Virginia Medical School (JGD), Norfolk, Va; Department of. Internal Medicine, University of South Florida, College of. Medicine (BAB), Tampa, Fla; Department of ...
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ORIGINAL ARTICLES
Teaching Women's Health Skills C o n f i d e n c e , A t t i t u d e s , a n d P r a c t i c e P a t t e r n s of A c a d e m i c Generalist Physicians James G. Dixon, MD, Bryan A. Bognar, MD, Thomas C. Keyserling, MD, MPH, Connie T. DuPre, MD, Sharon X. Xie, PhD, Glenda C. Wickstrom, MD, MS, Maria M. Kolar, MD OBJECTIVE: This study assesses the readiness of academic general internists to perform and precept a commonly utilized women's health examination, and procedural and management skills. DESIGN: Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women's health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: ``Performing routine Pap smears is a good use of my time'' (GIMs 65%, FPs 84%); ``It is a waste of health care dollars for primary care physicians to
Received from the Department of Internal Medicine, Eastern Virginia Medical School (JGD), Norfolk, Va; Department of Internal Medicine, University of South Florida, College of Medicine (BAB), Tampa, Fla; Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine (TCK), Chapel Hill, NC; Section of General Medicine, Medical College of Georgia (CTD), Augusta, Ga; Department of Health Evaluation Sciences, Pennsylvania State University (SXX), Hershey, Pa; Department of Medicine, Summa Health System/Northeastern Ohio, Universities College of Medicine (GCW), Akron, Ohio; and Department of Internal Medicine, West Virginia University School of Medicine (MMK), Morgantown, WVa. Presented in part at the 1996 annual national meeting of the Society of General Internal Medicine, May 2±4, Washington, DC. Address correspondence and requests for requests to Dr. Dixon: 825 Fairfax Ave., Norfolk, VA 23507 (e-mail: dixonjg@ evms.edu).
refer patients to gynecologists for routine Pap/pelvic exams'' (GIMs 69%, FPs 90%); ``I feel very well trained to do a routine bimanual exam'' (GIMs 71%, FPs 98%), and ``The clinic where I practice is well equipped to do a Pap smear'' (GIMs 78%, FPs 94%). CONCLUSIONS: Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women's health skills. KEY WORDS: women's health; primary care faculty; residency training; confidence. J GEN INTERN MED 2003;18:411±418.
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he American Board of Internal Medicine (ABIM) acknowledges that the residency training environment does not always facilitate optimal care of women,1 and that it has not insisted that all trainees be competent in examining the female urogenital tract,2 and capable of diagnosing and treating common gynecologic problems.3±5 Recognizing that training in women's health must improve in order to correct deficiencies in the medical care provided to women, the ABIM's commentary, ``Training Internists in Women's Health,''2 recommends assessing trainee competence in women's health, including women's health topics in didactic presentations to residents, and exploring the benefits of cross training between obstetrics/gynecology and family medicine. Furthermore, the Board's subcommittee on Clinical Competence in Women's Health has recently identified a set of core competencies that all internists seeking board certification should demonstrate.6 These competencies include management of common gynecologic disorders and family planning, as well as the following essential skills: breast exam, pelvic exam/rectal exam, and obtaining a Pap smear. New Internal Medicine Residency Review Committee gender-specific special requirements7 mandate that those who commence training subsequent to July 1997 demonstrate competence with the breast, pelvic, and rectal exams. These requirements also suggest that 411
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residents, depending on their practice expectations, should be trained in several additional women's health management and procedural skills. Expanding residency training in women's health likely will require faculty development8 for those who received little exposure to these skills during their own training or for faculty who do not routinely utilize these skills.9 This study assessed the readiness of academic general internal medicine physicians (GIMs) and family medicine physicians (FPs) to perform and precept a commonly utilized women's health care examination and procedural and management skills, and assessed their attitudes toward performing the pelvic exam and obtaining a Pap smear. Contrasting GIM and FP faculty responses allowed us to compare faculty from a discipline that has recently emphasized women's health residency education, internal medicine, with a discipline that has emphasized women's health education for many years, family practice. The American Academy of Family Practice has had Women's Health Core Educational Guidelines since 1994,10 has required obstetrics/gynecology training since its inception, and has always required a substantial amount of ambulatory training experience in which women's health issues are most often encountered.
