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Foundations for a Novel Emergency Medicine Subspecialty: Sex, Gender, and Women's Health

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

10.1111/acem.12544

1553-2712

Alyson J. McGregor, Tracy E. Madsen, Brian Clyne,

Sex and Gender in Healthcare

Sex and gender affect all aspects of health and disease, including pathophysiology, epidemiology, presentation, treatment, and outcomes. Sex- and gender-specific medicine (SGM) is a rapidly developing field rooted in women's health; however, inclusion of SGM in emergency medicine (EM) is currently lacking. Incorporating principles of sex, gender, and women's health into emergency care and training curricula is an important first step toward establishing a novel subspecialty. EM is an ideal specialty to cultivate this new field because of its broad interdisciplinary nature, increasing numbers of patient visits, and support from academic medical centers to promote expertise in women's health. This article describes methods used to establish a new multidisciplinary training program in sex, gender, and women's health based in a department of EM. Women's health and SGM program initiatives span clinical care, patient education, clinical research, resident and fellow training, and faculty development. El género y el sexo afectan a todos los aspectos de la salud y la enfermedad, incluyendo la fisiopatología, la epidemiología, la atención, el tratamiento y los resultados. La medicina específica de género y sexo (MGS) es un campo en rápido desarrollo basado en la salud de la mujer; sin embargo, la inclusión de la MGS en la Medicina de Urgencias y Emergencias (MUE) es escasa en la actualidad. La incorporación de los principios de género, sexo y salud de la mujer a la atención de urgencias y emergencias y el plan de formación es un primer paso importante para establecer una nueva subespecialidad. La MUE es una especialidad ideal para cultivar este nuevo campo debido a su amplia naturaleza interdisciplinar, el incremento del número de visitas de pacientes y el soporte de los centros médicos académicos para promover expertos en salud de la mujer. Este artículo describe los métodos usados para establecer un nuevo programa de formación multidisciplinar en género, sexo y salud de la mujer basado en un servicio de MUE. La salud de la mujer y las iniciativas del programa de la MGS abarcan la atención clínica, la formación del paciente, la investigación clínica, la formación de residentes y adjuntos y el desarrollo académico. “Women's health” has evolved over the past 30 years from a strict focus on reproductive health into the burgeoning discipline of sex- and gender-specific medicine (SGM). Historically, medical research has been both sex- and gender-neutral or skewed toward male physiology. This has resulted in missed opportunities for prevention, diagnosis, and treatments specific for women. Despite progress during the past 20 years, women still have not achieved equity in biomedical and health outcomes investigations. Failing to routinely consider the effect of sex and gender on research, medical education, and training, women's health is being left to chance. For this reason, women's health and SGM are inextricably linked. During the early 1990s, women's health and SGM became a focus for clinical research, resulting in numerous studies establishing the role of sex and gender in health and disease.1-6 At the same time, there has been increasing emphasis on women's health in graduate medical education. Internal medicine, family medicine, obstetrics and gynecology (OB/GYN), and psychiatry have endorsed or developed curricula related to sex, gender, and women's health. As early as 1997, the American Board of Internal Medicine and the American Academy of Family Physicians published women's health competencies for residency training. Further curriculum recommendations have been published by the National Academy of Women's Health in Medical Education7and the Council on Graduate Medical Education.8 Despite progress identifying sex and gender differences in many conditions encountered in emergency medicine (EM), residency programs currently offer little formal training in this area. This may relate to a historical lack of emphasis on women's health in the EM core content and accreditation standards. In the 2011 Model of the Clinical Practice of Emergency Medicine, the term gender occurs only once, within the physician task of recognizing “age, gender, ethnicity … and other factors that may affect patient management.” In the same document, sex is only found under sexual assault examination, and women is not mentioned at all.9 Similarly, the 2013 Accreditation Council for Graduate Medical Education (ACGME) program requirements for EM do not mention the terms women or sex. The term gender is found in relation to treating a comprehensive patient population and in the context of demonstrating “sensitivity to different patient populations.”10 The move toward competency-based education and acceptance of the milestones has highlighted the need for curricula in women's health and SGM. Without referencing women directly, the new EM milestones11 demand resident competency caring for patients with specific needs. Milestone 20 (Professional Values 1) calls for competency “interacting with a diverse population of patients and families.” Milestone 3 (Patient Care 3) includes appropriate diagnostic testing “based on the probability of disease,” and Milestone 5 (Patient Care 5) calls for selecting appropriate pharmacotherapy based on “mechanism of action, intended effect, possible adverse effects, … and other modifying factors.” One of the goals of the Clinical Learning Environment Reviews initiative is for institutions to demonstrate “a reduction in health care disparities”; this is further rationale to include education about women's health and SGM in residency training.12 In 2013, The Journal of Women's Health published a “Directory of Residency and Fellowship Programs