EDITORIAL Internal Medicine Training and Women's Health: Politics and Pap Tests THERE HAS BEEN a recent surge of interest in w o m e n ' s

health care in terms of access, research, and services. 1 It has b e c o m e a medical, social, and political priority to i m p r o v e health care for w o m e n , as d e m o n s t r a t e d b y the W o m e n ' s Health Initiative, the largest p r e v e n t i o n study ever funded in this country. 2 The National Institutes of Health (NIH) has listed the following d e t e r m i n a n t s of a particular health p r o b l e m as a w o m e n ' s issue: diseases, disorders, or conditions that are u n i q u e to w o m e n , m o r e prevalent in w o m e n , or m o r e serious a m o n g w o m e n , or that have different risk factors or interventions in w o m e n . The w o m e n ' s liberation m o v e m e n t has influenced b o t h medical practice and training. The early w o m e n ' s health activists challenged the medical profession's authority o v e r w o m e n and e n c o u r a g e d w o m e n to regain control over their bodies and personal health care decisions. These statements may s e e m like platitudes in o u r era of informed consent, b u t they represent a d e p a r t u r e from h o w w o m e n w e r e treated historically b y the medical profession. While the p r i m a r y concentration continues to be on r e p r o d u c t i v e concerns, w o m e n ' s health activists have w i d e n e d their focus to ensure that w o m e n ' s health b e treated w i t h the same care and seriousness that m e n ' s health has always received.3 In 1989 the Congressional Caucus for W o m e n ' s Issues t o o k notice of the inadequate attention to the research, diagnosis, and t r e a t m e n t of w o m e n ' s health care p r o b l e m s by the medical profession. These political efforts have b e e n instrumental in raising the medical establishm e n t ' s consciousness a b o u t the insufficient research a b o u t health p r o b l e m s in w o m e n . The 1988 Task Force on the Future Internist described a paradigmatic shift in w h i c h general internists will be e x p e c t e d to provide p r i m a r y care w i t h less reliance u p o n specialists for the m a n a g e m e n t of c o m m o n a m b u l a t o r y p r o b l e m s that fall outside the traditional domain of internal m e d i c i n e (including relevant information from psychiatry, dermatology, orthopedics, gynecology, and otolaryngology). ~ This has b e e n reflected in internal m e d i c i n e training programs. The Accreditation Council for Graduate Medical Education m a n d a t e d that at least 25% of the three years of internal medicine training be in the a m b u l a t o r y care setting. Residents are e x p e c t e d to a p p r e c i a t e the presentations of disease in outpatients and to b e c o m e familiar w i t h c o m m o n p r o b l e m s e n c o u n t e r e d in daily practice. Optimal care for w o m e n clearly involves m o r e than gyne-

cologic skills and k n o w l e d g e alone and requires a sensitivity to the full breadth of distress e x p e r i e n c e d b y women. The p a p e r b y Coodley, Elliot, and G o l d b e r g in this issue of the J o u r n a l 5 is i m p o r t a n t to general internists i n their roles as clinicians and educators. The authors have undertaken an i m p o r t a n t effort to assess internists' p e r c e p t i o n s of their training in the m a n a g e m e n t of c o m m o n p r o b l e m s of a m b u l a t o r y g y n e c o l o g y and to c o m p a r e their p e r c e p t i o n s w i t h their clinical practice experiences. T h e y f o u n d that w o m e n physicians had higher p e r c e n t a g e s of w o m e n patients than did m e n physicians. Preparation in a m b u l a t o r y g y n e c o l o g y did not vary b e t w e e n male and female residents. Independ e n t of the p e r c e n t a g e of female patients in their practices, the female internists w e r e m o r e likely than their male colleagues to manage p r o b l e m s in a m b u l a t o r y gynecology. The authors did not identify major differences in residency trainings or practices o v e r different time periods. T h e y did not specify w h e t h e r the internists had c o m p l e t e d p r i m a r y care or traditional programs or w h e t h e r the p e r c e n t a g e of general internists varied b e t w e e n the m a l e and female physicians. The major limitations of the study w e r e the relatively low response rate, the small sample of female internists from w h i c h to generalize a b o u t practice patterns, and the limited g e o g r a p h i c representation of the m e t r o p o l i t a n Portland area. Given that this was an educational survey and not a cohort study, the characteristics of the internists p r i o r to starting training or practice are u n k n o w n . O n l y p e r c e p t i o n s w e r e assessed and there was no measure of o u t c o m e such as a written or practical e x a m i n a t i o n or a questionnaire of patient satisfaction. The major value of this study is that it highlights the areas in w h i c h the training of internists in ambulatory g y n e c o l o g y is deficient in p r e p a r i n g physicians to m e e t the d e m a n d s of an average practice. Since most of the k n o w l e d g e a b o u t a m b u l a t o r y g y n e c o l o g y was acquired after residency, future studies n e e d to determ i n e h o w such e x p e r t i s e was attained. Several possibilities include individualized reading, c o n t i n u i n g medical e d u c a t i o n courses, and learning f r o m consultations w i t h g y n e c o l o g y colleagues. There are m a n y possible solutions to the challenge o f teaching w o m e n ' s health to residents. This is a multidisciplinary field, and the faculty will likely c o m e f r o m obstetrics/gynecology, psychiatry, and family practice, 665

