American College of Physicians: Internal Medicine — Doctors for Adults ®

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From the President

Equipping internists to meet the needs of women's health

From the June 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By Christine K. Cassel, FACP

While women visit physicians more frequently than do men, their health care needs are too often not well-served. Research in women's health suggests that physical illness is not as thoroughly investigated or as well-understood in female patients as in male patients. Extensive clinical trials into common disorders such as heart disease are much more likely to enroll male patients and therefore provide information less relevant to the treatment of women, in whom such disorders cause as much morbidity and mortality as they do in men. In addition, numerous studies have documented that women are less likely to have their symptoms carefully evaluated and their illnesses more likely to be assumed to be psychological. While women live longer than men on average, they have a higher prevalence of chronic illness and disability.

All of these observations have come to a head with the growing concern for women's health as an area of special expertise. The National Institutes of Health took the lead by acknowledging the gaps in clinical research about women's health problems. In response, the Women's Health Initiative was launched with an enormous commitment to major longitudinal studies focusing on diseases that are special threats to women, such as breast and ovarian cancer, and diseases that are overrepresented in women, such as osteoporosis and auto-immune disorders. Studies have been initiated to learn about diseases that affect men and women more or less equally but in which pathogenesis and treatment in women has been less well-studied, such as hypertension, diabetes and heart disease. It will be years before the results of these trials are known, yet the visibility of these efforts has stimulated physicians to be more aware of the needs for women's health.

There is another force driving the development of this special area of women's health--managed care. At a time when health systems are asking patients to select one physician as a primary care physician, many women are in a quandary. They are used to seeking reproductive care from a gynecologist and, if they are reasonably healthy, may not have seen another physician over most of their lives. If they have medical problems, however--and as they get older and are more in need of preventive services such as mammography, colon cancer screening, and hypertension screening and treatment--they may seek primary care from a physician other than a gynecologist. It was this problem that led Hillary Rodham Clinton to insist that obstetrics and gynecology be considered a primary care specialty. Leaders in obstetrics and gynecology have begun to include primary care training as part of the ob/gyn residency.

Internists and family physicians, however, are concerned that six months of training in primary care will not provide the necessary expertise to offer the best comprehensive primary care to women, especially as they age. Thus, some programs have begun to develop special training programs in women's health that emphasize reproductive health as well as internal medicine training.

Internal medicine needs to do more to equip itself well to meet the needs of female patients. For the sake of efficiency as well as continuity, internists ought to be trained at least to provide basic reproductive services such as screening Pap smears, adequate pelvic exams, contraception, evaluation of abnormal bleeding, menopausal symptoms and hormone replacement therapy for their female patients who prefer to be cared for by a single physician. In surveys done by the Council on Graduate Medical Education, both family and internal medicine were shown to provide less than adequate training in many of these aspects of reproductive health.

Recent statements by the American Board of Internal Medicine (ABIM) support enhancing our training in these areas, and an ABIM survey suggests that residency programs have begun to do so. More than half of internal medicine programs surveyed had a women's health center with a rotation in women's health required or available to residents. Most of these programs, however, were new, indicating that the awareness of this need was only recent. These new programs could respond to the wealth of new information that can benefit our female patients. They can also respond to collaborative training and practice agreements with our colleagues in obstetrics and gynecology and family medicine. As internal medicine expands its purview to a number of outpatient subspecialties, none could be more important than those for women's health.

Indeed, there have been numerous efforts to launch training programs for physicians in women's health. One such session was the College's widely-acclaimed minicourse at Annual Session in San Francisco.

It would be a shame to see this emphasis on women's health be focused only as a new and separate "specialty" area for medicine. Women represent more than half of the population that internists see; thus, adequate training and competency in women's health should be required components of every internist's practice.

Some years ago, in reference to the growing number of women going into careers in medicine, Carolla Eisenberg, MD, then dean for student affairs at Harvard Medical School, authored an important editorial in The New England Journal of Medicine titled "Here Come the Women." Now we can reiterate that same statement about our patients. No doubt some of the energy behind our increased awareness of women's health needs is related to Dr. Eisenberg's observations of the gender transition in the population of physicians.

Some managed care leaders report that female patients are increasingly likely to request female physicians as their providers. This creates a special quandary for women internists who have been trained to treat patients of both sexes and do not particularly want to become physicians only for women. And yet, in this time of patient-centered care, health care systems and multispecialty groups want to respond to patients' requests.

The only way to avoid becoming a sex-segregated health care system is for all of us learn more about women's health and create confidence in our patients so that we can provide the knowledge and sensitivity and thorough approach to health care that they deserve.

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