Portal de Periódicos da CAPES

Emergency Medicine Gender-specific Education

2014; Wiley; Volume: 21; Issue: 12 Linguagem: Inglês

10.1111/acem.12545

1553-2712

John Ashurst, Alyson J. McGregor, Basmah Safdar, Kevin Weaver, Shawn M. Quinn, Alex Rosenau, Terrence E. Goyke, Kevin R. Roth, Marna Rayl Greenberg,

Innovations in Medical Education

The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender-specific care as an area of importance to both emergency medicine (EM) and research. To improve patient care, we need to address educational gaps in this area concurrent with research gaps. In this article, the authors highlight the need for sex- and gender-specific education in EM and propose guidelines for medical student, resident, and faculty education. Specific examples of incorporating this content into grand rounds, simulation, bedside teaching, and journal club sessions are reviewed. Future challenges and strategies to fill the gaps in the current education model are also described. La conferencia consenso de Academic Emergency Medicine de 2014 ha dado el primer paso en identificar la atención específica de género como un área importante tanto en Medicina de Urgencias y Emergencias como en investigación. Con el fin de mejorar la atención del paciente, necesitamos evaluar las lagunas formativas en esta área a la vez que las lagunas en investigación. En este artículo, los autores destacan la necesidad de formación de género y sexo en Medicina de Urgencias y Emergencias, y proponen guías clínicas para los estudiantes de medicina, los residentes y la formación universitaria. Se revisaron ejemplos específicos de cómo incorporar este contenido en las rotaciones, las simulaciones, la formación a pie de cama y las sesiones clínicas. También se describen las futuras oportunidades y estrategias para cubrir las lagunas modelo formativo actual. Clinicians have observed sex and gender differences in patient care for decades. However, these differences have been formally recognized only in recent years. The American Medical Association style guide defines sex as the classification of living things as male or female according to their reproductive organs and functions assigned by chromosomal complement.1 This chromosomal complement affects a patient's vulnerability to disease and his or her response to medications and treatments. Gender, however, refers to a person's self-representation as man or woman or how that person is responded to by social institutions on the basis of the person's gender presentation. Frequently confined to reproductive health, sex- and gender-specific medicine (SGM) also addresses why some diseases, such as cardiovascular diseases or strokes, are more common in men versus women and whether these differences affect treatment and prognosis. In 1994, the field of SGM gained new momentum as Congress mandated the recognition of sex- and gender-based research and education for every organ system.2 As a result of these mandates, sex and gender differences in the etiology, diagnosis, progression, outcomes, treatment, and prevention of many conditions have been described that affect care for both women and men patients in the acute care setting. Some examples of sex differences include strokes and cardiovascular conditions are more common in men and yet mortality is worse in women for the same conditions, digoxin causes more adverse events in women being treated for congestive heart failure, Brugada syndrome is 10 times more common in men due to the effect of testosterone on cardiac sodium channels, the slower metabolism of zolpidem in women puts them at increased risk for sleep-associated motor vehicle crashes, aspirin is variably effective in the treatment of myocardial infarction and stroke in men compared to women, and men have an increased susceptibility to sepsis.3-6 Despite recent advances in gender-specific medicine, this information is largely ignored in current emergency medicine (EM) research and clinical practice.7 The 2013 RAND Corporation report has independently documented the central role of EM in health care delivery in the United States.8 The report highlights how EM is uniquely positioned to influence acute care as a specialty that sees nearly 130 million patients annually, is increasingly being used by other specialties and primary care practitioners to perform complex diagnostic workups, and remains the primary access point for the majority of hospital admissions.9 Incorporating sex- and gender-specific EM education for emergency physicians (EPs), medical students, and residents therefore has far-reaching potential influence for acute care of our patients. To provide optimal individualized medical care for both men and women, the concepts of sex and gender health need to be introduced early and become systematically embedded into medical school and postgraduate curricula, as well as continuing medical education (CME). These curricula continue to primarily be taught in a unisex fashion that has the potential of introducing conscious and unconscious biases in learning and ignores the differences between men and women in response to diseases and treatments. This article provides an overview of the need for optimizing medical and postgraduate education in SGM, current challenges, and recommendations to overcome gaps in the current education model. In 1996, medical student and resident surveys demonstrated that their programs lacked education in gender-specific health, and primary care residency programs were not adequately preparing trainees to provide comprehensive health care to women.10 In late 2012, sample U.S. Medical Licensing Examination (USMLE) forms were reviewed by the Sex and Gender Women's Health Collaborative group to identify sex- and gender-based topics already covered and missed opportunities that might be addressed.11 Many internal medicine programs responded by developing women's health tracks to improve competencies in areas related to women's health and gender-specific medical conditions.12 In September 2012, the Mayo Clinic hosted a workshop in an attempt to address a need to integrate sex and gender concepts into medical education and training. Representative leaders were brought together from 13 U.S. schools of medicine and schools of public health, the National Institutes of Health, Health Resources and Services Administration Office of Women's Health, and the Canadian Institute of Health and Gender, to identify barriers to incorporating SGM in health education and to communicate and share practical strategies for addressing them. The symposium recommended the following proposals to assist implementation and sustainability using existing curricula: 1) engage educators, administrators, and professional societies early in the process; 2) collect and disseminate evidence regarding the added value of including SGM education and training; 3) foster interprofessional and interdisciplinary collaborations; and 4) develop and maintain new resources using various technologies.13 A follow-up 2013 survey identified nine residency programs and 23 fellowships that were designed to train future physicians in women's health issues.14 These comprehensive care programs spanned several