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Contraception Corner

Educating Tomorrowês Physicians in Reproductive Health

Barbara Clark, RN, MSN, MPH; Cathy J. Lazarus, MD; Jennifer Hurlburt, MPH

Reproductive health comprises issues that are intensely personal, culturally charged, politically sensitive, and just plain embarrassing—all the more reason to give these topics special attention during medical education.

Each year in the United States, there are approximately 15 million new cases of sexually transmitted infections (STIs),1 more than 3 million unintended pregnancies,2 and 2.1 million couples presenting with infertility.3 Training in reproductive health care is essential to prepare future physicians to assist their patients in preventing these conditions, but few medical schools teach about STIs, contraception, pregnancy testing/counseling, and infertility as a separate course or elective.4

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REPRODUCTIVE HEALTH CARE GAP


Women face missed diagnoses of STIs, challenging contraceptive choices, obstacles to abortions, and inferior primary care for infertility. However, the morbidity and mortality associated with STIs, labeled the –hidden epidemic,” are especially noteworthy. Women often have more frequent and more serious complications from STIs than men do; in fact, 10% to 20% of women with gonorrhea and chlamydia develop pelvic inflammatory disease, which can lead to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy.1 To dramatically improve outcomes, physicians need to educate patients about prevention and recognize and treat STIs early through comprehensive reproductive health care.

Reproductive health also involves sexuality. The International Conference on Population and Development established the importance of sexual health in 1994, stating that –Reproductive health Ä also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not mere counseling and care related to reproduction and sexually transmitted diseases.–5 Indeed, the estimated prevalence of sexual dysfunction in women may be as high as 63%.6-8

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MEDICAL TRAINING

Training in reproductive health should be part of the medical school Curriculum. However, a prospective cohort study of 125 medical schools in the United States and 16 in Canada determined that < 30% of US medical programs required course work in human sexuality or taught how to take detailed sexual histories.9 Studies of residency programs also cite a need for more training. A 1995 survey found that the majority of graduating family practice chief residents had no clinical experience in fitting cervical caps or diaphragms, inserting or removing intrauterine devices, or performing first-trimester elective abortions.10

Training in abortion services deserves special mention because the number of US abortion providers fell by 37% between 1982 and 2000.11 Despite the Accreditation Council for Graduate Medical Education requirements that abortion instruction be offered, studies indicate that < 50% of all OB/GYN residency programs include first-trimester abortion training.12 A 2003 national survey with a 51% response rate showed that only 33% of medical schools included abortion in the preclinical Curriculum and 41% of schools offered a clinical abortion experience.13

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COMMUNICATION SKILLS

Taking a sexual history is integral to reproductive health care. Through questioning, physicians can obtain information about sexual partners, condom use, and potential risk for contracting human immunodeficiency virus and other STIs. They can also evaluate the need for preventive care (eg, immunization against hepatitis B), obtain a contraceptive history, and assess for sexual dysfunction. However, only 35% of primary care physicians report that they often (75% of the time) or always take a sexual history.14 Physicians are often reluctant to address sexual issues because they are embarrassed, feel ill-prepared, believe that the sexual history is not relevant to the chief complaint, or feel pressed for time.15-17

Physicians need effective communication skills for sexual history-taking, counseling, and educating patients on reproductive issues. With the addition of communication skills to the Liaison Committee on Medical Education accreditations standards in 2002, medical schools are now taking a more active role in teaching health communication skills.18 According to a 1999 Association of American Medical Colleges survey, only five of 115 reporting medical colleges did not teach some basic communication skills beyond history-taking, and only eight did not assess communication skills. Still, many schools lack structure for teaching such skills: Only 30 of 95 schools (32%) used a model or framework for teaching communication skills, and only 22 schools (23%) reported using an integrated framework for teaching and assessment.19

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MODEL Curriculum

One tool available to help strengthen medical education in reproductive health is the Reproductive Health Model Curriculum, which is now in its second edition.20 Since the release of the first edition, the Curriculum has been accessed by faculty and students in more than 60 US medical schools, and internationally in more than 25 countries. Formerly housed at the American Medical Womenês Association, the Curriculum was recently transferred to the Association of Reproductive Health Professionals.