in Women's Health,” listing 23 fellowship programs in the United States dedicated to providing subspecialty training in women's health.13 None were sponsored by departments of EM. To address this educational gap, the authors developed a curriculum for EM residents on sex, gender, and women's health. They also identified areas where emergency care, gender-specific medicine, and clinical research overlap to contribute to the growing body of scholarship on women's health beyond reproductive issues. The curriculum subsequently evolved into a novel postgraduate training program designed to meet the need for focused and intensive training in women's health and SGM in the context of EM. The program draws on local resources—in medical education, research, and clinical care—to provide a unique specialty training experience. While the nature and extent of training in women's health and SGM within EM is not well described, many departments have the ability to sponsor similar fellowship experiences. The purposes of this article are to: 1) describe one program's experience developing a postgraduate training curriculum in women's health and SGM; 2) encourage the formation of other similar programs that improve patient care and create academic opportunities for residents, fellows, and faculty; and 3) construct the foundation for women's health and SGM to become a recognized subspecialty area within EM. Emergency medicine is important to the growth of women's health and SGM and arguably an ideal home for this new field. Emergency department (ED) visits are steadily increasing, with the number of women seeking emergency care rising faster than men. Recent studies indicate that women make up 54.3% of all ED visits, with a steep trend toward increased ED occupancy.14 EM sits at the cross-section of many disciplines, allowing natural collaborations with specialties that have experience in women's health but lack access to a large patient population with acute, undifferentiated illness. Despite the range of conditions seen in the ED, most patients are readily identified by their gender, making it an excellent setting for comparative effectiveness research or gender-based clinical interventions. As medicine grows more complex, subspecialization has become increasingly common. For instance, internal medicine has over 20 approved subspecialties in which the American Board of Medical Specialties can offer certification; areas including geriatric medicine and adolescent medicine are subspecialties directed toward subpopulations of society as a whole. In contrast, EM currently includes eight subspecialties where certification is offered by the American Board of Emergency Medicine with only pediatric EM offered as a subpopulation. Women's health currently is not offered as a subspecialty within any of the medical or surgical specialties, as it has often been defined as reproductive health and assumed by the medical specialty of OB/GYN. National EM specialty societies have increasingly devoted educational and research resources to women's health, creating favorable conditions for a new field of study to flourish. Organizations like the American College of Emergency Physicians and the Society for Academic Emergency Medicine (SAEM) include subcommittees, interest groups, leadership opportunities, and grant programs dedicated to supporting women's health and faculty development. Core EM journals are publishing research studies, educational articles, and commentaries related to sex, gender, and women's health with increasing frequency.2, 15, 16 In 2013, the U.S. Department of Health and Human Services Office of Women's Health published findings of a national expert panel summarizing the women's health literature and highlighting opportunities to improve education. The report includes recommendations for curriculum development and calls for the establishment of additional women's health clerkships and fellowships.17 Academic Emergency Medicine has declared 2014 the year to emphasize the inclusion of sex and gender into the research and clinical practice of EM. The focus of its annual consensus conference was “Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes.” Collectively, these efforts provide a forum within EM to study, teach, and improve outcomes in women's health and SGM. The authors used established educational methods to develop the elective curriculum for EM residents.18 An initial needs assessment and literature search were conducted followed by a review of guidelines and women's health curricula from other specialties and health professions.19-22 Core faculty held informational interviews with content experts and developed educational objectives. For example, faculty met with experts in women's cardiovascular disease to identify how gender can affect the presentation, diagnosis, or treatment of cardiac disease in the ED. Focus groups with local educational stakeholders were conducted to refine the learning objectives and identify available resources. The process resulted in a distinct educational goal: To teach residents how to improve emergency medical care of women through discovery of the biological, physiological, pathological, and therapeutic differences between men and women and how that influences emergency care for all. Learning objectives were then developed that broadly reflect the important topics for EM residents to learn on a women's health/SGM elective. Individual competencies were developed using the ACGME framework of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Competencies specific to women's health and SGM were integrated with existing EM core competencies.10 Table 1 represents the results of this process: the essential knowledge, skills, and attributes for EM residents to achieve basic competence in women's health and SGM. In addition to defining the educational content, curriculum leaders considered the delivery methods, teaching strategies, and methods of learner assessment. The elective was modeled on existing rotations