive learning strategies. Modules have been presented to ∼175 residents annually, beginning in 2015. To assess the curriculum, we used formative evaluation methods, using primarily anonymous, electronic surveys, and collected quantitative and qualitative data. Most surveys assessed resident learning by quantifying residents' self-reported comfort with skills taught in the module pre- and postsession.

Results:

Of 131 residents who completed an evaluation in 2022/23, 121 (90%) “somewhat” or “strongly” agreed with their readiness to perform a range of skills taught in the module. In all previous years where pre- and postsurveys were used to evaluate modules, we observed a consistent meaningful increase in the proportion of residents reporting high levels of comfort with the material. Residents particularly valued interactive teaching methods, and direct learning from community members and peers.

Conclusion:

Our interdisciplinary curriculum was feasible, valued by trainees, and increased resident learning. The curriculum provides a template to address equity issues across a spectrum of women's and gender-affirming care conditions that can be used by other institutions in implementing similar curricula.

Background

Understanding the fundamental aspects of comprehensive women's health and gender-affirming care is key to providing equitable, high-quality care to patients. However, studies show continuing gaps in internal medicine (IM) residents' knowledge and skills in the area of sex- and gender-specific women's health.^1

–6 The slow integration of this content into residency training is due partly to uncertainty about the domain of sex- and gender-specific women's health and what should be included in the curriculum, as well as ambiguity over which discipline is responsible for teaching these topics.^7,8

In 2018, the American College of Physicians (ACP) clarified the scope of sex- and gender-specific women's health care to include conditions that are more prevalent or manifest differently in individuals who identify as women, including routine office gynecological and reproductive care and health disparities in racial/ethnic minority women and gender-diverse individuals.⁹ The ACP was clear that the primary and comprehensive care of women and gender-diverse individuals is the responsibility of internists, and recommended the inclusion of this content in residency training.⁹

Strategies to incorporate sex- and gender-specific women's health education and training into IM residency programs have focused primarily on short-term curricular and clinical experiences,^{2
–4,10

–14} and women's health clinics and subspecialty electives.^10,15
–17 A small number of IM programs have dedicated women's or women's and sex- and gender-specific health tracks or concentrations,^18
–20 or have used a longitudinal or interdisciplinary approach.^3,8,13,15

Opportunities to teach women's and gender-affirming care occur primarily in the ambulatory setting. It is difficult, however, to provide a uniform educational and training experience to all residents at academic centers that have multiple IM residency programs, each with unique curricula and diverse clinical practice sites. In addition, the COVID-19 pandemic further exposed health disparities in racial, ethnic, and gender-diverse minority groups, the populations served by many IM training programs. It is thus essential that residency education and training programs address the needs of these individuals in the community.^21

–24

To meet these challenges, we designed and implemented a novel, interdisciplinary curriculum with the goal of providing IM residents with the knowledge and skills to care for patients at the intersection of women's health, gender-affirming care, and health disparities. We defined women's health as the unique manifestations of conditions experienced by individuals assigned female at birth or those who self-identify as women or as nonbinary, irrespective of sex at birth.

Women's health is influenced by the full context of women's lives, and is not limited to conditions experienced only or mostly by women. We defined gender-affirming care as an approach to clinical care that acknowledges and respects a patient's gender identity. Gender-affirming care is not limited to medical treatment, but is present throughout the entire approach to care, including use of language and approach to the history and physical examination.

Finally, health disparities were a crosscutting theme of our curriculum. We adopted the National Institutes of Health definition of health disparities as “gaps in the quality of health and health care that mirror differences in socioeconomic status, racial and ethnic background, and education level.”²⁵

This article describes the development, implementation, and experience with the curriculum and lessons learned that may be helpful to other institutions.

Materials and Methods

Setting and participants

The curriculum was established in the Department of Medicine (DOM) in 2015 in response to a 2013 needs assessment that identified gaps in IM residents' education and training around women's health and gender-affirming care.⁵ To address these deficiencies, a core group of IM faculty developed a series of educational modules designed to cover key gap areas identified in the survey.

The curriculum was first taught in 2015, and grew with the incorporation of new content as well as extension and diversification of faculty to comprise a team of 10 current core members from general IM, Obstetrics and Gynecology (Ob/Gyn), and Surgery. To support the increasing scope of the curriculum, we recruited partnering teachers, including faculty and fellows from other disciplines, and community experts, who are a critical component of our teaching effort. The curriculum has been presented yearly to ∼175 residents in three residency programs housed in the DOM (Traditional, Primary Care, and Combined Internal Medicine-Pediatrics).

To ensure sustainability of the curriculum, we held a day-long retreat in 2021 with core curriculum faculty, interdisciplinary collaborators, community health care representatives, and institutional education leaders. A key goal was to review the status of the curriculum, and help inform decisions about its direction and mission. Components included a brainstorming session to identify and prioritize growth ideas for the curriculum; a faculty development needs discussion; and a session on community outreach and community-based program opportunities. The retreat was crucial in securing official DOM status and funding to help support basic curriculum administrative and operating costs.

Curriculum structure and content

We used several sources to select curricular topics. These included gaps identified in the 2013 needs assessment,⁵ the American Board of Internal Medicine Certification Blueprint topic map,²⁶ curricular guidelines from professional organizations,^27

–32 surveys,^1,33 reports,³⁴ an internal curriculum assessment, and expert opinions from outside leaders.^35,36

The curriculum was structured around a series of educational modules that focused, on average, on three topics each academic year. Modules were presented in 4-hour, protected, half-day educational sessions during ambulatory rotations, using diverse, interactive teaching methods. To deliver the curriculum to all residents, a single module was presented eight times a year with 15–30 residents attending each session. Primary Care and Medicine-Pediatrics (Med-Peds) residents were first included in year 2 of the curriculum (2016/17). Curriculum modules were thus not synchronized between programs until year 4 (2017/18), resulting in asynchronous module presentations in the curriculum's first 3 years.