The Curriculum is an interdisciplinary resource, providing a broad overview of topics that are important to the overall health of women and men. The Web-based format is easy to use, and allows both students and faculty to take responsibility for their own learning. The Curriculum provides links to other organizations and national guidelines to enhance core material. Curriculum modules include: Implementation Guide, Psychosocial Factors, Communication, STIs, Primary Care for Infertility, Contraception, and Abortion.20 Download the Curriculum free of charge at www.arhp.org/Curriculum.

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CONCLUSION

One basic barrier to improving reproductive health training is the limited knowledge about reproductive health in medical education. This topic has not been extensively studied, and much of the existing research is outdated. Physicians who care for women will inevitably encounter many reproductive health issues in practice. Before they can provide high-quality care, however, they must receive structured, specific training in medical schools, residency programs, and continuing education programs. The Reproductive Health Model Curriculum facilitates integration of these important topics into physician training programs.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Cathy J. Lazarus, MD, is professor, Department of Medicine, and senior associate dean, Student Affairs and Medical Education, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Ill. Jennifer Hurlburt, MPH, is program manager, Association of Reproductive Health Professionals, Washington, DC.

References

1. Cates W Jr. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel. Sex Transm Dis. 1999;26 (4 suppl):S2-S7.
2. The Alan Guttmacher Institute. Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics. New York, NY: Alan Guttmacher Institute; 2000.
3. Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ. Fertility, family planning, and womenês health: new data from the 1995 National Survey of Family Growth. Vital Health Stat 23. 1997;(19):1-114.
4. Sumaya CV, Pinn VW, Blumenthal SJ. Womenês Health in the Medical School Curriculum: Report of a Survey and Recommendations. Rockville, Md: Health Resources and Services Administration, National Institutes of Health, Dept of Health and Human Services; 1996. HRSA-A-OEA-96-1.
5. United Nations. Programme of action: reproductive rights and reproductive health: Proceedings of the International Conference on Population and Development. September 5—13, 1994. Cairo; Egypt. Section 7.2:43.
6. Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence of sexual dysfunction in women: results of a survey study of 329 women in an outpatient gynecological clinic. J Sex Marital Ther. 1993;19(3):171-188.
7. Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature. Arch Sex Behav. 1990;19(4):389-408.
8. Read S, King M, Watson J. Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner. J Public Health Med. 1997;19(4):387-391.
9. Solursh DS, Ernst JL, Lewis RW, et al. The human sexuality education of physicians in North American medical schools. Int J Impot Res. 2003;15(suppl 5):S41-S45.
10. Steinauer JE, DePineres T, Robert AM, Westfall J, Darney P. Training family practice residents in abortion and other reproductive health care: a nationwide survey. Fam Plann Perspect. 1997;29(5):222-227.
11. Finer LB, Henshaw SK. Abortion incidence and services in the United States in 2000. Perspect Sex Reprod Health. 2003;35(1):6-15.
12. Foster AM, van Dis J, Steinauer J. MSJAMA. Educational and legislative initiatives affecting residency training in abortion. JAMA. 2003;290(13):1777-1778.
13. Espey E, Ogburn T, Chavez A, Qualls C, Leyba M. Abortion education in medical schools: a national survey. Am J Obstet Gynecol. 2005;192(2): 640-643.
14. McCance KL, Moser R Jr, Smith KR. A survey of physiciansê knowledge and application of AIDS prevention capabilities. Am J Prev Med. 1991;7(3):141-145.
15. Bull SS, Rietmeijer C, Fortenberry JD, et al. Practice patterns for the elicitation of sexual history, education, and counseling among providers of STD services: results from the gonorrhea community action project (GCAP). Sex Transm Dis. 1999;26(10):584-589.
16. Moore LW, Amburgey LB. Older adults and HIV. AORN J. 2000;71(4):873-876.
17. Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J. 1990;83(6):613-617.
18. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington, DC: Liaison Committee on Medical Education; 2004.
19. Association of American Medical Colleges. Report III. Contemporary Issues in Medicine: Communication in Medicine. Medical School Objectives Project. Washington, DC: Association of American Medical Colleges; 1999.
20. Association of Reproductive Health Professionals. Reproductive Health Model Curriculum. 2nd ed. Washington, DC: Association of Reproductive Health Professionals; 2004.

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