METHODS Study Participants Full-time faculty from the divisions of general internal medicine and the departments of family practice at all 37 medical schools in the 9 states (Fla, Ga, Ky, NC, Ohio, Pa, Ind, Va, and WVa) represented by the investigators were invited to participate in this survey. Two medical schools declined to participate. A questionnaire was mailed to GIMs and FPs at the 35 remaining schools. Nonrespondents received a reminder postcard 2 weeks after the initial mailing and a second letter and questionnaire at 6 weeks.
Questionnaire Design Items for the questionnaire were selected to represent a sample of women's health skills considered important, or expected to grow in importance for the practice of general internal medicine. The skills were chosen based on a review of the literature and author consensus. Most of these skills have since been included as part of the ABIM's Core Competencies in Women's Health6 and the Federated Council of Internal Medicine Task Force recommendations for in-depth knowledge of conditions in women's health.11 The questionnaire addressed the examination and procedural and management skills (see Table 2). For each skill, respondents estimated the number they performed or precepted each month or year, their confidence precepting these skills, and the importance of these skills to primary care practice. Confidence and importance were measured using Likert scales where 1 = not confident at all or not important at all, and 6 = very confident or very important.
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In addition, using Likert scales where 1 = strongly disagree and 6 = strongly agree, participants were asked to indicate their level of agreement with 19 statements relevant to performing the pelvic examination and obtaining a Pap smear. Each statement regarding the Pap/pelvic exam is designed to assess either the importance respondents place on performing the exam, the quality of their Pap/pelvic training, their confidence performing the exam, the extent to which their practice setting facilitates performing the exam, or their opinion on patient preferences for who performs this exam.
Statistical Analysis The Wilcoxon-Mann-Whitney rank sum test was used to compare the median number of procedural and clinical encounters between GIMs and FPs. The Fisher's exact test was used to compare by discipline importance of performing/managing, confidence precepting, early referral, and the percentage of physicians who strongly agreed with the 19 Pap/pelvic statements. Binary logistic regression was used to model the probability of having a high level of confidence precepting women's health management skills. High confidence was defined as a Likert score of 5 or 6, while low/medium confidence was defined as a Likert score of 1 to 4. The main independent variables (all categorical) included: number of procedures/conditions the physician performed/encountered (grouped into 0, 1±9 and 10 procedures per month or year); self-reported importance of performing/managing conditions that were classified as having a high level of importance (Likert score 5 or 6) versus a low level of importance (Likert score 1±4); physician type (GIM vs FP); frequency of early referral to another health care professional; and gender. Additional independent variables regarding physician attitudes concerning the Pap/pelvic exam were included when the binary logistic regression model was built for that examination. A forward selection procedure was used, with a P value of .05 as the criterion for entry into the model. Goodness-of-fit tests were performed, and the results supported the adequacy of the final models.12 All analyses were conducted using SAS software, Version 6.12 (SAS Institute, Cary, NC). Two-sided P values and 95% confidence intervals (95% CIs) are reported.
RESULTS Demographics Surveys were mailed to 571 GIMs and 434 FPs. A total of 331 GIMs and 271 FPs returned completed confidential questionnaires for response rates of 57% and 65%, respectively. Forty-five GIMs who identified a Veterans Affairs hospital clinic as their primary ambulatory practice site, where the majority of patient encounters were assumed to be with men, were excluded from the analyses. As seen in Table 1, 40% and 30% of the GIM and FP respondents, respectively, were female. The majority of
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Table 1. Respondent Characteristics by Specialty
Characteristic Mean age, y (SD) Women, % Average year residency completed (SD) Post-graduate program location, %* University Community Current practice type, %y University-based practice Private practice Community health center Public clinic HMO Other Current practice location (population), % Large city/metropolitan area (>200,000) Large town/small city (50,000±200,000) Rural/small town (
