Despite considerable attention to women's health over the past decade, it is uncertain what progress has been made in integrating women's health and sex- and gender-specific content into medical school curricula. A review of the findings of published surveys that tracked women's health curriculum activities in U.S. medical schools between 1994 and 2001 concluded that progress has been slow at best.1 To obtain additional information, we used data from the Curriculum Management and Information Tool (CurrMIT), managed by the Association of American Medical Colleges (AAMC).2 Our purpose was to provide a current estimate of the extent to which selected women's health and sex- and gender-specific information is integrated into U.S. medical school curricula, assess progress made by schools over the past ten years in the inclusion of this content, and assess the relationship between selected institutional characteristics and the inclusion of women's health and gender-specific topics in schools' curricula.
In 1994 and 1995 the AAMC, in collaboration with the Office of Research on Women's Health at the National Institutes of Health and other government agencies, conducted the first comprehensive survey of the women's health content of medical school curricula.3 In the first phase of this mailed questionnaire, conducted in 1994, school administrators of all medical schools in the United States were asked if they had a core curriculum on women's health that was taught across basic science and/or clinical departments. One hundred and seven of the 126 schools responded to the survey, for a response rate of 85%; of these schools, 18 (17%) reported that they had implemented such a curriculum. These curricula were limited to a single course or seminar focusing on a specific topic, such as domestic violence, or were the didactic component of an existing clerkship or clinical elective. Schools were also asked if they offered clinical rotations in women's health that were separate from traditional obstetrics–gynecology clerkships; one fourth of responding schools indicated that they offered such a rotation.
In the second phase of the survey, conducted in 1995, schools were asked whether certain topics—selected to represent the knowledge base, skills, attitudes, and behaviors students need to provide comprehensive care to women—were included in their curricula. Seventy-eight of the 126 schools responded (62%). Between 94% and 100% of the 78 schools reported that they included information related to sexual and reproductive function, and to medical interviewing and examination skills and tests specific to women. A smaller proportion included gender-specific information on leading causes of death in women and on medical disorders that disproportionately affect women.
Of three subsequent surveys conducted between 1999 and 2002 (independent of the AAMC collaboration),4–6 one showed a doubling in the number of schools that reported having a women's health curriculum,4 while two others found no change in the number of schools with a clinical elective/rotation.5,6 Many of the schools represented in these surveys had U.S. Department of Health and Human Services funded National Centers of Excellence (CoEs) in Women's Health that are required under their federal contract to develop women's health curriculum models.7
Curriculum Management and Information Tool (CurrMIT)
We took a different approach than that used in previous surveys. Instead of using questionnaires, we extracted data from CurrMIT, a centralized medical school curriculum database made available online in 1999 by the Division of Medical Education at the AAMC.2 CurrMIT is a Web-based program used primarily by medical schools to monitor and manage their curricula. In addition to supporting curriculum management at individual institutions, schools use CurrMIT to respond to surveys, provide information for annual Liaison Committee on Medical Education (LCME) questionnaires, and prepare for LCME accreditation.2 For example, schools are asked yearly by the LCME whether they teach a list of particularly important and timely topics, referred to as “hot topics.”
CurrMIT contains curriculum information on required courses and clerkships, sessions taught within courses and clerkships, and course “elements,” which include the detailed content of courses and sessions as well as details of instruction.2 As of June 2004, CurrMIT contained data entries on more than 18,560 courses or clerkships in U.S. schools, more than 155,822 sessions, and more than 527,702 elements that are linked to specific courses and sessions.
We searched the CurrMIT database to identity interdisciplinary women's health courses or clerkships, or sessions within any course/clerkship, that had a women's health or gender-specific focus. We also searched all curriculum entries for a specified list of 18 topics (see Table 1), as well as gender-specific information on any topic.
Women's health courses/clerkships.
Between November 2003 and February 2004, 95 of the 126 medical schools (and one preclinical school) had entered data in CurrMIT on required courses/clerkships; these schools constituted our study sample. Using an Existing Reports option in CurrMIT that was customized for us by CurrMIT staff, we searched the curricula of these schools to identify courses or clerkships with an interdisciplinary women's health focus, or a gender-specific focus separate from traditional ob–gyn offerings. We then contacted the directors of these courses/clerkships and spoke to them or their designee by phone to learn more about the content of the course or clerkship and the faculty who taught or oversaw it. Courses/clerkships were designated as a women's health course if they offered a multi- or interdisciplinary didactic approach or clinical experience, included faculty from more than one discipline, included substantial content outside the reproductive tract, emphasized women's health issues across the lifespan, or focused on issues that have special relevance to women patients and physicians. Courses were not included if they were primarily traditional ob–gyn courses or clerkships.