The core faculty team met several times before each academic year to identify the year's module theme, topics, learning objectives, and teaching methods (Table 1). Developing the curriculum as a team allowed for a cohesive flow across topics, and ensured that module themes were woven throughout the half-day session. After each session, core faculty reviewed resident evaluations, and met to debrief and reflect to support ongoing modifications of teaching content and approach.

Table 1.

Curriculum Map: Module Themes, Topics, Learning Objectives, Instructional Methods, and Teaching Partners

Module/year/themes	Topics/learning objectives	Instructional methods	Teaching partners
Module 1 (2015/16) From contraception to menopause	1. Treatment of menopausal symptoms—recognize menopausal symptoms; describe risks/benefits of hormonal and nonhormonal treatments; prescribe evidence-based treatments	Resident-led debate on hormonal and nonhormonal treatments	Reproductive endocrinology fellows
	2. Contraception options—identify and prescribe contraception options in different risk populations; describe noncontraceptive benefits of hormonal contraception	Case-based discussion	Family planning fellows
	3. Practicum on the pelvic and breast examinations—interpret a wet mount; gain proficiency in pelvic/breast examinations; identify and manage common cervical and pelvic abnormalities	Interpretation of a wet mount video Latex pelvic/breast models Interactive slide show
Module 2 (2016/17)Clinical controversies in women's health	1. Breast cancer screening guidelines—describe rationale and controversy behind major screening guidelines; describe role of shared decision-making; apply guidelines in average risk women of different ages	Resident-led debate	Diagnostic radiology breast-imaging faculty
	2. Preconception care—identify risk factors for and optimize management of underlying conditions associated with poor pregnancy outcomes	Case-based discussion
	3. Approach to a patient with AUB—describe age and PALM COEIN frameworks for evaluating AUB; diagnose and manage AUB; recognize when to refer to gyn	Case-based discussion	General gynecology fellows
Module 3 (2017/18)Clinical guidelines updates	1. Osteoporosis—assess major risk factors for osteoporosis and osteoporotic fractures; describe screening recommendations for osteoporosis; employ interventions to prevent and treat osteoporosis	Case-based discussion	Endocrinology faculty
Module 3 (2017/18)Clinical guidelines updates	2. Cervical cancer prevention, screening, and management of an abnormal Pap test—describe supporting data for cervical cancer prevention and screening; apply prevention, screening, and management guidelines	Case-based discussion	General gynecology fellows
Module 4 (2018/19)From anatomy to identity	1. The difficult pelvic examination—describe basics of pelvic examination; define and employ trauma-focused care; apply techniques for the difficult pelvic examination; identify common cervical and pelvic abnormalities	Pelvic examination video: the basicsLatex pelvic modelsSmall group discussionsInteractive slide show
	2. Urinary incontinence—describe the epidemiology/pathophysiology of UI; identify and manage UI in women	Case-based discussion	Urogynecology faculty/fellows
	3. Gender diversity and identity—identify and employ glossary of gender identity and relationship language; apply gender-affirming communication skills; appreciate TGD community perspectives	Resident-led discussionRole playCommunity panel discussion	Community panelists
Module 5 (2019/20)Hormones across the spectrum	1. Contraception options in patients with medical conditions—identify and prescribe contraception options in higher risk populations; apply U.S. Medical Eligibility Criteria for Contraceptive Use	Case-based discussion	Family planning fellows
	2. Management of menopausal symptoms—describe pathophysiology of menopausal clinical syndromes; apply evidence-based hormonal and nonhormonal treatments based on age, risk factors, since menopause	Resident-led debate	Reproductive endocrinology fellows
	3. Medical care of TGD individuals—describe gender-affirming HT effects; conduct appropriate history and medical evaluation for initiating HT; discuss, initiate, monitor gender-affirming HT; appreciate TGD community perspectives	Resident-led discussionCommunity perspectives panel	Community members
Module 6 (2020/21)Primary care across the spectrum(Zoom online teaching)	1. Gender-affriming care: surgical and other options—describe range of surgical and other nonmedical options and their medical implications and post-op care; identify barriers to care; name surgical referral resources	Core faculty presentation	Community members
	2. Advanced topics in breast cancer screening—appreciate women's perspective on mammography; discuss risks/benefits of mammography at different ages; apply screening strategies in average risk women and in special populations (dense breasts, TGD individuals, breast augmentation); engage in shared decision-making	Patient video “Women talk about mammography”Multiple choice questionsClinical decision-making practicum	Community women (video)Health service research faculty
	3. Hypertension in the pregnant patient: preconception to postpartum—describe physiologic changes in pregnancy; define and manage hypertension disorders during pregnancy and postpartum; describe role of primary care providers in postpartum care		Nephrology faculty
Module 7 (2021/22)From anatomy to identity	1. Fundamentals of gender-affirming care—identify and employ glossary of gender identity and relationship language; describe and apply top 10 things that TGD patients want providers to know; appreciate TGD and nonbinary community perspectives	Core faculty presentationPanel discussion with core faculty and community panelists	Community members
	2. Pelvic examinations; challenges and abnormalities—similar to Module 4 with revisions	Same as Module 4 with minor revisions
	3. AUB—similar to Module 2 with added focus on polycystic ovary syndrome (describe diagnostic/clinical features; identify and manage cardiometabolic risks; know when to refer for fertility management)	Case-based discussion
Module 8 (2022/23)Hormones across the gender spectrum: reproductive health and gender-affirming care	1. Gender-affirming care; initiation of gender-affirming HT—describe sexual orientation and gender identity data and anatomy relevance to primary care; order age, anatomy, risk-based preventive screening; discuss, initiate, and monitor gender-affirming HT
	2. Contraception options in patients with comorbidities—describe U.S. maternal mortality rates by race; identify and prescribe contraception options in higher risk populations and gender-diverse people; apply U.S. Medical Eligibility Criteria for Contraceptive use	Case-based discussionPracticum on U.S. Medical Eligibility Criteria for Contraceptive use
	3. Medication abortion—describe abortion medication actions, complications, and laws regulating use; recognize complications and describe how to refer patients; describe how to counsel patients on pregnancy options	Cased-based discussionPanel discussion with core faculty experts	Legal expert in reproductive health