specialties, including internal medicine, family medicine, obstetrics and gynecology, and psychiatry, but EM was notably absent. As highlighted by the RAND report, this gap represents a glaring omission, as EPs are inherently multidisciplinary and uniquely positioned to translate gender-specific research and care into lifesaving outcomes.8 The transfer of new evidence in sex and gender research into clinical practice requires systematic incorporation into medical education, postgraduate EM training, and CME courses for practicing physicians. Numerous educational opportunities exist, including curriculum development, grand rounds didactics, simulation, bedside and clinical teaching, and journal clubs, that allow the learner to gain a basic understanding of how sex and gender play a role in presentation and response to diseases, occurrence of injury, and acute care management. Specific sex- and gender-specific instructional strategies can enhance this experience while tailoring them for students versus EM trainees and practitioners. While the core concepts and venues for educational opportunities are similar between medical student and postgraduate curricula, the goals are somewhat different for each group. The main difference lies in the mode of instruction. In medical school, primary instruction is through a large amount of didactic instruction that is intended to remove conscious and unconscious biases in learning, as well as longitudinal case-based learning. Postgraduate education, on the other hand, is largely through experiential learning that emphasizes patient responsibility, professionalism, and nuances of clinical care. The following venues and strategies will need to incorporate these nuances into educational programs, student clerkships, and CME courses. A curriculum represents the expression of educational ideas in practice and should be communicated to those associated with the learning institution, be open to critique, and have the ability to be readily transformed into practice.15 Previous research has shown that curricula have four key elements: content, teaching and learning strategies, assessment processes, and evaluation tools.16 Research shows that medical school curricula have been slow in incorporating these key elements of curriculum to address sex and gender issues in medicine. Fewer than half of medical schools report having women's health curricula,17 and even fewer (7%) offer interdisciplinary courses that have structural grounding in women's health.18 Sex and gender curriculum interventions and instructional strategies are listed in Table 1, and can be used by curriculum directors and educators to better develop a curriculum for students and residents. Learners should have an appreciation for the topics in the Association of Professors of Gynecology and Obstetrics Women's Healthcare Competencies (see Table 2) and be able to describe how sex and gender play a role in the emergency care of patients.19 Examples of sex- and gender-specific instructional strategies include: Emergency medicine residency didactics and curricula have historically taught gender medicine in the context of reproductive health, but not how a patient's gender affects behaviors, roles, expectations, and activities in society.21 Examples of sex- and gender-specific instructional strategies include: Simulation has been shown to be an effective medium for teaching and transfer of information and resources in EM curricula.24 The growing role of simulation in education may lead us to successfully address gender and cultural differences in disease.25 However, the typical mannequin used for instruction is male-appearing, despite most mannequins being unisex in nature. Several steps can be taken to ensure culturally competent education through simulation. Examples of sex- and gender-specific instructional strategies include: Classic bedside teaching and case-based patient-specific teaching in the ED clinical environment are important opportunities to enrich student and resident knowledge of gender medicine. Examples of sex- and gender-specific instructional strategies include: Evidence-based medicine is a way of combining the best available scientific evidence, the practitioner's clinical judgment, and the patient's values to make medical decisions.26 Previous data have shown that journal clubs may improve knowledge of clinical epidemiology and biostatistics, reading habits, and the use of medical literature in practice.27 Examples of sex- and gender-specific instructional strategies include: For practicing physicians and EM graduates, key clinically relevant articles should be made available for CME to facilitate dissemination and incorporation into practice. Faculty education opportunities to strengthen knowledge in this content area should be readily available. Examples of sex- and gender-specific instructional strategies include: The primary challenge faced by researchers and educators is to keep up with the rapidly growing discipline of SGM and incorporate this new information into educational and training programs that will ultimately affect patient care.13 This is demonstrated in the various curricular models and instructional strategies that go beyond specific courses such as physiology and pharmacology. The challenges range from updating basic medical texts books with latest evidence in sex and gender research, to incorporating these findings into trainee clinical rotations. Second, a major barrier to the education of new learners is an absence of sufficient qualified educators in SGM.29 Finally, new evaluation competencies are required to measure improvement in sex- and gender-specific knowledge. Previously, curricular assessment and evaluation only assessed learner knowledge as outlined in the course's objectives. However, newer models are determining if there has been a desired change in learner attitude, knowledge, and skills. This is being accomplished through portfolios, 360-degree assessments, clinical simulations, direct observation, written examinations, and assessment by supervising clinicians.30 Such models will need to incorporate sex- and gender-based competencies to measure effectiveness of the educational efforts. Change is always difficult, and incorporating sex- and gender-specific education at a systems level requires concerted efforts at individual, institutional, regional, and national levels. We recommend the following strategies to overcome these barriers: Engagement in all aspects of medical education is essential to provide the impetus for change. Each educational component should identify opportunities for inclusion of faculty from other disciplines, as the broad scope of women's health, along with sex and gender medicine, offers significant potential for collaborative opportunities. The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender-specific care as an area of importance to emergency medicine. Continuing the momentum is critical in producing effective strategies that guide future research and educational opportunities for interdisciplinary collaboration in gender- and sex-specific knowledge and its translation to the bedside. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.