Women's health and gender-specific sessions.
We used the same search strategy to identify separate course sessions that had a women's health or gender-specific focus outside traditional ob–gyn teaching. Their designation as a women's health or gender-specific session was based solely on information entered in CurrMIT.
Sixty of the 95 schools had entered 100 or more sessions in CurrMIT, an indication that there was a reasonable depth of information to enable us to draw conclusions about focused areas of the curricula. Curriculum information from this subset of 60 schools constituted the study sample for the rest of the study. (The number of sessions listed by each of the 60 schools ranged from 136 to 6,622, with a mean of 2,185 [SD ± 1,749] and a median of 1,577.) Research assistants searched the curricula of the 60 schools to identify the 18 topics that we specified, as well as gender-specific information on any topic. The 18 specified topics included topics that were reported least likely to be taught in the 1995 AAMC curriculum survey, as well as other topics important to women's health. Many were current LCME “hot topics.” Several topics that were not unique to women were selected because they addressed important aspects of women's health, such as the diversity of women and their health needs over the lifespan. We did not include topics that virtually all schools reported that they taught in the 1995 AAMC survey (i.e., most topics on sexual and reproductive function, medical interviewing and examination skills, and diagnostic tests specific to women). Exploratory searches helped define a set of search terms that captured the words or phrases used by schools to describe the 18 topics (Table 1). To identify gender-specific topics, the research assistants used the search terms women, gender, sex, and female to identify any entry where these terms were used alone, in a phrase, such as “women's health,” or in association with other curriculum content, such as “women and heart disease” or “sex and gender differences in pharmacology.”
The research assistants used the Quick Search option in CurrMIT to search for these terms. Quick Search allowed them to search for each term through all courses and sessions and for all elements linked to courses and sessions at each school within graduating class years 2004 to 2007. Data extraction using Quick Search was conducted during a four-month period from November 2003 through February 2004.
We then entered information extracted from CurrMIT by school into an Excel database, including school name; search term identified; graduating class year in which the term was taught; course name, session name, and element associated with the term; and, if available, position of the course in the curriculum, academic period taught, disciplines involved, class format, and methods of assessment. Course/session objectives, notes, or descriptions were entered into a free text column. (We excluded the content of some LCME-required basic science and clinical courses, such as topics related to normal/abnormal physiology, embryology or development, and traditional ob–gyn topics taught by all schools, unless the topics were in the search term list.)
To derive the gender-specific topics, we listed alphabetically all curriculum entries with gender-specific content, identified by the search terms women, gender, sex, and female, and then condensed this list to form 24 topics (see Figure 1 below). For example, the topic gender differences in heart disease contains CurrMIT entries with the terms “myocardial infarction,” “angina,” “cardiovascular,” “heart,” or “vascular” linked to the terms “women,” “gender,” “sex,” or “female.” These 24 gender-specific topics were added to the 18 specified topics, for a total of 42 topics.
We calculated the distribution of the total number of topic entries listed by the 60 schools and their position in the curriculum. (If a topic was taught in different courses or in different sessions of a course within a school, it was counted each time it was listed.) We also determined the number of unique topics taught at each school. We evaluated selected school characteristics for their bivariate relationship to the number of unique topics taught, using the t-test to compare differences between means. SAS version 9.1 statistical software (SAS Institute, Inc., Cary, NC) was used for all analyses. To adjust for the amount of information entered in CurrMIT, we calculated the weighted number of topics as the number of unique topics listed by each school divided by the total number of sessions entered by that school. School characteristics included the school's geographic location, public or private status, designation as a National CoE in Women's Health, presence of a female medical school dean, and proportion of tenured women on the faculty. (We coded geographic region for the Northeastern, Southern, Central, and Western United States, using four dummy indicator variables.) We then examined the relationship between these characteristics and the number of unique topics taught in bivariate analysis and by considering all features in a stepwise regression model. We repeated these calculations in a weighted analysis using log-transformed data.
Women's health courses
Among the 95 of 126 U.S. medical schools that had entered data on courses/clerkships in CurrMIT, ten courses offered by nine schools warranted a designation as a women's health course. Six were interdisciplinary elective or selective clinical rotations offered during the third or fourth academic years; two were required ob–gyn courses taught in the second or third academic years that included prominent interdisciplinary content in the areas of domestic violence, psychosocial issues, and preventive care; and two were elective courses offered during the first two academic years by departments of family medicine and community health, respectively. Although the directors of the ten courses were from departments of family medicine, internal medicine, ob–gyn, and community medicine, faculty from many other disciplines participated (diagnostic imaging, geriatrics, neurology, pathology, pediatrics, psychiatry, public health, nursing, sports medicine, and surgery). Except for required courses, enrollment was limited to a small number of students, both men and women; however, most enrollees were women.