AUB, abnormal uterine bleeding; HT, hormone therapy; TGD, transgender and gender diverse; UI, urinary incontinence.

Modules were thematic and included multilayered, inter-related topics (Table 1). Most topics within a module repeated in a 3-year cycle with regular updates to content. Residents, therefore, were exposed to all modules over 3 years of training, though the order of the exposure varied. Topics on gender-affirming care were presented as a thematic series with sequential learning across modules.

There were continuing modifications to all modules based on resident feedback, changing guidelines, emerging new data, or controversial “hot topics.” For example, the first module on breast cancer screening focused on screening guideline controversies, while the second incorporated newer data on overdiagnosis and dense breasts. Residents were assigned key readings and other preparatory work before each module, and had active roles throughout the half-day session (Table 2).

Table 2.

Overview of Typical Half-Day Educational Module: Module 7 (2021/22), “From Anatomy to Identity”

Topic 1. Fundamentals of gender-affirming Care	Topic 2. Pelvic examinations: challenges and abnormalities	Topic 3. Approach to abnormal uterine bleeding
8:00–9:30 am	9:40–11:10 am	11:15 am–12:00 pm
Content:Glossary of gender identityGender-affirming communicationTop 10 concepts providers need to knowTransgender and nonbinary community perspectives	Content:Pelvic examination video, the basicsPelvic examination practicum, tips, and tricksTrauma-informed examination and careTransgender, nonbinary careCommon cervical and pelvic examination abnormalitiesCervical cancer screening guidelines Management of an abnormal Pap test	Content:Prevalence of AUBAUB definition andcategoriesCauses of AUB and association with changes in hormonesFramework to evaluate AUB
Teaching methods: interactive panel discussion with faculty and community panelists	Teaching methods: videos, latex pelvic models, small group discussions, interactive slide show, demonstration of American Society for Colposcopy and Cervical Pathology app	Teaching methods: faculty-led interactive Q&A case-based slide presentation
Teachers:IM and surgery core facultyTransgender and nonbinary community leaders	Teachers:IM core faculty	Teachers:IM core faculty
Resident preparatory assignments:“LGBTQI+ Terminology: ABrief Summary” (Yale SOMDean's Advisory Councilpublication)Video: Health Care for Transgender and Gender Diverse People (National LGBTQIA+ Health Education Center)	Resident preparatory assignments:Video: “Trauma Informed Patient Interviewing and Vaginal Exam” (B. Elliot, P. Rezaierfar, University of Ottawa)	Resident preparatory assignments: none

IM, internal medicine.

We were specific and deliberate in our goal for each module to focus on health inequities that exist in the racial, ethnic, and gender-diverse minority populations served by our IM training programs. Our approach to teaching about disparities focused not only on differences in epidemiology and disease outcomes but also on factors that drive disparities, including differences in access to, timeliness, and quality of care (e.g., topics on breast cancer screening, contraception, preconception and peripartum care, and gender-affirming care).

For gender-affirming care, specifically, we addressed the effects of legal and insurance barriers to care, discrimination and discomfort in health care settings, and poor quality, uninformed care on patients' physical and emotional health, and well-being. Teaching was amplified by gender-diverse community panelists who spoke about their lived experience. Module 8, “Hormones across the gender spectrum,” taught in early 2022, was dedicated to teaching reproductive and gender-affirming care topics that disproportionately affect individuals who live in poverty, or are minoritized.

Interdisciplinary teaching

Interdisciplinary teaching was a core feature of the curriculum. We invited faculty and fellows from other disciplines with topic-specific expertise to assist with content development and to participate in module sessions as “expert consultants.” Importantly, core curriculum faculty retained their role as the primary teachers. This interdisciplinary learning format modeled the role of IM in managing crossdisciplinary conditions. The residents became familiar with consultants, and learned when and how to refer patients.

The “expert consultants” in turn gained a platform for educating IM residents in their area of expertise and benefited from bidirectional teaching. The curriculum also highlighted the lived experience of patients and community members. For example, we partnered with community women to develop a video chronicling experiences with mammography that created the framework for a discussion on shared decision-making during modules on breast cancer screening. Gender-diverse community members also participated as panelists during modules on gender-affirming care and were remunerated for their time.

