Much has been accomplished in women's health medical education. The curricular survey of 1995, Women's Health in the Medical School Curriculum,1 provided encouraging evidence that schools were modifying their curricula. Another survey on the presence of family violence curricula in U.S. medical schools showed an increase since 1987 in the number of schools addressing the issue, even though time spent had not increased in a decade.2 Further evidence of progress was documented in the recent American Medical Association (AMA) Resolution, Medical Education and Training in Women's Health, prepared as a Joint Report of the Council on Medical Education and the Council on Scientific Affairs, and passed by the AMA's House of Delegates in June 1999.3 In addition to recapping the progress in medical school education and in continuing professional development, the resolution summarized the actions that have been taken by Residency Review Committees (RRCs): by 1999, five of the six RRCs in the fields that conduct major medical school clerkships had added language to their guidelines to encourage residency training in topics related to women's health. (Surgery had not yet done so.)
The medical literature also contains reports of a number of efforts to include women's health in the curriculum. A brief selection demonstrates the range of these publications: Sandra Levison et al.4 recently reported on the comprehensive reforms that have been made in the problem-based curriculum at one medical school; Anna Spielvogel et al., Michelle Roberts et al., Kathleen Thomsen, and Kelly Parsey et al.5–8 have reported curricular innovations around women's health in, respectively, psychiatry, internal medicine, family medicine, and ob-gyn residencies; a domestic violence intervention across several disciplines has been reported by Dean Coonrod et al.,9 and Deborah Kwolek et al.10 have reported on a women's health update course that reaches both residents and those practicing physicians who are engaged in student education. The Centers of Excellence (CoE) in Women's Health project, under the auspices of the Office of Women's Health of the Department of Health and Human Services (DHHS), requires that all of the academic centers designated as CoEs conduct curricular revisions to address women's health.11
Professional organizations are contributing to the available literature as well. For instance, in 1995 the National Academy on Women's Health Medical Education published a resource guide for faculty,12 which is used by more than a third of U.S. medical schools; the Association of Professors of Gynecology and Obstetrics has developed core objectives for medical student education in women's health issues13 and has established a Women's Healthcare Education Office, 〈www.apgo.org〉. And the American College of Women's Health Physicians (ACWHP) is developing a Web-based concept map to guide interdisciplinary curriculum development in women's health (which was introduced at the ACWHP Annual Meeting in Washington, D.C., in June 1999).
Given this remarkable progress, why do we need this theme issue? Jordan Cohen, MD, in his November 1999 “From the President” column in Academic Medicine,14 answers this questions in both direct and more subtle ways. First, the reforms are not yet translating into equitable care for women patients15; second, and more important, leaders of educational organizations fail to consciously recognize deficiencies related to women's health the first time through, as Dr. Cohen himself admits to doing. It is critical that leaders who can influence curricular reform take ownership of the process of introducing women's health information into our nation's medical education.
LEADERSHIP OF CURRICULAR REFORM
To date, most of the progress reported in the literature in women's health medical education has been led by women faculty. Functioning as individual proponents, where they hold leadership roles (and this is still a disturbingly rare phenomenon),16,17 they can, if they are interested in women's health medical education themselves, ensure appropriate adjustments. Some of the major curricular reforms in women's health that have been reported to date4 have relied on the happenstance of senior female leadership, but in many cases women's health curricular changes are led by junior women who might be able to influence only portions of the curriculum. Outside the medical schools, but within the medical “establishment,” the creation of support structures such as the Special Interest Group on Interdisciplinary Women's Health Education at the Association of American Medical Colleges (AAMC) is spearheaded predominantly by women. In contrast, the mainstream leadership of medical schools and the supplementary mechanisms for influencing curricular change (examinations designed by the National Board of Medical Examiners; accreditation standards promoted by Liaison Council on Medical Education; the professional focus of AAMC) remains overwhelmingly in the hands of men. The incorporation of women's health into the medical curriculum should and would be most efficiently advanced by the intervention of this current leadership, regardless of gender.
How can the leadership of medicine be persuaded to adopt women's health educational reform as it has, for instance, adopted ethics and professionalism as educational imperatives? Articulating such a clear, compelling case for women's health is, of course, only a first step on the path to sustainable change. The transition of curricular responsibility from individual proponent to mainstream process takes time, as we know, but for women's health it seems to be slower than for new scientific information in other fields. We can speculate on the reasons for this, and gender bias is frequently proposed as an explanation. Other possibilities are that the field embraces notions uncomfortable for biomedical scientists (e.g., teaching holistic care as well as reductionist science),18 or that there is personal and academic discomfort with sex and gender differences. Furthermore, women's health also holds out a new imperative—patient-centeredness,19 and the incorporation of patients' views on what research, care strategies, and expected outcomes should be considered. While this is congruent with new definitions of physicians' roles described by the Educating Future Physicians for Ontario (EFPO) project and the AAMC's Medical School Objectives Project (MSOP),20 this notion is not yet widely tried in medical education. Finally, of course, the “competition” for curricular time is fearsome: the results and possibilities of the genome project; breakthroughs in cancer research, tissue engineering, in-vitro fertilization, and cloning, etc. Sex- and gender-based science, with its emphasis on discovering variants to what is already thought to be known, by comparison may not seem “sexy” enough to provoke excitement among medical educators unfamiliar with the content. The potential importance of this topic for future biomedical technology may not be immediately obvious to them.