in the core EM residency program, using similar didactic approaches and evaluation tools. The principal components of the curriculum include assigned readings and questions; didactic conferences (case discussions, simulations, or small group learning); a capstone presentation whereby participants teach peers about a topic related to sex and gender in emergency care; and clinical experiences. For other EM departments developing a sex, gender, and women's health curriculum, the mix of clinical experience will be program-dependent; many EM programs, however, will have access to high-volume academic or community EDs, a women's specialty or primary care clinic, and a specialized women's hospital that routinely treats pregnant patients. A sample resident elective schedule listing our program's clinical training sites can be found in Table 2. Depending on the site, clinical supervision may be provided by faculty from other disciplines (i.e., internal medicine, OB/GYN, and family medicine) or other professional backgrounds (i.e., nurses, midwives, and advanced care providers). Supervising faculty should be informed about the competencies and trained to assess learners. Methods for assessment are competency-specific, but may include multiple-choice examinations, standardized direct observation, objective structured clinical examination, standardized patients, oral examinations, global rating scales, or reflective essays. The resident elective is designed to run over 4 weeks to allow for in-depth exploration of topics and exposure to multiple clinical settings, although women's health/SGM resident electives can also be offered as a 2-week experience. The decision to establish a women's health/SGM fellowship evolved from positive experiences with the EM elective, favorable institutional conditions, and the need to develop leaders in the field of women's health and SGM. Developing the curriculum followed a rigorous process, similar to that of creating the resident elective, but with emphasis on advanced clinical proficiency, research skills, teaching abilities, and leadership. The goal of a women's health/SGM fellowship is to develop physician-leaders with the specialized knowledge and skills for clinical care, education, research, and advocacy in women's health and SGM. The selection process seeks to identify EM residents with demonstrated interest and aptitude for academic medicine. Non-EM graduates may also be considered, with options to complete their clinical experience in primary care or urgent care settings. This flexibility allows a program to accommodate candidates with various training backgrounds and support career interests that include acute care, but perhaps not EM. A 2-year program provides sufficient breadth and allows fellows to customize some aspects of the experience. The fellowship will likely be less structured than the resident elective to allow for exploration of specific interests. Depending on their specific goals, fellows may choose to spend more time focusing on either teaching or research activities, especially during their second year. The women's health/SGM fellowship was designed as a 2-year experience with adequate time to achieve the following objectives: Table 3 illustrates an expanded list of competencies for fellows with an emphasis on research, teaching, and the routine incorporation of sex and gender into clinical practice. The fellowship extends beyond EM, promoting a broader understanding of sex, gender, and women's health through experiences in public health and population research. Key fellowship elements include clinical work, formal research training through coursework, hands-on research experience, teaching opportunities, leadership development, and ongoing self-directed learning. Table 4 shows a sample block schedule for a 2-year fellowship incorporating these elements. Clinical experiences are used to reinforce consistent use of the gender lens at the bedside. Over the course of the fellowship, fellows have the opportunity to develop this skill in a variety of clinical settings including the ED. The combination of experiences will vary based on the available institutional resources; recommended supplementary experiences include an OB acute care site and outpatient clinics specializing in the care of nonpregnant women with a variety of medical issues. In each of these settings, as well as the ED, fellows are taught to incorporate patient sex and gender into the diagnostic and therapeutic decisions. To solidify this core competency, fellowship directors should evaluate fellows' ability to integrate gender into bedside decisions through case reports, presentations, and regularly scheduled follow-up meetings. In the current women's health/SGM fellowship, longitudinal core clinical rotations are based at a women's specialty hospital and include experience in an OB emergency care setting and a dedicated OB/GYN hospital with an emergency triage unit. The fellow can benefit from clinical elective time each month by rotating at this facility and others committed to practicing specialty care for women such as inpatient OB-medicine consulting service, a women's cardiac center, an adolescent clinic with providers trained to evaluate transgender patients, and a women's outpatient health center with gastrointestinal, pulmonary, oncological, and behavioral medicine services. Whether to include an advanced degree is an important decision when establishing a women's health/SGM fellowship. In these early stages of the field, it is important to equip fellows with the skills to contribute meaningfully to the body of research in sex, gender, and women's health. As such, including a master of public health (MPH) or a master of clinical and translational research (MCTR) is advantageous. A 2-year program allows fellows to receive additional training in research methodology and the analytic capabilities required to advance the field. This added instruction will serve the fellow in many ways, including increasing proficiency