Other curriculum components

Our curriculum offered career development opportunities for faculty by providing mentoring around teaching, scholarship, and career advancement, and by creating recognition for work in the curriculum. Faculty were provided opportunities for leadership development through established teaching and faculty development programs at our institution and opportunities to attend and present the curriculum locally and at national meetings. Senior faculty, specifically, mentored younger members on curriculum development and teaching, presentations, and authorship.

Evaluation

Curriculum evaluation methods were formative, and were designed with the goals of improving content and teaching, and gauging resident learning and acceptance of the curriculum (Table 3). Core curriculum faculty with training in survey design (K.A.G.) created the evaluations specifically for each module, tailored to learning objectives. Evaluations were iteratively revised for content by all core faculty (Supplementary Appendices SA1–SA6). Most evaluations used an anonymous, electronic form, using the Qualtrics platform, to request information on resident characteristics (training year, clinical practice site), although we occasionally used anonymous paper-based surveys. Most evaluations assessed self-reported comfort, or confidence with information and skills taught in the modules.

Table 3.

Evaluation Methods, Main Outcome Measures, and Main Results, Modules 1 to 8

Module/theme	Evaluation method	Main outcome measure	Main results
Module 1, 2015/16Module 1, 2016/17From contraception to menopause	Pre/postsurvey-based self-assessment of residents' comfort with module topicsNote: Traditional program residents did not evaluate the module	Proportion of residents reporting comfort level of ≥50 on 0–100 visual analog scale	Managing menopause symptoms: Pre: 11/51 (22%) versus Post: 48/49 (98%); p- < 0.001 Prescribing contraception: Pre: 12/59 (20%) versus Post: 41/44 (93%); p < 0.001
Module 2, 2016/17Clinical controversies in women's health	Pre/postsurvey-based self-assessment of residents' comfort with module topics	Proportion of residents reporting comfort level of ≥50 on 0–100 visual analog scale	Discussing risks and benefits of mammography: Pre: 4/50 (8%); Post: 33/47 (70%); p < 0.001 Preconception counseling: Pre: 8/52 (15%); Post: 39/46 (85%); p < 0.001 Managing AUB: Pre: 3/50 (6%); Post: 33/46 (72%); p < 0.001
Module 3, 2017/18Clinical guidelines updates	Postmodule survey: residents' assessment of most/least effective module components; suggestions for future teaching (Supplementary Appendix SA1)	Qualitative assessment	N = 33Most effective component—“excellent presentations”Least effective component—presentations too longSuggestions—offer again without major changes (64%), important content/needs work (33%)
Module 4, 2018/19From anatomy to identity	Pre/postsurvey-based self-assessment of residents' comfort with module topics. Pap smear exercise (Supplementary Appendix SA2)	Proportion of residents reporting comfort level of ≥50 on 0–100 visual analog scale	Performing a routine pelvic examination: Pre: 33/58 (57%), Post: 11/11 (100%), p = 0.006 Communicating about gender identity: Pre: 30/58 (52%), Post: 10/11 (91%), p = 0.02
Module 5, 2019/20Hormones across the spectrum	Pre/postsurvey-based self-assessment of amount of supervision needed to perform clinical skills/tasks (Supplementary Appendix SA3)	Proportion of residents who feel ready to perform skill with partial or no attending supervision	Discussing hormone replacement therapy for menopause: Pre: 38/67 (57%), post 20/25 (80%), p = 0.04 Prescribing contraception: Pre: 46/64 (72%), post 24/25 (96%), p = 0.01 Prescribing gender-affirming hormone therapy: Pre: 17/59 (29%) Post: 20/25 (80%), p < 0.001
Module 6, 2020/21Primary care across the spectrum (Zoom online teaching)	Pre/postsurvey-based self-assessment of residents' comfort with module topics (Supplementary Appendix SA4)	Proportion of residents who report being “somewhat comfortable” or “extremely comfortable”	Counseling patients about surgical gender-affirming care Pre: 8/84 (9.5%), post 30/41 (73%), p < 0.001 Counseling patients about supplemental screening for people with dense breasts Pre: 30/84 (36%), post 39/41 (95%), p < 0.001 Hypertension management for people who may become pregnant Pre: 24/84 (29%), post 36/41 (88%), p < 0.001
Module 7, 2021/22From anatomy to identity	Postsession survey: one thing residents learned, how to incorporate into practice, and barriers to incorporation(Supplementary Appendix SA5)	Qualitative assessment	Response rate = 126/175 (72%)(See Table 3. Selected Resident Survey Responses)
Module 8, 2022/23Hormones across the gender spectrum	Postsession survey: residents' readiness to implement module training (Supplementary Appendix SA6)	Proportion of residents who “somewhat” or “strongly” agree with readiness to perform range of skills	Describe steps of prescribing gender-affirming hormone therapy: 115/121 (95%) Recommend contraceptive methods based on patient preferences and comorbidities: 114/121 (94%) Describe the steps of medication abortion: 110/119 (92%)

Some modules used a visual analog scale ranging from 0 (not comfortable) to 100 (completely comfortable). Other modules asked residents to rate the level of supervision they would need to perform a task or skill covered in the module. All evaluations included open-ended questions inviting resident feedback on the effectiveness of teaching and suggestions for curriculum change. Although all modules were evaluated not all sessions were evaluated, and, in some years, evaluations were collected for either the Traditional or the Primary Care and Med-Peds program residents.

To analyze survey data, we dichotomized visual analog scales and categorical variables for ease of interpretation (Table 3). We evaluated the proportion of residents who were comfortable with skills taught in the module pre- and postsession using chi-squared testing. We selected the most representative questions (i.e., those that assessed the main content of the modules) to report.

