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Department of Health and Human Services
Council on Graduate Medical Education

Summary of Fifth Report

Women in Medicine: Physician Education in Women's Health.
Women in the Physician Workforce 

May 1998

Physician Education in Women's Health

The current interest in women's health has its basis in the women's health movement of the 1960's. This grass-roots movement was fueled by the feminist movement and reflected women's discontent with the lack of accessible information regarding their health and the prevailing paternalistic attitude of medicine. The most prominent product of this movement was the book Our Bodies, Ourselves by the Boston Women's Health collaborative. The goal of this book was to improve the health of women by teaching them how their bodies worked and how they could become active participants in their health care. Over the past three decades, it has served as a guide for women interested in understanding their basic health needs.

Political forces behind the current women's health movement differ markedly form those of the 1960's. In 1983, the Assistant Secretary for Health commissioned the US. Public Health Service to form a task force to assess the status of women's health in the United States and to identify the most important factors that influence health and disease. The task force's recommendations, published in 1985, presented a blueprint for change in the approach to women's health. The task force broadly defined women's health issues as "diseases or conditions that are unique to or more prevalent or serious in women, have distinct causes or manifest themselves differently in women, or have different outcomes or interventions." It recognized the effect of social and demographic changes on women's health status and stressed the importance of preventive health services for women. Furthermore, the report identified potential biases in research and clinical practice that result in inadequate care for women.

In response to this report, the General Accounting Office examined expenditures by the National Institutes of Health (NIH) in 1987 to determine how research funds were allocated according to gender. The study found that 13.5% of the NIH budget supported research on women's health issues. About 80% of all NIH research funds were expended either for studies of diseases that affect both men and women or for fundamental research that has significance for diseases of all segments of the population. Further review, however, showed that women were not adequately represented in many of the research studies affecting both genders.

These findings brought an outcry from the Congressional Caucus for Women's Issues. In response, NIH established the Office of Research on Women's Health (ORWH) in 1990. This freestanding office, located within the Office of the Director of NIH, has a threefold mandate: 1) to enhance research in women's health and to ensure that women's health issues are addressed adequately in research conducted by NIH; 2) to ensure that women are appropriately represented in all studies supported by NIH; and 3) to increase the number of women in biomedical careers (4). Coincident with the establishment of the ORWH, Dr. Bernadine Healy was appointed the first woman director of NIH. Her commitment to women' health issues helped establish the strong scientific framework necessary to advance a women's health agenda.

Recently, public and professional attention has focused on whether physicians are being adequately trained to care for the health needs of women. Within the medical profession some women's health advocates have called for a separate women's health specialty. In 1993, Congress requested that the Department of Health and Human Services examine the content of undergraduate medical education devoted to women's health. This legislation authorizes the Health and Human Services Secretary to survey medical school curricula to determine how women's health issues are incorporated and, if inadequate, to make recommendations for change.

These developments reflect a call for change in the education of physicians who care for women. Medical educators, researchers, and practitioners are being challenged to reexamine curricula, research agendas, and competencies with regard to the health of women. The call for change has been prompted by the perception that the health care needs of women are not being met by the current health care delivery and medical education systems. The issues extend beyond the current national debate over the restructuring and refinancing of health care. They concern basic institutional precepts that have guided the conduct of medical research, education, and practice, as well as societal biases that have influenced the health of women and other populations in society today.

Through studies, recommendations, and conclusions, medical research provides the biopsychosocial framework for health care. Yet for years, knowledge about illness and diseases as well as aspects of treatment, including pharmacology, was derived from studies of men and applied to women with the supposition that there are no significant differences in women's reactions to such applications. In recent years, increased attention to these issues through grass-roots efforts and news media coverage has supported studying the determinants of health in women. From resulting new knowledge, approaches may be designed to improve the status of women's health.

Many have called for a broadening of the knowledge base and training of health professionals to better prepare them to be responsive to women's health concerns. This broadening entails an appreciation of the basic biological differences between the genders as well as the demographic, psychosocial, economic, and environmental factors that affect women's health. Educational and clinical initiatives are needed to increase the understanding of similarities as well as differences and unique qualities of women's health with the goal of improving health care.

The area of women's health traditionally has focused on reproductive issues in adolescent girls and adult women. As such, the reference for women's health care has been confined primarily to the disciplines pertaining to childbearing. This limited perspective does not take into account the broad spectrum of women's health concerns or the relative differences between men and women in terms of health behaviors, morbidity, disability, and mortality. This more limited perspective also may not recognize the demographic, social, cultural, or political influences on women's health or their approach to health care.

