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

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One doctor's efforts to improve women's health care

From the October 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

As director of an internal medicine women's health residency track, Pamela Charney, FACP, has witnessed first hand the need to bring together the vast amount of clinical evidence on various topics in women's health.

"There are many voices within internal medicine and among epidemiologists, gynecologists and women's health activists saying we need to rethink some of the things we do, but they have been solo voices," said Dr. Charney, who is professor of clinical medicine and associate professor of clinical obstetrics and gynecology and women's health at Albert Einstein College of Medicine. She is also an attending internist in the ambulatory care service at Jacobi Medical Center in the Bronx. "What we need are places to pull it all together so that people have easy access to women's health information."

In her role as Editor of the College's new series of books on women's health, she is doing exactly that. The first publication in the series, "Coronary Artery Disease in Women: What All Physicians Need to Know," came out this spring. In the works are books on medical care of the pregnant patient (slated for publication next spring), gynecology for the internist, dealing with domestic violence and treating eating disorders.

Dr. Charney is also the leading force behind a new College clinical skills course on women's health, offered for the first time this summer in Philadelphia. The three-day course uses standardized patients to teach physical examination skills. "Caring for Women: A Focus on Clinical Skills" will be offered again Nov. 14-16 in San Antonio and Feb. 5-7, 2000 in Charleston, S.C. (For information, call ACP-ASIM Customer Service at 800-523-1546, ext. 2600.)

Dr. Charney recently talked to ACP­ASIM Observer about the women's health book series and her goals for the women's health clinical skills course.

Q: The first book addresses coronary artery disease. Why is there a need for a book that looks specifically at treating women with heart disease?

A: This is an area where we certainly could do better by our women patients. Many studies have shown that post MI, women are treated less aggressively for their lipid abnormalities. Women are frequently not receiving aspirin or beta-blockers post MI.

If you look at national trends, the rate of decline in heart disease has been much slower in women than in men since 1979. I think that's because we haven't been focusing on it, and I think we haven't been focusing on it because there wasn't a widespread understanding about how big an epidemic heart disease is in women as well as in men.

There also hasn't been widespread understanding that we have therapies that work for women, that we can prevent and treat heart disease in women. Some of the morbidity associated with heart disease can be avoided.

Q: Why do doctors treat men differently than women?

A: I think there's a lag between doing the research and getting the word out to doctors. The No. 1 cause of death for both men and women is heart disease. There is a 10-year lag between women's clinical presentation and men's clinical presentation of heart disease. It's only relatively recently that we have studied older populations.

The Framingham study, for example, began with a middle-aged population and looked at cardiac outcomes. When all cases of chest pain were considered, more women had symptoms than men, and there were fewer female deaths. This was interpreted as meaning that heart disease is more serious in men than in women. However, when they went back later and looked at typical angina in women and men, the prognosis was similar.

Q: You frequently say in the book that multiple physicians from different vantage points came to similar conclusions. Can you give an example?

A: Everyone in the book articulates that if you are going to do one thing to change cardiac risk, it is tobacco cessation, but what is often inadequately thought about are the differences between women's and men's tobacco initiation, use and cessation.

More young women are beginning to smoke, and they have a higher average consumption rate than young men do. Women report that they are more likely to smoke to deal with stress. And women are much less likely to stop smoking both initially and long-term.

Social pressure is the most common reason that women stop, and for women the pressure comes from their children, while for men it's usually from co-workers and friends. Therefore, programs that focus on issues important to women, including fear of weight gain, and in terms of family, emotional support and stress reduction, are more effective.

Q: How can the College improve the gynecologic skills of internists?

A: Our new clinical skills course is a start. It would be a great course for internists who have never done a Pap smear. At the first course in June, we had a 100% success rate, with everyone going home saying, "I can now find a cervix. I can feel ovaries."

Pressure from the public is one of the reasons internists change what they do. Plenty of patients are saying, "If I have gynecological problems, then I need my gynecologist, but if I just need a Pap test and biannual exam and I've been fine for 20 years, maybe I don't want to go to two doctors for that."

There are also a couple of things happening that could help motivate internists to learn these skills. The American Board of Internal Medicine several years ago announced that it was changing both the internal medicine boards and the recertification exam to include women's health. That's already setting a different kind of standard, and it helps us as internists to claim this as part of what we do. The Federated Council for Internal Medicine includes women's health as part of the core competencies for internal medicine.

The question, then, is how do we provide more opportunities for people to get up to speed, especially people who have been out of training for a while? That is the challenge.

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