IRB review

The article is considered a Quality Improvement Project in education and does not require IRB review by Yale University.

Results

Resident characteristics and clinical exposures

The number of residents overall, and the proportion in each training program and at each clinical teaching site varied slightly by year. For academic year 2022/23, of the ∼175 residents in the three training programs who were eligible to participate in the curriculum, 131 responded to the Module 8 postsurvey. Two-thirds were in the Traditional, and the remaining one-third in the Primary Care and Med-Peds Programs. The majority (60%) practiced at a Federally Qualified Health Center, 33% at a VA-based clinic, and 7% at other sites. Forty-one residents (34%) reported seeing ≤25% female patients in continuity clinic encounters; 18 (14%) reported direct care of at least one gender-nonconforming patient in continuity clinic.

Resident learning and comfort with module skills

Our most recent evaluations were from Module 7 (2021/22) and Module 8 (2022/23). For Module 7 (2021/22), “From Anatomy to Identity,” the survey was completed by 126 of the ∼175 residents who attended module sessions (72%). For the topic, gender-affirming care, residents responded that they learned the importance of taking a gender history, asking about chosen pronouns, and taking an anatomical inventory. They indicated their intent to use more inclusive terminology, or to use an anatomy inventory graphic when discussing cancer screening with gender-diverse patients (Table 4).

Table 4.

Selected Resident Survey Responses: Module 7 (2021/22), “From Anatomy to Identity”

Question: Please write down one thing you learned today along with thoughts on either how you will incorporate it into your practice or barriers that will prevent incorporation.
Topic 1: Fundamentals of gender-affirming care
I learned about initiating a conversation about gender identity and about naming anatomical parts, especially before a clinically relevant physical examination. I think that the main barrier to having those discussions will be time limitations.
Using sensitive language and approaches to patients, for example, making sure questions about sexuality/sexual practices are asked only when relevant and explaining why you are asking.
Will try to consistently ask about gender identity and pronouns at visits.
Anatomy inventory—will use when discussing preventive care, particularly cancer screening.
I feel better equipped to help members of the LGTBQ+ community.
Topic 2: Pelvic examinations: challenges and abnormalities
How to elicit a patient's preferences for how the examination is performed and the importance of screening for sexual abuse.
The pelvic examination is sensitive, and it was helpful to be able to practice with the speculum.
Review of abnormal findings was very helpful!
I will incorporate trauma informed examination techniques.
It was a great opportunity to review the pelvic examination, especially since we see very few female patients in clinic (from a resident with clinic at the VA).
Topic 3: Approach to AUB
It was good to review PALM COEIN and risk stratify patients for etiologies of AUB.
Distinguishing ovulating versus anovulatory bleeding, and having a high suspicion for endometrial cancer in perimenopausal and postmenopausal women with AUB.
I learned about how to use estrogen and progesterone therapies to manage particular types of AUB.
Helpful insights on when to refer to gyn, labs to send like thyroid stimulating hormone, prolactin.
Question: What were the most effective components of today's session?
Amazing that we met and learned from the panelists who shared their experiences in the LGBTQ community.
Having multiple modalities with panelists and hands-on/interactive sessions which really helped to keep me engaged.
Each presentation flowed well (from one to the other) and provided a lot of great learning).
Panelists were awesome! And the small group breakouts for the pelvic examination section.
Hands-on practice and case-based learning.
Dynamic content, engaging speakers, community partners.
Question: What could be improved about today's session?
Detailing what to handle as the primary care provider versus when it's safer to refer to specialists.
More scripting for the things we talked about in regard to transgender care. I've never had a transgender patient (to my knowledge) so key phrases would be helpful.
It would be helpful to have an experienced provider model how they take an inclusive sexual history.

For Module 8 (2022/23), “Hormones across the gender spectrum,” 95% of the 121 residents who completed the survey felt ready to describe the steps of prescribing gender-affirming hormone therapy; 94% felt ready to recommend contraceptive methods in patients with comorbidities; and 92% felt ready to describe the steps of medication abortion.

In previous years, survey design varied to assess different dimensions of resident learning, although most years (Modules 1, 2, 4, 5, 6) used pre- and postsurveys to assess aspects of residents' comfort, or degree of supervision needed, to apply the skills taught in the module. Resident participation in the surveys and response rate to post module surveys varied. However, in all years evaluated, we observed a meaningful increase in the proportion of residents reporting high levels of comfort with the material (Table 3).

Curriculum content and teaching

Resident feedback to open-ended questions identified consistent themes across modules. Residents appreciated the structure and content of modules, and commented on the importance of curriculum topics, especially those not taught elsewhere in training. They valued the quality of presentations and the teachers. They particularly valued interactive teaching methods, skills development training, hands-on practicums, direct learning from community members, and learning from peers (e.g., resident-led debates) and “guest consultants.” Some residents commented that modules were too long (4 hours) and requested more “breaks.”

Other curriculum measures

As a measure of the reach of the curriculum, its modules were imbedded in the educational programs of all three IM training programs. Over 600 IM residents participated in the modules over 8 years. In addition to 13 core curriculum faculty, >20 interdisciplinary faculty, fellows, and community members participated as teachers, demonstrating the depth and breadth of content covered by the diverse faculty. Although participating teachers changed across modules, core curriculum faculty remained constant, except for departures to other institutions/positions.

Discussion

The women's health and gender-affirming care curriculum demonstrates the feasibility of implementing an interdisciplinary curriculum with a focus on preparing IM residents to address the unique health needs of these populations. Curriculum evaluation surveys support an increase in resident comfort with curriculum topics, and highlight the value residents place on interactive learning from community members, peers, and faculty/fellows from other disciplines. Resident feedback indicates their acceptance of the curriculum.