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i n a d d i t i o n to i n t e r n a l m e d i c i n e . At o u r m e d i c a l c e n t e r , a g e n e r a l i n t e r n i s t has c o o r d i n a t e d a p r o g r a m o f m o n t h l y l e c t u r e s o n w o m e n ' s h e a l t h i n c o r e areas f r o m c o n t r a c e p t i o n to m e n o p a u s e a n d i n c l u d i n g t h e i m p a c t o f v i o l e n c e o n w o m e n ' s lives. T h e f i n d i n g s f r o m " I n ternal Medicine Training in Ambulatory Gynecology" w i l l b e u s e d to p r i o r i t i z e f u r t h e r c u r r i c u l u m development. T w o g e n e r a l i n t e r n i s t s offer a c l i n i c a l e l e c t i v e o n w o m e n ' s h e a l t h for r e s i d e n t s a n d m e d i c a l s t u d e n t s . T h e processes of critical reading and self-directed learning are e m p h a s i z e d . T h e s t u d e n t or r e s i d e n t sees p a t i e n t s w i t h a n u r s e p r a c t i t i o n e r at e i t h e r a c o l l e g e h e a l t h c e n t e r or a P l a n n e d P a r e n t h o o d office. T h e p r o f e s s i o n a l d e v e l o p m e n t that r e s u l t s f r o m w o r k i n g o u t s i d e t h e hosp i t a l w i t h w o m e n p r o v i d e r s , w h o are p a t i e n t a d v o c a t e s as w e l l as teachers, has b e e n v a l u a b l e . Diverse strategies to i m p r o v e m e d i c a l e d u c a t i o n a n d r e s e a r c h a b o u t w o m e n ' s h e a l t h have b e e n proposed.6, 7 W e n e e d to r e v i s e i n t e r n a l m e d i c i n e t r a i n i n g p r o g r a m s a n d o u r p r a c t i c e s so that t h e n e w p u b l i c at-

t e n t i o n a n d p o l i t i c a l i n t e r e s t w i l l r e s u l t i n real imp r o v e m e n t s i n h e a l t h care for w o m e n . - - M A R G O J. KRASNOFF, MD, Section o f General I n t e r n a l Medicine,

Dartmouth-Hitchcock N H 03 756

M e d i c a l Center, Lebanon,

REFERENCES 1. Healy B. Women's health, public welfare. JAMA. 1991;226: 566-8. 2. Healy B. A celebration and new resolve. J Women's Health. 1992; 1:xvii. 3. Schroeder P. Women's health: a focus for the 1990s. Women's Health Issues. 1992;2:1-2. 4. The Task Force on the Future Internist. The future internist. Ann Intern Med. 1988;108:145-7. 5. Coodley GO, Elliot DL, Goldberg L. Internal medicine training in ambulatory gynecology. J Gen Intern Med. 1992;7:636-9. 6. Council on Ethical andJudicial Affairs,American Medical Association. Gender disparities in clinical decision making. JAMA. 1991;266:559-62. 7. Moulton AW, Montgomery K, Cyr MG, Landau C. Women's health education: what to do until we have the data. SGIM News. 1991;14:1, 5.

LETTERS TO THE EDITOR Memory of C. Everett Koop To the Editor:-- Dr. Viner's sensitive review of Dr. Koop's memoirs 1 brought back a memory of my own regarding Dr. Koop. I was a third-year medical student at Penn, on the first day of the first rotation of my third year: surgery at Children's Hospital under the tutelage of the renowned Dr. C. Everett Koop. After tying on a surgical mask for the first time in my life, I proceeded to scrub for the requisite time (I've forgotten the n u m b e r of minutes but it was the time of very long, pregermicidal cleanser scrubs, back in the green-soap days.) Using my fanny to push open the door, I accepted the waiting nurse's help in gowning and gloving. And then my mask fell down. What to do? I feared machine guns would appear from hidden gun stations and mow me down for contaminating Dr. Koop's OR. I was afraid I

might flunk the entire surgical rotation; goodbye medical school. Fearfully, I backed back into the scrub room where Dr. Koop was by now scrubbing his hands. He immediately realized what had happened. Calling me by name (and it was just the first day of the service), he broke his own scrub to retie my mask so I would not have to do it myself, with the resulting need to do the entire scrub over. "Miss Ziegler," he said genially, "you look just like a urologist." I have loved him in an unquestioning, apolitical way ever since. Chiefs of service are not always that kind to medical students. - - BERNADINEZ. PAULSHOCK,MD, Medical Center of

Delaware, Wilmington, DE 19718 Reference 1. Viner E. Koop: the memoirs of America's family doctor [book review]. J Gen Intern Med. 1992;7:372-3.

Internal medicine training and women's health: politics and Pap tests.

EDITORIAL Internal Medicine Training and Women's Health: Politics and Pap Tests THERE HAS BEEN a recent surge of interest in w o m e n ' s health car...
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