Haskell, Sally G. MD; Reisman, Anna B. MD
During the 1990s, medical school and residency educators became increasingly aware of the need for improvements in women's health education.1–3 This focus on women's health education brought attention to the need to monitor the numbers of male and female patients that residents encounter during their training. With this need in mind, the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) now requires that an internal medicine resident's patient panel be at least 25% women in the ambulatory clinic setting.4 Similar ACGME requirements for residents in other specialties have also been made.
These requirements pose specific difficulties for residency programs that use Department of Veterans Affairs (VA) hospitals for training sites, because the traditional VA outpatient panel is composed primarily of men. Nationwide, the VA has formal affiliations with 107 of the nation's 125 medical schools and funds more than 8,900 residency positions. Approximately one-third of all resident physicians in the United States receive training in the VA health care system every year.5 In particular, the expanding role of outpatient education in traditional internal medicine residency programs has made VA hospital clinics even more important sites for medical education. Because of the VA's important role in internal medicine residents’ outpatient education, lack of an adequate gender mix in the VA health care system has had a significant impact on medical training, in both the outpatient and inpatient sectors.
Residency programs that utilize VA hospitals for outpatient training are now being challenged to make creative changes to accommodate the need for improved women's health education. In 1992 the VA began encouraging the development of specialized women's health programs to address the disparities in health care for female veterans,6 and a majority of VA sites have now established women's health centers.7 Located in private settings within most hospitals, VA women's health centers provide primary care to female veterans, including gender-specific care such as Pap smears and breast examinations. These centers have been associated with higher patient satisfaction than traditional primary care clinics within the VA system.8 VA women's health centers also represent an important educational opportunity for residents.9 Trainees are supervised by attendings with a special interest in women's health and have exposure to specialists in women's health areas.
In 1997 VA Connecticut Healthcare System, a VA hospital in West Haven, Connecticut, opened a women's health center. Internal medicine residents from Yale University School of Medicine were integrated into the women's health center program, but female patients still represented a minority of the primary care population, with only 200–300 female patients initially enrolled in a patient population of over 15,000 men. Because of the requirement that a resident's primary care patient panel (the number of patients assigned to that resident for longitudinal care) be at least 25% women, and to meet the educational goals of our internal medicine residency at Yale, we (the authors) sought to not only incorporate the medical residents into the women's health center, but to increase the numbers of women seeking primary care in that center. To that end, we designed the “Sharing Program” in 2001 that enabled the VA Women's Health Center to provide care to wives of male veterans who were also enrolled in primary care at our facility. Since over 15,000 men receive primary care in VA Connecticut, we hypothesized that there would be sufficient interest in such a program to substantially increase the numbers of patients in the women's health center and thereby improve the educational experience of our internal medicine residents in the primary care of women.
The purpose of the project described in this article was to document the number of patients followed by residents before and after the implementation of the Sharing Program and to measure patients’ and residents’ satisfaction with the program.
The “Sharing Program”
The Yale Internal Medicine residency program has 98 residents who receive training in three hospitals, including Yale–New Haven Hospital, VA Connecticut (West Haven), and Waterbury Hospital. The medical residents attend a longitudinal ambulatory clinic one afternoon each week. Approximately half of the residents have their clinic in the university's primary care center and the other half are based at the VA. At the VA, the resident clinic is based in the primary care center. This is a large, newly renovated clinic area that is separated into two firms (i.e., practices), provides care to over 15,000 patients, and is staffed by 18 internal medicine faculty members. The residents are each assigned a panel of patients for whom they provide primary care over the course of their three-year residency. Each resident is expected to develop a panel size of at least 50 primary care patients. Most patients are seen approximately two to four times each year. Residents see three to six patients (three new patients or six return visits) one afternoon each week and are precepted by one of the general internal medicine faculty.
To increase the number of women assigned to each resident, we modified the clinic schedule at the VA, beginning in 1997, so that each resident had a clinic in the women's health area, instead of in primary care, every fourth week. The VA Women's Health Center is located in a separate building from the primary care clinic area. It was renovated to provide an area for women veterans to receive their care in a private, comfortable environment. The women's health center is open 40 hours per week to provide primary care and gynecologic care to women veterans. Each resident is assigned to the women's health center one afternoon each month. During that time, the residents are assigned female patients for whom they provide primary care, including gender-specific care such as breast examinations and Pap smears. These sessions are precepted by internal medicine faculty with a special interest in women's health. As in the primary care clinic, the residents generally see between three and six patients each session. Residents are expected to achieve panel sizes of approximately 50 primary care patients and 20 women's health patients, presuming that each patient would be seen several times each year.
Although the inclusion of the monthly women's clinic sessions increased the number of female patients seen by the residents, the goal that at least 25% of each resident's panel be women was not yet attained by 2001. In 2001 the Sharing Program, to increase the number of female patients enrolled in the VA Women's Health Center, was proposed and subsequently approved by our university's Department of Medicine. The program created a way for wives of veterans, not usually eligible for VA health care benefits, to be able to receive primary care at the VA Women's Health Center. In this program, the wives of veterans who have either Medicare or any private insurance are seen in the center by internal medicine residents, supervised by VA staff physicians (who are also university faculty members). The patients are registered by computer into the University Medical Group billing and scheduling system and, for those patients, the VA Women's Health Center functions as a satellite clinic of the University Medical Group. The VA bills the university Department of Medicine on a per-visit basis for the “cost” to provide care to each patient. The University Medical Group collects from the patients and their insurance and then reimburses the VA through the collections received. Patients in the Sharing Program receive primary care, gynecologic screening, and basic laboratory services at the VA, but specialty consultations and radiographic studies must be done at the university or at other non-VA facilities. These non-VA services are billed directly to the patient's insurance. Prescriptions are filled at non-VA pharmacies at the patient's expense, or under provision of their health insurance plans, rather than at the VA pharmacy.