Our curriculum was designed to address residency training and societal needs at the intersection of women's health, gender-affirming care, and health disparities. The motivation to create the curriculum stemmed from identified gaps and needs in residents' education but was also driven by our sense of obligation as faculty educators to provide all IM residents, regardless of career path, with the knowledge and skills needed to improve the care of the most vulnerable patients they serve.^9,23 Similar to most U.S.-based academic medical centers, our training programs are a main source of care to these populations and are uniquely positioned to assume this responsibility.^21,37

Although other papers have described the development and evaluation of women's health curricula, our curriculum is distinct from other published curricula in several ways.⁸ First, most other curricula were discrete, or taught over the course of a day or during a women's health rotation. Our curriculum was intended to be continuous and dynamic, providing education to all IM residents over the entire course of their training. We also continually updated content to reflect the most contemporary issues and controversies in women's health. Perhaps the way in which our curriculum is most distinct from other published curricula, though, is the way in which we have taken a broad view of women's health by incorporating concepts of gender diversity and health disparities.

Previous publications document the need for integrating issues of equity into residency training.^{9,21,23,24,37
–39} Some also offer guidelines for how to achieve this goal.^21,37
–39 Guidelines include expanding national accreditation program requirements for competency in caring for diverse populations,³⁹ developing interdisciplinary and interprofessional learning opportunities,^21,39 adopting an intersectional perspective,³⁸ and seeking community engagement.²¹ Our curriculum creates a multidimensional educational model that addresses equity issues across a spectrum of women's and gender-affirming care conditions, and can serve as a template for other programs interested in implementing similar curricula.

Several key concepts were important for the successful design and implementation of the curriculum. Some may be helpful to other institutions planning similar curricula:

Protected educational time. Fortuitously, at the time we were designing the curriculum in 2015, outpatient clinic blocks were established for residents in our IM training programs. Blocks included a weekly, protected, half-day educational session for all residents “on block.” We volunteered to implement our curriculum during the first year of block rotations and continue to teach in this venue. Collaboration across our three IM residency programs facilitated the coordination of educational half-days, which allowed us to reach all residents annually and ensured a uniform educational experience for residents, regardless of training program or clinical practice site.

Dynamic, inclusive curriculum. A needs assessment and knowledge of changing residency core competency requirements were fundamental to curriculum development. The inclusion of gender-affirming care topics in year 4 of the curriculum, and the deliberate focus on equity issues across all topics after COVID-19, created a more fluid and dynamic curriculum. Gender-affirming care topics are now taught as a 3-year series with sequential learning. All curriculum topics undergo continuous, extensive revisions. The curriculum's durability allows flexibility to respond quickly to important social and medical controversies, including a recent module that addressed legal, medical, and equity issues related to access to reproductive and gender-affirming care.

Interdisciplinary partnerships. Partnerships formed with faculty from other disciplines around shared goals resulted in unexpected, synergistic collaborations that expanded the curriculum in a broad and inclusive way. Collaborations with Ob/Gyn on menopausal symptoms and contraception options, and with diagnostic radiology on breast cancer screening, for example, generated bidirectional teaching, and created new understanding and appreciation of the central role of general IM in managing crossdisciplinary topics, with appropriate use of consultants.

Community collaborations. The deliberate integration of teaching about health inequities in all aspects of the curriculum was essential in addressing the needs of the racial, ethnic, and gender-diverse minority populations served by our IM training programs. Collaboration with gender-diverse community members, specifically, was essential in bringing their perspectives and experiences to our teaching, and was an effective way to increase residents' awareness of disparities in care. Residents particularly value teaching sessions with community panelists, and we work closely with panelists on content and teaching.

Curriculum sustainability. We received basic departmental administrative support for the curriculum 2 years ago when the curriculum was mature. A day-long retreat with institution education leaders and other stakeholders to review the curriculum's goals and direction was crucial to obtaining support, with the expectation that we would also secure outside funding. Core faculty and participating teachers do not currently receive extra support for their work in the curriculum. However, a team approach to designing and teaching the multifaceted, interdisciplinary curriculum creates, and sustains a sense of purpose and identity and investment in the educational initiative.

The curriculum has limitations. Results are based on experience at one institution and may not be applicable to other residency programs. Although resident responses to evaluation surveys support an increase in learning and skills, data were limited with variable response rates based on self-evaluations, with the inherent limitations of self-evaluation. We were also unable to evaluate whether the perceived acceptability and efficacy of the curriculum differed by resident characteristics, including level of training or primary practice site.

The data, however, are consistent in showing an increase in residents' comfort with curricular content across the modules where this was evaluated. We do not have data on retention of learning, or on post module resident behavior or patient outcomes, important measures lacking for most programs.⁸ The curriculum is also a time-intensive educational intervention that relies on extensive core faculty and volunteer faculty participation to succeed.