This report is directed to the health of women. Gender-specific health concerns arise during childhood and have a long-term impact; although these early issues are important, they are not included in this report. Actually, the health of women can be perceived as a continuum that extends throughout life. Biological differences between males and females become established in the embryonic period and are among the factors that affect subsequent physical, cognitive, and social development. From a societal perspective, the health of women to a great extent affects the health and well being of their children. During the preconceptional and prenatal periods, the health of the mother can have a direct effect on her unborn baby. Undetected or untreated medical conditions can increase morbidity and mortality in both the mother and the baby. The inter generational implications of women's health are illustrated dramatically by the tragic effects of the maternal use of harmful substances such as thalidomide and diethylstilbestrol. Emphasis on routine and preventive care can address psychosocial aspects of women's health and provide opportunities for counseling, health, maintenance, and early intervention. The following findings and information identify special health needs of women and factors that may influence their future health.

Findings and Recommendations

Physicians should have an increased understanding of the differences and unique qualities of women's health. Aspects of mortality and morbidity, important and common health concerns, women's patterns of seeking care, and the need for continued research should all be taken into account in developing courses for action.

Findings

  1. Women have important health needs throughout their life span.
  2. Demographic shifts will affect health trends in the United States in general and the health status of women specifically.
  3. Many women receive incomplete and poorly coordinated care for their routine and comprehensive health concerns. Barriers include inadequate health insurance, fragmented delivery of primary care services, and deficiencies in physician training.
  4. Changes in undergraduate and graduate medical education, in addition to continuing medical education, are needed to address adequately the comprehensive health needs of women.
  5. Gender inequalities and bias in research design and implementation, through exclusion or underrepresentation of women in clinical studies, have contributed to gaps in knowledge concerning women's health care and the needs of women and may lead to suboptimal care.

Recommendations

  1. Changes in physician education and training should take into account the impact of the changing demographics of the population and recognize the special needs of economically, socially, and culturally excluded populations.
  2. Institutions should take actions to ensure that women are full participants in the institutional, community, regional, and national changes that are occurring in health care. Collaborations between existing community and national health care groups and student and faculty organizations may be used to foster this goal.
  3. Physicians acting as primary care providers for women should have broad understanding of, competency in, and ongoing education about women's health.
  4. Academic health centers should evaluate systematically the knowledge base within each of the basic and clinical science disciplines to determine what is being taught concerning gender issues and how new information is being incorporated. This information should be used to help identify deficiencies in the understanding and teaching of women's health issues and to make recommendations for change.
  5. Evaluation of student performance related to women's health should include assessment criteria to identify and correct deficiencies in knowledge, clinical management, and women patients.
  6. Medical school faculties should develop clinical simulations of the health problems most critical to the comprehensive care of women in all age and racial or ethnic groups. Students should be expected to manage these simulations in accordance with a faulty-derived standard in order to receive a medical or osteopathy degree.
  7. The National Board of Medical Examiners should review its three examinations to ensure adequate assessment of competency in the knowledge and skills requisite to providing comprehensive care for women. The subsequent nationwide assessment of knowledge and problem-solving abilities would help medical educators identify the clinical simulations to be included in undergraduate medical education.
  8. The education of physicians should prepare them to recognize and respond appropriately to the effects of the changing roles of women with regard to their relationships to the medical system, patterns of acquiring health care, access to care, methods of communication, and compliance with treatment and medical advice.
  9. Accreditation bodies - the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the American Osteopathic Association - and other national organizations with major involvement in undergraduate, graduate, and continuing medical education - the Association of American Medical Colleges, the Association of American Colleges of Osteopathic Medicine, the American Medical Association, the National Board of Medical Specialties, the National Board of Medical Examiners, the Federation of State Medical Boards, and the Council of Medical Specialty Societies - should collaborate in furthering the development of educational programs that address issues of women's health at all educational levels.
  10. Continuing medical education should provide opportunities for practicing physicians to remedy any deficiencies in their knowledge and practices with respect to women's health issues.
  11. Fundamental changes that cross traditional departmental boundaries in medical school and postgraduate curricula are needed. Such changes would be facilitated by collaborative centers or programs in women's health within academic health centers.
  12. Medical schools and other teaching institutions should develop innovative approaches to medical education and training in women's health that cross traditional institutional boundaries; that facilitate the development of integrated curricula interdisciplinary research, and more responsive clinical models; and that support the development of expert faculty committed to advancing women's health at all levels.
  13. Congress should provide funding for competitive grants to support and stimulate women's health initiatives within academic institutions. The programs could include interdisciplinary educational offerings, research, health promotion and disease prevention, and patient care. Such grants should acknowledge programs on the basis of their innovation, their potential to be models for new programs, and their cost effectiveness. These initiatives would facilitate the development of more efficient and responsive clinical models, integrated curricula, and interdisciplinary research in women's health.
  14. Congress should establish academic awards in women's health. Such grants should provide support of individual faculty member for their professional development and for the implementation of innovative programs in women's health. Congress should provide funding for competitive grants to support and stimulate academic institutions' efforts at improving women's health.
  15. Interdisciplinary fellowship programs in women's health should be established to allow physicians to acquire additional skills and training in the comprehensive care of women and gender-relevant research. Although the programs would vary in emphasis and design, depending on the characteristics of participating institutions, each would have a core program that would introduce fellows to basic principles and knowledge essential to an integrated understanding of women's health and to the scientific methods used in women's health research.
  16. Current and expanded efforts to promote researching women's health should be supported.