in conducting sex- and gender-specific research in EM, gaining the skills necessary to assume leadership roles locally and nationally and using the knowledge to translate research findings into clinical practice in EDs. If institutional resources are limited, a robust 1-year fellowship program without an advanced degree is still highly valuable. As the field gains momentum, it is more important to generate well-trained scholars than to restrict the training to institutions that can offer advanced degrees. It is important for the fellow to understand the application of research skills in an interdisciplinary arena. Having prior experience in research methodology and design is favorable; however, instruction on designing and conducting sex, gender, and women's health research will be a critical aspect of the fellowship training. Given that much historical research focused disproportionately on males, this area is ripe for study questions and offers many opportunities for collaborative analysis of existing data sets. Fellows should also learn the importance of sex-specific data analysis and reporting in research studies not primarily focused on women's health. In particular, opportunities exist that allow the fellow to leverage the core strengths of any institution by evaluating sex and gender differences in many areas germane to EM such as injury prevention, cardiovascular, neurological, and other health care systems science. Fellows should have opportunities to teach in a variety of settings including departmental grand rounds, residency conference lectures, small group learning, bedside rounds, and one-on-one mentoring with a variety of learners (medical students, residents, and staff) interested in advancing SGM. Medical students may have a high degree of interest in this area, which leads to many mentor–mentee experiences that are mutually beneficial and often identifies and engages future scholars. Collaborative teaching efforts in other departments or institutions are encouraged. Much of the current scientific knowledge about SGM and women's health has emerged only recently and from many different disciplines, making accessibility and coordination into an organized curriculum challenging. Currently, there is no centralized resource for this diffuse body of knowledge; therefore, a reading list should take into account the varied resources available, including journal articles, textbooks, and Web-based continuing medical education courses. One example of a useful online resource includes Sex and Gender Women's Health Collaborative (http://www.sgwhc.org), a professional organization whose aim is to provide a universally accessible digital library of evidence-based sex and gender educational resources that include curriculum and training, teaching tools, presentations, reports, guidelines, and professional education modules that focus on using the gender lens in research and clinical practice. Additional online resources include Stanford University's Gendered Innovations (http://genderedinnovations.stanford.edu) and the Canadian Institute of Gender Health: What a Difference Sex and Gender Make (http://www.cihr-irsc.gc.ca/e/44082.html). Opportunities exist for a medical student and resident educational project to compile relevant reading resources for each institution. Despite the fact that the attention on sex and gender has prompted institutions to create focused women's health fellowship tracks, training remains inadequate. Furthermore, confidence in knowledge and self-efficacy in women's health among trainees remains low.16 Establishing a women's health/SGM curriculum is likely to face the same challenges as other new educational initiatives. We present commonly cited challenges to new educational initiatives and propose strategies to address them. BARRIER 1: There is limited time and space in the existing curriculum. The current curriculum must prepare residents to demonstrate aptitude in the core competencies endorsed by ACGME. This allows little opportunity for the inclusion of new material. STRATEGY 1: Integrate sex and gender using the current curriculum. From grand rounds to resident lectures, presenters should be asked to address whether sex or gender affects the presentation, diagnosis, treatment, or prognosis of the specific entity. When simulation cases are under peer review, discuss how a change in gender would affect outcome. Journal club should include discussion of whether gender composition was reported, included in the study design, included as an independent variable, or considered in the primary hypothesis. BARRIER 2: Competition with other specific interests (geriatrics, ultrasound, toxicology, international, etc.) for resources. The American Board of Medical Specialties currently recognizes eight subspecialty areas within EM that are competing for department-level resources and support as well as resident interest and commitment. STRATEGY 2: Start with small wins: create a resident elective. Residents can choose to spend their clinical elective time completing a 2- to 4-week elective. A well-rounded elective can include the resident creating sex and gender case studies, becoming involved in ongoing research projects, and constructing educational modules that can supplement the clinical time. Make the elective available to residents from outside programs nationally to assist in fellowship recruitment and networking. In addition, emphasize the relevant overlap between gender-specific medicine and other subspecialties. BARRIER 3: An absence of faculty and role models knowledgeable in this subspecialty area. Novel subspecialties require the support of many stakeholders, including the department chair, faculty members, program directors, residents, and students. STRATEGY 3.1: Make it interdisciplinary by finding qualified faculty from other specialties. Since sex, gender, and emergency care cross many specialties and health professions, these relationships are critical to the success of similar fellowship program