To address these limitations, we are working with education resources at our institution to develop outcome-related evaluation tools to assess the multifaceted curriculum, and to archive and disseminate the curriculum. To address challenges in data collection, we are designating time during each teaching session for residents to participate in evaluation methods. We are also exploring ways to build capacity at existing clinical sites to provide residents with increased opportunities to care for women and gender-diverse patients, and to apply key concepts learned in the curriculum. A challenge at all institutions is to secure external support to sustain and grow curricula and faculty, and we are pursuing this course.³

Future plans for our curriculum include expanding its scope and content; identifying additional venues for teaching; growing the team of teachers and partners to include other schools and programs at our university; and facilitating the integration of women's and gender-affirming care at IM clinical teaching sites. A recent Position Paper from the Society of General Internal Medicine that defines core competencies in sex- and gender-based women's health care reflects many of our curriculum goals, and will serve as a guide in expediting these efforts.⁴⁰

Conclusion

Creating an interdisciplinary curriculum to prepare IM residents to address the health needs of racial and ethnic minority women or persons who are gender diverse was feasible, increased resident learning, and was acceptable to trainees. Residents particularly valued interactive teaching methods and direct learning from community members and peers. The inclusion of health equity and gender-affirming care provides a model for incorporating these topics into longitudinal curricula. Other training programs with similar educational goals may wish to adapt aspects of our model's design and content, based on local needs and resources.

Footnotes

Acknowledgments

The authors acknowledge the contributions of individuals who participated in the modules as community panelists, including Iris Artin, Tony Ferraiolo, Layne Gianakos, Lindsey Pasquale, and Karleigh Webb. They also acknowledge Dr. Cary Gross who performed the data analyses for Module 1 and Module 2, and Alyssa Grimshaw, Clinical Research and Education Librarian, for her review of the article and assistance with references.

Authors' Contributions

J.B.H. designed conceptualization (lead), methodology (equal), supervision (lead), visualization (equal), writing—original draft (lead). I.R. assisted with conceptualization (equal), data curation (colead), formal analysis (colead), methodology (equal), resources (equal), writing and editing (revision colead). T.L.R. designed conceptualization (equal), data curation (equal), formal analysis (supporting), methodology (equal), project administration (equal), supervision (supporting), visualization (supporting), writing—original draft (supporting), writing—review and editing (equal). K.A.G. contributed to conceptualization (equal), data curation (colead), formal analysis (colead), methodology (equal), visualization (equal), writing—original draft (equal), writing—review and editing (equal). M.D. contributed to conceptualization (equal), methodology (equal), resources (equal), visualization (supporting), writing (supporting), writing—review and editing (equal). J.X.C. and A.L.H. carried out conceptualization (equal), methodology (equal), resources (equal), visualization (supporting), writing (supporting), writing—review and editing (supporting).

M.R.W., C.M., and S.P. assisted with conceptualization (equal), methodology (equal), resources (equal), writing—review and editing (supporting). S.M. aided conceptualization (equal), methodology (equal), resources (equal), writing (supporting), writing—review and editing (supporting). P.B. assisted conceptualization (supporting), visualization (supporting), writing—review and editing (equal). R.S. helped with conceptualization (supporting), visualization (supporting), writing—review and editing (supporting). L.V. designed conceptualization (equal), methodology (equal), visualization (supporting), writing—original draft (supporting), writing—review and editing (equal).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

Supplementary Appendix SA3

Supplementary Appendix SA4

Supplementary Appendix SA5

Supplementary Appendix SA6

References

Casas

, Hallett

, Rich

, et al. Program directors' perceptions of resident education in women's health: A national survey. J Womens Health, 2017; 26(2):133–140.

Spencer

, Kern

. Primary care program directors' perceptions of women's health education: A gap in graduate medical education persists. J Womens Health, 2008; 17(4):549–556.

Shrivastava

, Gandhi

, Spencer

. Integrating women's health education into the internal medicine residency program curriculum. South Med J, 2021; 114(2):116–122.

Casas

, Prifti

, Bachorik

, et al. Contraceptive procedures in internal medicine clinics and resident education: A qualitative study of implementation methods, barriers, and facilitators. J Gen Intern Med, 2021; 1–7.

Hsieh

, Nunez-Smith

, Henrich

. Needs and priorities in women's health training: Perspectives from an internal medicine residency program. J Womens Health, 2013; 22(8):667–672.

Dirksen

, Shulman

, Teal

, et al. Contraceptive counseling by general internal medicine faculty and residents. J Womens Health, 2014; 23(8):707–713.

Henrich

JB.

Women's health education initiatives: Why have they stalled?. Acad Med, 2004; 79(4):283–288.

Zhang

, Insetta

, Caufield-Noll

, et al. Women's health curricula in internal medicine residency programs: A scoping review. J Womens Health, 2019; 28(12):1768–1779.

Daniel

, Erickson

, Bornstein

. Women's health policy in the United States: An American College of Physicians position paper. Ann Intern Med, 2018; 168(12):874–875.

10.

Swedish

KA.

Introducing a women's health clinic improves resident comfort and competence in performing women's health exams. J Gen Intern Med, 2019; 34(7):1081–1082.

11.

Davisson

, Nuss

, Cottrell

. Women's health curriculum for internal medicine residents: Development, implementation, and evaluation. J Grad Med Educ, 2010; 2(3):398–403.

12.

Ufomata

, Eckstrand

, Spagnoletti

, et al. Comprehensive curriculum for internal medicine residents on primary care of patients identifying as lesbian, gay, bisexual, or transgender. MedEdPORTAL, 2020; 16:10875.

13.

Spencer

, McNeil

. Interdisciplinary curriculum to train internal medicine and obstetrics-gynecology residents in ambulatory women's health: Adapting problem-based learning to residency education. J Womens Health, 2009; 18(9):1369–1375.

14.

Pace

, Dolan

, Tishler

, et al. Incorporating long-acting reversible contraception into primary care: A training and practice innovation. Womens Health Issues, 2016; 26(2):131–134.

15.