In fact, however, the underlying resistance to incorporating sex- and gender-based science into the curriculum may be that we are nearing saturation in the current structure of medical education. The time is upon us that we must transform our curricula to use, as Gunderman proposes,18 both reductive isolation (perhaps by making the knowledge we are developing about women's health accessible, in accurately searchable literature databases, to both trainees and practitioners as they identify their learning needs) and ascending interrelations (when medical education provides a theoretical framework that lets us see health and disease in “the larger, more complex reality of the patient”).
CHANGE IN MEDICAL EDUCATION
In the medical literature, two important processes of curricular reform are frequently described: integration and interdisciplinary collaboration. Integration enjoys many definitions. They range from “vertical” integration of basic and clinical sciences21 to the “horizontal” integration of multiple specialty perspectives,22–24 or both simultaneously.25 The goal to integrate biopsychosocial content26 has driven a variety of curriculum reform efforts, as has the desire to introduce approaches to population health.25,27 Nelson et al.,28 in considering women's health, see integration as a subtle variety of the “add and/or substitute” approaches that pit faculty proponents against one another on curricular committees. Conversely, Levison et al.4 see integration of women's health as a way to assure that all faculty take responsibility for championing the inclusion of sex- and gender-based science wherever they teach.
Interdisciplinary curricular reform also takes on many shades of meaning in medical academia. The most obvious is the inclusion of multiple different medical disciplines in curricular planning efforts (i.e., committees).29 When disciplines other than medicine, such as nursing and social work, are included in a teaching team, the team is called interdisciplinary.25 Interdisciplinary goals can also drive student assessment.21 Less frequently, the lay or patient perspective is incorporated into planning, conducting, and evaluating medical student education; we see descriptions of addressing patients' views in health care delivery19 and research,30 but not in curricular design.
There is also a substantial medical literature on curricular transformation. Gunderman18 and Iserson31 both see the need for totally new approaches. Papa has described the reform movements that have addressed medical curriculum transformation in the past two centuries,32 and Maudsley20 points out that most have been efforts to bring medical education into congruence with society.
In this theme issue we contemplate women's health as a catalyst—first for reforming existing medical curricula, and then for larger curricular transformation, which can result only from systemic changes. We emphasize strategies that can be used to tackle these challenges. It is not the purpose of the collection to provide a litany of what “needs to be taught,” since there are now numerous resources available for faculty to adapt to their teaching responsibilities.12,13 Rather, this collection first examines the processes of curricular revision in medical education, and how they apply to and can be informed by women's health, and then examines women's health medical education in the context of science and the health care system.
WOMEN'S HEALTH AS A CATALYST FOR CURRICULAR REFORM
Both integration and interdisciplinary collaboration are important strategies for incorporating sex- and gender-based science into medical education, and the first set of papers describes strategies for addressing the potential “restraining forces.” While each paper is specific to women's health, each also describes models with general applicability to other curricular reform initiatives.
- Within a single discipline, but integrating perspectives from different points on the vertical spectrum—an activist student and a clerkship director—Nicolette and Jacobs describe the revision of an internal medicine clerkship without school-wide curricular transformation. This article gives a reality-based nod to the fact that most schools will not undertake massive curricular changes at the cutting edge of teaching/learning theory. Ross et al.26 have suggested that while smaller schools with missions focused on service and education can be expected to attempt wholesale curricular reform, larger schools with comprehensive teaching-research-service missions are more likely to address reform with a piecemeal approach, course-by-course, as these authors did.
- For schools undertaking more extensive reforms involving integration and interdisciplinary strategies across the undergraduate curriculum, Magrane and her interdisciplinary authorship team describe a range of possible approaches to introducing a comprehensive, lifespan approach to women's health for the clinical clerkships. Freestanding electives, delegated models, and new interdisciplinary curricula illustrate the possible options.