Women's health and gender-specific sessions
An additional 23 schools offered 36 course sessions that had a women's health focus separate from traditional ob–gyn topics, and 13 schools offered 19 sessions with a gender-specific focus. The session titles were wide-ranging, including “drug responses in women,” “the evaluation of abdominal pain in women,” “bone mineral density testing in women,” and “gender differences in mental health.” Two schools offered individual sessions devoted to the National Institutes of Health-sponsored Women's Health Initiative clinical trial.
We based the analyses in this section on data from the subset of 60 schools with 100 or more session entries in CurrMIT. Many of the 42 topics listed by these 60 schools were taught in more than one session or course, or in more than one academic year, for a total of 1,954 topic entries. Seventy-four percent of all topic entries were taught during the first two academic years, and 23% were taught in the third year; only 3% were taught in the fourth year or later. Not all schools had curriculum entries for all four graduating years included in the study (78% of the schools had entered data for three or more graduating years.)
The number of unique topics taught by each of the 60 schools ranged from zero to 26 with a mean of 11 (i.e., no school listed more than 26 of the 42 topics). Four schools listed none of the topics.
Figure 2 shows the proportion of schools that listed each of the 18 specified topics at least once in their curriculum entries. More than 50% of schools included information on 11 of the 18 topics. In contrast, for each of the 24 gender-specific topics shown in Figure 1, fewer than 30% of schools included data on that topic in their curriculum entries. These topics included gender-specific information on disorders that affect both women and men for which there are gender differences that are especially important for women, such as cardiovascular disease, mental health disorders, HIV infection, and substance abuse. While many of the topics listed by the highest proportion of schools were also taught across the greatest number of academic years, most topics on gender differences were taught during only one academic year (data not shown).
Many factors may influence the curriculum content of schools or their use of CurrMIT, including geographic location, private or public status, designation as a CoE in Women's Health, presence of a female dean, and proportion of women on the tenured faculty. We compared these characteristics of schools with 100 or more session entries in CurrMIT to those of schools with fewer that 100 entries (see Table 2). Of the schools that entered 100 or more sessions into CurrMIT, ten (17%) were designated CoEs, accounting for half of the 19 CoEs (52%) existing at the time of the study. Compared to schools with fewer than 100 entries, schools with 100 or more session entries were significantly less likely to be privately funded.
We then compared the mean number of unique topics listed by each school with 100 or more session entries according to schools' characteristics. In bivariate analysis, the mean number of topics listed was marginally significantly lower in Northeastern schools compared to schools in other regions (see Table 3). When we entered the schools' characteristics into a logistical regression model, the mean number of topics listed was lower in Northeastern schools, and, after controlling for that region, inversely proportional to the number of women on the tenured faculty; however, only the Northeastern region was statistically significant at a p value of less than .05.
We repeated the analysis based on the number of unique topics listed as a proportion of the number of sessions entered (weighted analysis). The distribution of weighted topics ranged from 0% to 15%, with a mean of 1% (data not shown). Because the distribution was skewed, we used log-transformed data in the analysis. We then back-transformed the means to their original units (Table 3). Although there was no statistically significant association between schools' characteristics and mean weighted topics in the bivariate analysis, both a CoE designation and the presence of a female dean were selected in the regression model, although only a CoE designation was statistically significant.
Our findings from this analysis of the curriculum content of U.S. medical schools suggest that progress toward integrating women's health and gender-specific content into medical school curricula has been uneven. Interdisciplinary women's health courses or clerkships can facilitate the development of comprehensive women's health curricula and provide a mechanism to address expanded core competencies in this area8; however, very few schools in this study (nine of the 95 schools that had entered courses/clerkships in CurrMIT) offered an interdisciplinary women's health didactic or clinical learning experience. This number is markedly lower than both the 27 schools listed in the 1994 AAMC survey results3 and the 30 schools in a 2002 study6 that reported that they offered such rotations. Although the number of schools that responded to these surveys varied, the disparity is most likely due to the specific criteria we used, which excluded many traditional ob–gyn clerkships. While many of these traditional course/clerkships included non-reproductive-tract topics, few offered an integrated approach to a broad range of women's health issues over the lifespan.