Jiang

, Sab

, Diamen

, et al. Menopausal medicine clinic: An innovative approach to enhancing the effectiveness of medical education. Menopause, 2012; 19(10):1092–1094.

16.

Henrich

, Chambers

, Steiner

. Development of an interdisciplinary women's health training model. Acad Med, 2003; 78(9):877–884; doi: 10.1097/00001888-200309000-00006

17.

Rusiecki

, Rojas

, Oyler

, et al. An expanded primary care-based women's health clinic to improve resident education and patient care in resident continuity clinic. J Gen Intern Med, 2022; 37(9):2314–2317; doi: 10.1007/s11606-022-07512-6

18.

Farkas

, Vanderberg

, McNeil

, et al. The impact of women's health residency tracks on career outcomes. J Womens Health, 2018; 27(7):927–932.

19.

Directory of Residency and Fellowship Programs in Women's Health, 2015. J Womens Health, 2015; 24(5):411–453; doi: 10.1089/jwh.2015.dir9

20.

Hempel

, Cooper

, Raoof

, et al. Characterizing the prevalence and types of curricular tracks in internal medicine residency training programs. J Gen Intern Med, 2021; 36(10):3273–3275.

21.

Streed

, Lunn

, Siegel

, et al. Meeting the patient care, education, and research missions: Academic medical centers must comprehensively address sexual and gender minority health. Acad Med, 2021; 96(6):822–827.

22.

Daniel

, Bornstein

, Kane

. Addressing social determinants to improve patient care and promote health equity: An American College of Physicians position paper. Ann Intern Med, 2018; 168(8):577–578.

23.

Ortega

, Roby

. Ending structural racism in the US health care system to eliminate health care inequities. JAMA, 2021; 326(7):613–615.

24.

Chowkwanyun

, Reed Jr

. Racial health disparities and Covid-19—Caution and context. N Engl J Med, 2020; 383(3):201–203.

25.

Minority Health and Health Disparities

U.S.

Department of Health and Human Services, National Instituties of Heatlh, February 23, 2022. Available from: https://www.niaid.nih.gov/research/minority-health-disparities# [Last accessed: August 30, 2023 ].

26.

American Board of Internal Medicine. Internal Medicine Certification Examination Blueprint. 2021. Available from: https://www.abim.org/Media/h5whkrfe/internal-medicine.pdf [Last accessed: December 3, 2023 ].

27.

Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Internal Medicine. 2021. Available from: https://www.acgme.org/globalassets/pfassets/programrequirements/140_internalmedicine_2022v4.pdf [Last accessed: December 3, 2023 ].

28.

Department of Veterans Affairs Veterans Health Administration. VHA DIRECTIVE 1330.01(4): Health Care Services for Women Veterans. 2021. Available from: https://crsreports.congress.gov/product/pdf/IF/IF11082 [Last accessed: December 3, 2023 ].

29.

Association of American Medical Colleges. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. 2014. Available from: https://store.aamc.org/downloadable/download/sample/sample_id/129/ [Last accessed: December 3, 2023 ].

30.

Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 729: Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol, 2018; 131(1):e43–e48.

31.

American Academy of Family Physicians. Women's health and gynecologic care recommended curriculum guidelines for family medicine residents. AAFP Rpt, 2018; 282.

32.

American Academy of Family Physicians. Lesbian, gay, bisexual, transgender, queer/questioning, and asexual health. Recommended curriculum guidelines for family medicine resident. AAFP Rpt, 2019; 289D.

33.

Farkas

, Tilstra

, Borrero

, et al. Establishing consensus on residency education in women's health. J Womens Health, 2017; 26(1):13–17.

34.

Zumwalt

, Carter

, Gell-Levey

, et al. A novel curriculum assessment tool, based on AAMC competencies, to improve medical education about sexual and gender minority populations. Acad Med, 2022; 97(4):524–528, doi:10.1097/acm.0000000000004203

35.

Kwolek

, Jenkins

. Women's health and sex- and gender-based medicine: Past, present, and future. In: Sex-and Gender-Based Women's Health: A Practical Guide for Primary Care. ( Tilstra

, Kwolek

, Mitchell

, Dolan

, Carson

. ed.) Springer Nature: Switzerland; 2020.

36.

Bonifacino

, Corbelli

The female sex- and gender-specific history and examination. In: Sex-and Gender-Based Women's Health: A Practical Guide for Primary Care. ( Tilstra

, Kwolek

, Mitchell

, Dolan

, Carson

. ed.) Springer Nature: Switzerland; 2020.

37.

Dupras

, Wieland

, Halvorsen

, et al. Assessment of training in health disparities in US internal medicine residency programs. JAMA Netw Open, 2020; 3(8):e2012757; doi: 10.1001/jamanetworkopen.2020.12757

38.

Turpin

, Akré

, Williams

, et al. Differences in health care access and satisfaction across intersections of race/ethnicity and sexual identity. Acad Med, 2021; 96(11):1592–1597; doi: 10.1097/ACM.0000000000004243

39.

Pregnall

, Churchwell

, Ehrenfeld

. A call for LGBTQ content in graduate medical education program requirements. Acad Med, 2021; 96(6):828–835; doi: 10.1097/ACM.0000000000003581

40.

Henrich

, Schwarz

, McClintock

, et al. Position paper: SGIM Sex- and gender-based women's health core competencies. J Gen Intern Med, 2023; 38(10):2407–2411; doi: 10.1007/s11606-023-08170-y

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB

0.29 MB

0.15 MB

0.21 MB

0.09 MB

0.12 MB