Assessing the Program’s Value
Surveying the Patients and Residents
In order to evaluate the value of the Sharing Program after one year, the proportion of female patients assigned to residents in 2001 (before the development of the Sharing Program) was compared to the proportion of female patients assigned to residents in 2002. In addition, questionnaires were developed to assess both patients’ and residents’ satisfaction with the program.
Patient satisfaction questionnaires were mailed to all patients who had an office visit in the Sharing Program within the first year. Patients who did not return the questionnaire received a second mailing, and those who did not return the questionnaire then were telephoned by the administrative assistant at the women's health center and asked if they would be willing to complete the questionnaire by phone. All questionnaires were completed anonymously.
The patient satisfaction questionnaire was designed to provide information that would be helpful in continuing to recruit veteran's wives, and in maintaining a viable program with high levels of patient satisfaction. Information was collected to determine how patients learned about the Sharing Program; why they chose it; whether they were satisfied with the facility, the physicians, and the care they received; whether they had an objection to receiving care from a medical resident; and whether they planned to continue their care at the VA Women's Health Center.
Resident satisfaction questionnaires were distributed to junior and senior residents to ensure that the respondents would have had at least one year's experience with the Sharing Program. The self-administered survey instrument was designed to enable residents to rate their satisfaction with caring for wives of veterans in the women's health center and to evaluate the effect of the Sharing Program on their learning experience. The residents were asked to indicate whether they felt the center provided a good atmosphere for learning the primary care of women, whether their female-patient panels had grown significantly, whether they were getting improved experience in the outpatient care of women, and whether they felt the Sharing Program had improved their learning experience in women's health.
This project was approved by the Human Investigation Committee of the VA Connecticut Health care System.
What the Surveys Revealed
After one year, 150 nonveterans had enrolled in the Sharing Program. The number of female patients assigned to resident panels increased significantly from 2001–2002. In 2002 the mean proportion of female patients assigned to residents had reached 25%.
Results of the patient satisfaction survey.
At the time of the patient satisfaction survey, 70 of the 150 patients enrolled in the Sharing Program had completed their appointments in the Women's Health Center. Of these 70, 61 were able to be contacted by mail or by phone. Fifty-five (79% of those who had completed their appointments) agreed to participate in the survey.
Fifty-one of the 55 respondents (93%) rated the VA facility to be as nice or nicer than a private doctors office. Most (greater than 90%) rated the physicians thorough, or very thorough, and knowledgeable. Fifty respondents (91%) rated the quality of care they received to be as good or better than at a private doctor's office. Forty-two respondents (76%) clearly understood they were being cared for by residents, and most had no objection to be cared for by a resident–attending team.
Thirty-seven of the patients surveyed (67%) indicated that they would continue to receive their care through the Sharing Program. The most common reasons cited for discontinuing the program included learning that they would not receive their medications through the VA pharmacy at a discounted rate, and learning that they would be billed for their care.
Results of the resident satisfaction survey.
All 28 residents involved completed the survey. Twenty-five residents (89%) felt that the women's health center provided a good atmosphere for learning the primary care of women. Nineteen residents (68%) agreed that their patient panels had grown significantly over the last year. Twenty-six residents (93%) rated their educational experience in the outpatient care of women as improved. Seventeen residents (61%) felt that the Sharing Program, specifically, had improved their learning experience in women's health.
Pros and Cons of the Program
The Sharing Program was designed (1) so that veteran's wives could be seen in the VA Women's Health Center, (2) because the center was considered an underutilized area within the VA system, and (3) because the university's residency program needed to increase the number of female patients seen by residents in the VA clinics. These last two factors prompted the VA and the university's Department of Medicine to work together to develop a contract that allowed nonveterans to be seen at the VA Women's Health Center.
At the time the questionnaires described earlier had been completed in 2002, there were 150 new Sharing Program patients in the Women's Health Center, and most residents had reached the goal of at least twenty five percent of female patients in their panels. This achievement has been particularly important for our residency program. Failure to achieve this goal would have prompted alternative solutions to the “gender” problem within the VA clinic, and might have resulted in the withdrawal of our residency program from the VA clinic, or, at minimum, would have created a more cumbersome system in which residents would have had to see female patients at an alternative location.
The results of our survey demonstrate a high level of patient satisfaction. The majority of the patients in the program rated the physicians highly and stated that they would continue to receive their care at the VA. Most of those who stated they would not continue with the program had misunderstood the program design and thought that either free care or free medication would be available. Improved education and orientation for new Sharing Program patients has since resulted in a significantly lower attrition rate.
The resident satisfaction surveys showed that most residents perceived an improvement in their education in the outpatient care of women since the inception of the Sharing Program.
There are several limitations to the Sharing Program and its evaluation. First, the number of wives of veterans interested in such a program has been relatively small compared with the number of male veterans in primary care. It was initially hypothesized that the convenience of a husband and wife's having an appointment on the same day would encourage a greater participation rate, but that was not the case. The influx of 150 new patients has brought the mean percentage of women patients assigned to residents to the 25% goal, but some resident panels remain below the 25% goal. Increased publicity may improve recruitment of new patients.
Second, data on improvement in resident education is based on resident self-report, rather than objective measurement of knowledge relating to women's health. Further studies should include objective measurements of residents’ skills in women's health care.
Because of the increased emphasis on outpatient education in internal medicine and other specialties, adequate training in the care of women in the outpatient setting has become of paramount importance. Other residency programs with VA affiliations may consider implementing similar systems to increase the numbers of female patients followed longitudinally by their residents.