Findings and Recommendations: Women in the Physician Workforce

Although women physicians are increasing in numbers, they are not gaining as rapidly in positions of leadership, in certain specialties, and in research opportunities. Gender bias, family responsibilities, and societal perceptions create barriers to women's progress in the medical profession. Institutions need to support the advancement of women and maintain flexible policies that will enable them to participate in activities that will foster their personal and professional development and to contribute to the practice of medicine.

Findings

  1. The projected eightfold increase between 1970 and 2010 in the number of women entering the medical profession will increasingly affect all aspects of medical education, research, and practice.
  2. Women physicians remain underrepresented among the leaders in medicine.
  3. Women physicians tend to select a relatively limited number of medical specialties as their areas of practice. The reasons for this clustering have not been fully delineated.
  4. Physician gender has little impact on workforce forecasting.
  5. Gender bias, a reflection of society's value system, remains the single greatest deterrent to women achieving their full potential in every aspect of the medical profession and is a barrier throughout the professional life cycle.

Recommendations

  1. Medical schools and academic health centers should be encouraged to stimulate interest in medical careers among talented girls through specific outreach programs, starting in the early elementary school years with increasing emphasis through high school and into the junior year in college.

  2. Medical schools, academic health centers, and professional societies for physicians should develop explicit programs of leadership development for women physicians. This should include a mentoring process for students, residents, fellows, and union faculty members.

  3. Because most institutional leadership positions are filled by men, it is critical that these male leaders take an active role in creating opportunities that groom potential future female replacements.

  4. Female physicians should receive the same compensation as male physicians for the same work. To ensure this happens, salaries should be analyzed at specific internals based on gender.

  5. Current and expanded efforts to increase the training of women and their participation in both basic and clinical medical research should be supported.

  6. Optional alternative career paths that do not foreclose tenure or advancement should be provided without pejorative labels. At a minimum, maternity and childrearing leave should be excluded form the time limits for eligibility for tenure.

  7. Eligibility and age requirements for fellowships and other positions should permit gaps in career activity associated with childbearing.

  8. A national physician workforce commission should continue to monitor the gender ratio in the physician workforce and among the leadership. The commission could be charged with setting goals and assessing progress.

  9. Implementation of workforce policies should not disproportionately restrict or otherwise impair women's access to any aspect of the medical profession.

  10. Previous COGME recommendations are not intended to limit disproportionately the opportunities for women in subspecialty care. Workforce policies aimed at decreasing the number of residency positions and increasing the proportion of residency positions in primary care should be monitored for their impact on women physicians.

  11. All medical schools, academic health centers, and residency and fellowship programs should have explicit procedures for providing education about gender bias and for assuring accountability to the principle of equal opportunity, compensation, and advancement for women.

  12. Perceptions of bias against women and their work should be minimized by instituting simple blinding mechanisms such as authorless review of scientific papers and grant applications.

  13. Medical schools, academic health centers, and residency programs must openly report cases of sexual harassment and have an explicit process for changing behavior.

  14. Educational, training, and work schedules should be flexible. women and men have personal and family responsibilities that may interfere with a rigid program Each medical and osteopathic school should examine its policies in this matter. The Liaison Committee on Medical Education and the American Osteopathic Association should consider modifying their standards to reflect the value of this accommodation to the educational accomplishments of its students and faculty. Flexibility should also be encouraged by Residency Review Committees and the Accreditation Council for Graduate Medical Education.

  15. Medical education and graduate medical education programs should have appropriate and explicit family leave policies and provide or ensure access to high-quality dependent care for physicians and other faculty, students, and staff. Academic medicine should make available less-than-full-time options and flexible work schedules to accommodate child rearing and create a model for career-long opportunities to balance the professional and personal lives of women physicians.