- Cultural variation is as relevant to women's as to men's health. There are significant cultural, ethnic, and racial factors that require inclusion in sex- and gender-informed science, to maintain a lens that sees variation instead of difference from some old or new “norm.” Considering the increasingly diverse population served by our health care system, it is crucial that clinicians of today and tomorrow develop cultural competence,19 and that medical education and the evaluation of student accomplishment be enhanced accordingly.33 Núñez describes methods for expanding women's health teaching to promote our students' cultural efficacy. Her article also explores the incorporation of a comprehensive approach to measuring competence by adding self-awareness evaluation to the usual complement of reported assessment strategies.34,35
One could be forgiven for feeling, at this point, that the integration of culturally appropriate sex- and gender-related information into an already overcrowded medical curriculum is more than can reasonably be expected of busy faculty. We have therefore included a group of articles that describe tools for making the task easier: using case-based strategies and/or concept mapping; adapting curricular resources prepared by outside individuals or organizations; and engaging in focused faculty development strategies to help overcome the special restraining forces associated with the sex- and gender-related sciences.
- Case-based teaching has been prominently featured in many curricular reform efforts, and its value in developing diagnostic competence has been documented.36 It is also the fundamental strategy that will facilitate the simulation-based learning Iserson predicts will dominate future medical education in this country.31 Weiss and Levison describe how designing and revising cases for case-based teaching provides opportunities to integrate sex-based biology and gender-based science into complex clinical scenarios, and present concept mapping as an alternative way to develop learning objectives that “reveal the structure of knowledge within and between the various disciplines.”37
- In recent years we have seen increasing numbers of curriculum guides, made available by professional organizations, medical schools, and lay activists. Although most faculty have traditionally developed their curricula “from scratch,” these teaching aids, which students can also use as tools for self-directed learning, are one approach to addressing the educational time crunch referred to earlier.38 Krasnoff next evaluates a number of available curriculum resources that faculty could use to facilitate the integration of women's health into their teaching, or use to develop customized stand-alone courses. She focuses on a number of topics that have not been widely addressed in the medical curriculum to date.39
- Faculty need to have access to the emerging women's health information (so that they know what needs to be taught) and they also need to build and maintain collaborations29 and the appropriate skills to develop and teach curricula and to model clinical competencies. Patterson Neely et al. describe an innovative group process that adds feminist learning theory and conflict management theory to more traditional faculty development design, and that has succeeded in producing faculty with the competence to teach and advance the interdisciplinary field of women's health, in this case for a residency training program. While the group process is intricate and more complex than that usually engaged in by groups of medical faculty, the description offers insights that others might use to facilitate the development of collaborative faculty behaviors.
WOMEN'S HEALTH AS A CATALYST FOR CURRICULAR TRANSFORMATION
In the next section of this theme issue we consider the more global perspective of curricular transformation. Should medicine, perhaps through the sex- and gender-based sciences, undergo a more complete scientific transformation, bringing it into line with reforms in other fields that have embraced complexity science? Should we be more responsive to the health care environment in our medical curricula?
- Many other fields have embraced the science of complexity, described in 1992 by M. Michael Waldrop in Complexity. The Emerging Science at the Edge of Order and Chaos.40 In the same book, University of Michigan economist John H. Holland, a major contributor to work in complexity science, includes biological systems such as the immune system, the brain, and developing embryos along with the economy, ecologies, and social systems, as examples of “complex adaptive systems.” This new approach involves a “systems unit” of inquiry that supplants the unit used by the reductionist sciences—the “smallest unit” that is part of a whole. Berkeley economist Brain W. Arthur states that “The crucial sight was insight, the ability to see connection.”40 In this issue, Hoffman proposes that if we were to embrace complexity theory as the underpinning for sex- and gender-based sciences, we could teach principles that empower students' critical thinking and clinical decision making,41 not just rote learning of an ever-increasing list of facts that are hard to link across disciplinary boundaries. As such, it would be a model for the rest of medicine and medical education.
- The health care environment is a continually evolving setting against which medical education proceeds. We must train our graduates to function in the world of managed care,42,43 with business skills, respect for evidence-based medicine, and the ability to comprehend and manage the tools of the information age. But most important, for women's health care to be comprehensive and effective, and for us to be able to achieve medicine's manifest accountability to society, our graduates must be competent to care for women in an increasingly challenging health care delivery system, and to deliver the health outcomes society is more vigorously demanding. Weisman's article describes the growing number of insurance/safety-net dilemmas that disproportionately affect women, and a number of efforts under way to measure and/or develop valid metrics for women's comprehensive health care outcomes. She also speculates on what this will mean for future medical curricula.
Women make up more than half of the population, and women's health—the science that elucidates sex and gender differences in health and disease—needs increased integration into the medical curriculum. But it should not be viewed as yet another supplicant to the largesse of curricular reformers. Its specific models, some described in this theme issue, are generalizable to other fields, and are useable by those leading major curriculum reform efforts as well as by individual faculty proponents. Women's health makes the case for and provides the tools and impetus for the much-needed curriculum transformation that Iserson predicts31 will occur as we move into the Information Age, with simulation-based learning and competency assessment. It also reminds us that overcoming resistance to change is as important as making a compelling case in moving forward. Most important, women's health aligns medicine and medical education with the current directions of science, science education, and social accountability.
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A New and Wider View—Women's Health as a Catalyst for Reform of Medical Education