In contrast to the small number of schools in our study that offered interdisciplinary women's health courses/clerkships, considerably more schools (23) listed sessions with a nonreproductive women's health focus, and 13 schools listed sessions with a gender-specific focus. There was little overlap between schools that listed each type of session, or a pattern across schools, to suggest an overall curricular approach to integrating this information. We cannot make assumptions about the curriculum approach of individual schools based solely on the data extracted from CurrMIT, however, and it is possible that a coordinated effort exists at some schools.
There was a definite pattern to the extent to which selected women's health topics and gender-specific information were integrated into schools' curricula. According to the information provided by the subset of 60 schools with 100 or more session entries in CurrMIT, more than half of the 18 topics that we targeted, particularly if they were LCME “hot topics,” were taught by more than 50% of schools. In contrast, for each of the 24 gender-specific topics that we identified, fewer than 30% of schools included information on that topic in their curriculum. A similar trend was reported in the 1995 AAMC survey.3
Those topics listed by the highest proportion of schools in our study were also taught across the greatest number of academic years, which may represent an attempt by schools to reinforce knowledge at different stages of learning, or, with respect to “hot topics,” to prepare for LCME questionnaires and accreditation. In addition to the importance placed on “hot topics” by the LCME, the impetus to address these subjects comes from student advocacy groups, professional organizations with special interest in certain topics, and highly publicized new research findings on topics such as menopause. Our findings suggest, however, that schools do not place equal emphasis on important new data in other areas such as gender differences in cardiovascular disease and in HIV infection, or information on sexual harassment and discrimination, gender-equity issues that adversely affect the health and well-being of women, including women medical students.9
The apparent slow integration of gender-specific information into schools' curricula may be due to a lack of awareness of data on gender differences, the lesser importance generally placed on this information, or the difficulties schools face in adding new information to already overloaded curricula. Data on important sex and gender differences are now available through many sources,10–13 and curriculum models are being developed to help schools incorporate this content.13–19 However, any curriculum change is both difficult and slow and requires leadership and support; senior faculty or administrative leaders and designated women's health programs or centers may facilitate this process.20 When we examined these and selected other school features, a designation as a CoE and the presence of a female medical school dean were both positively associated in a regression model with the mean number of topics taught that were reported in CurrMIT (weighted analysis), although only a CoE designation was statistically significant. This finding should be interpreted cautiously because it was significant only in the regression model. CoE-designated schools may also be more likely to enter this content in CurrMIT.
There are other limitations to using data from CurrMIT, the most important being the completeness and accuracy of information provided by schools, which may vary depending on a school's stage of data entry, the source of information entered (i.e., by student assistants, by course directors), the amount of detail included, and the content a school chooses to emphasize. We attempted to adjust for the amount of data provided by schools in the weighted analysis, but this cannot control for the other factors. Only 78% of the 60 schools used in our analysis of women's health and gender-specific topics had entered data for three or more academic years, which may result in an underestimation of topics that are taught only in the clinical years. We may also have underestimated gender-specific content if schools did not provide enough detail in their course and session entries to identify, for example, information on women and heart disease in a course on cardiovascular disease. Conversely, the frequency with which “hot topics” were listed may overestimate the amount of teaching related to these topics, since “hot topics” may have been entered preferentially in CurrMIT by some schools.
Finally, our findings may not be representative of all U.S. medical schools because only 95 of the 126 U.S. medical schools (75%) had entered data on courses/clerkships in CurrMIT, and only 60 of the 126 schools (47%) had entered sufficient information to allow a more detailed search for curriculum topics. Despite these limitations, there are certain unique advantages to CurrMIT. It is the most complete centralized repository of curriculum information on medical schools available, and continued data entry by schools will allow researchers to track this information over time.
Few medical schools in this study offered interdisciplinary women's health courses or clerkships; most were elective or selective clinical rotations that, as a result of limited enrollments, benefited a small number of students.
The majority of schools that provided detailed information in CurrMIT included important women's health topics in their curricula; however, there was considerably less emphasis on gender-specific information about many conditions that cause the greatest morbidity and mortality in women, a pattern that has persisted for a decade. Although the presence of a program or center responsible for developing women's health curriculum models at a given school may increase the women's health and gender-specific content of that school's curriculum, additional strategies are needed to accelerate the integration of this information.
The authors thank the Josiah Macy, Jr. Foundation for its funding and support of the project. The authors also thank Albert Salas, Assistant Vice President and CurrMIT Project Director, as well as members of the Division of Medical Education at the AAMC, for developing the Existing Reports search options in CurrMIT used in the study, providing data on CurrMIT utilization by medical schools, and sharing their expertise and advice during the study.
This project was funded by Grant No. B01-6 from The Josiah Macy, Jr. Foundation, New York, NY