initiatives. This will also help gain approval from local Graduate Medical Education (GME) committees. At this time, the women's health /SGM fellowship is a non-ACGME program, established with the approval of the institution's GME committee. STRATEGY 3.2: Faculty development for women's health/SGM mentors is critical for establishing and growing a new program. An important initial step is to educate existing EM faculty about the effect of sex and gender on patient outcomes. One example of an educational program to raise awareness among faculty is a series of brief online videos available through Academic Emergency Medicine: Peer-reviewed Lectures (PeRLs) that highlight gender differences in a number of acute conditions, including cardiovascular, neurology, pain, toxicology, injury, violence, substance abuse, pulmonary, and sports medicine and a historical perspective of the evolution of SGM.23, 24 An additional PeRLs reviews the effect that sex- and gender-specific research has on the field of EM, provides concrete examples of current EM literature that successfully investigates sex and gender differences, and presents analytical strategies to perform gender-based research in existing research data.25 BARRIER 4: Personal demands on the program and curriculum champions. Identifying faculty who are committed to establishing a novel program and implementing a new curriculum has many challenges that include competing demands of professional development and academic promotions, along with personal investments. STRATEGY 4.1: Enlist outside help. Build on successful working relationships with local and national EM faculty, as well as local faculty representing a wide variety of disciplines. STRATEGY 4.2: Give fellows the opportunity to advance the subspecialty. Having a fellow trained in SGM will allow infiltration of sex and gender principles into the residency education. For example, a fellow receiving adequate training will then be able to teach at residency conferences, intern orientations, and resident and faculty retreats. BARRIER 5: Funding. There may be a lack of financial resources for such wide-ranging needs. The economic needs include administrative, research, facilities, and faculty financial support to establish an adequate program that can fulfill the broad goals of women's health. STRATEGY 5.1: Identify funding sources. A critical goal of a fellowship program is financial independence. Initially, institutional support is necessary; however, any expansion of effort will require additional funds. National Institutes of Health, American Heart Association, SAEM Education Fellowship Grants, and Foundation for Gender-Specific Medicine Scholar Program as well as unrestricted educational grants from industry sponsors should be considered. STRATEGY 5.2: Incentivize faculty and residents. Due to the demands of managing clinical, educational, research, and administrative requirements, there is an opportunity to encourage individual faculty members and residents to take advantage of educational resources by offering incentives. Consider small financial rewards for completing modules, viewing videos, and responding to CME-style questions about the topic. Consider regular awards and recognition for the resident or faculty member who demonstrates advanced understanding of sex and gender concepts. BARRIER 6: Resistance to change. All medical disciplines are recognizing the need to rethink what constitutes appropriate health care for women and how to incorporate sex and gender into research agendas and bedside patient care. This is a fundamental shift in medicine with many challenges. STRATEGY 6.1: Establish a broad steering committee of supporters from all levels. To create a “team” of mentors, a women's health/SGM membership program should be created to engage active support for the fellowship mission. This membership program can comprise the founding members including EM faculty, residents, midlevel providers, nursing staff, regional and national research collaborators, national senior advisors, and a community advisory board. These members should attend quarterly meetings, provide educational opportunities, and assist in creating research initiatives and establishing collaborative projects. Community outreach programs are also a vital component. STRATEGY 6.2: Patients and staff engagement. Disseminating knowledge of gender-specific care to patients is vital in empowering them and their families when seeking emergency care. A series of educational posters can be created and displayed in the emergency waiting area and treatment rooms to inform patients about gender-specific symptoms, injury patterns, and research that may affect their care in the ED. To ensure all providers responsible for the care of ED patients are knowledgeable and informed about how sex and gender affect patient care, the nursing staff should also be encouraged to review the PeRLs videos. In addition, small-group educational sessions are critical to engaging and educating nursing staff. Emergency medicine residency programs have a responsibility to teach residents about gender differences in common and life-threatening diseases; residents must also understand how disease management differs based on sex and gender. Despite the fact that formal training is lacking in EM residencies, many programs have the resources to provide high-quality training and meet an identified educational need. We present suggestions for establishing elective and fellowship experiences that could serve as a framework for similar programs. Incorporating curricula in women's health, and sex- and gender-based medicine more formally within emergency medicine, is a first step toward recognition as a subspecialty. Additionally, these programs can be a strategic asset, serving as a resource for education, clinical care, and research. Establishing additional programs will benefit departments seeking to develop experts in women's health and sex- and gender-based medicine who can lead the next generation.