Internal Medicine Training in Ambulatory Gynecology GREGGO. COODLEY, MD, DIANE L. ELLIOT, MD, LINN GOLDBERG, MD Objective: To assess internists'perceptions o f their training in the management o f common problems in ambulatory gynecology and to c o m p a r e these perceptions with their clinical practice experiences. Methods: We surveyed 325 internists in the Portland, Oregon, metropolitan area about their residency training and practice experiences in the diagnosis and management o f 25 clinical problems in ambulatory gynecology and five nonggnecologic p r o b l e m s . Results: R e s p o n s e s w e r e r e c e i v e d f r o m 159 internists (48.5%). Overall the internists reported relatively little residency training in the m a n a g e m e n t o f m a n y c o m m o n gynecologic disorders. Women internists managed gynecologic problems m o r e than d i d their male counterparts, independent o f the n u m b e r o f w o m e n patients in their practices. Conclusions: I n t e r n a l m e d i c i n e residency programs n e e d to expand training in ambulatory ggnecology to betterprepare graduates f o r clinical practice. Key words: gynecology; g e n i a l internists; internal medicine residencies; ambulatory care. J GEN]_N'l'l~u~MED 1992;
7:636-639.
AMBULATORY INTERNAL MEDICINE PRACTICE involves managing p r o b l e m s outside traditional medical training, including outpatient gynecology. 1.2 Previous studies have d o c u m e n t e d that internal m e d i c i n e training m a y be deficient in certain k n o w l e d g e and skills req u i r e d in clinical practice, t, 3, 4 However, there are f e w data about h o w well residency p r o g r a m s p r e p a r e graduates to manage gynecologic p r o b l e m s . To date, inquiries c o n c e r n i n g a m b u l a t o r y g y n e c o l o g y teaching have focused on o b s t e t r i c s / g y n e c o l o g y residents or students during o b s t e t r i c s / g y n e c o l o g y clerkships. 5"8 In v i e w of the evidence that internal m e d i c i n e training has not always correlated w i t h the d e m a n d s of a m b u l a t o r y practice and the r e c o m m e n d a t i o n that internists manage c o m m o n g y n e c o l o g i c p r o b l e m s , w e evaluated internists' p e r c e p t i o n s of their residency preparations in g y n e c o l o g y as c o m p a r e d with their clinical practice experiences. We sought to identify specific areas w h e r e i m p r o v e m e n t in training m i g h t be warranted. In addition, w e e x a m i n e d the characteristics of physicians and their practice settings to observe h o w d e m o g r a p h i c data m i g h t relate to the n u m b e r and s p e c t r u m of w o m e n ' s health p r o b l e m s seen.
Received from the Division of General Medicine, Oregon Health Sciences University, Portland, Oregon. Supported in part by DHHS#5 D28 PE 10061-01. Address correspondence and reprint requests to Dr. Coodley: Oregon Health Sciences University, L475, 3181 SWSamJackson Park Road, Portland, OR 97201-3098.
636
METHODS We surveyed the initial 325 internists from the O r e g o n Medical Association's (OMA's) list of 6 0 0 Portland, Oregon, area internists, organized b y zip codes. The list included all physicians w h o classified their specialty as internal medicine. Data w e r e collected b y a mailed a n o n y m o u s questionnaire using standard survey methodology. Anonymity of individual replies was assured b y a cover letter. The survey instrument listed c o m m o n gynecologic p r o b l e m s suggested as curricula for residency training in p r i m a r y care internal m e d i c i n e at the Oregon Health Sciences University. Additional clinical p r o b l e m s w e r e added from topics contained in p r i m a r y care medicine textbooks.9, l0 The questionnaire was divided into three sections: questions about physician demographics, questions a b o u t residency training, and queries c o n c e r n i n g internists' clinical practice experiences. Internists w e r e asked to evaluate the f r e q u e n c y of 25 c o m m o n gynecologic and five nongynecologic medical p r o b l e m s e n c o u n t e r e d in their medical practices using a Likert scale of assessment, ranging from 1 (never e n c o u n t e r e d in practice) to 3 ( e n c o u n t e r e d at least m o n t h l y ) to 5 ( e n c o u n t e r e d on most days in practice). For each of these 3 0 clinical problems, the physicians also rated their preparations in residency for that condition on a scale ranging from 1 (no training) to 5 (very substantial training [structured teaching or freq u e n t care]). Statistical analysis included assessment of means and i n d e p e n d e n t g r o u p t-tests for continuous variables and chi-squares for categorical variables. Pearson's correlation coefficient was used to d e t e r m i n e relationships b e t w e e n variables. The data w e r e analyzed by s u b g r o u p to assess for significant differences by year of residency completion, by physician gender, and be-
TABLE 1
Percentagesof Women Patients by PhysicianGender* Percentage of Women Patientst 80-100% 60-80% 40-60% 20-40%
Men Physicians (n = 97) I 24 69 3
( i %) (25%) (71%) (3%)
Women Physicians (n = 31) 7 (23%) 13 (42%) 10 (33%) 1 (3%)
*Chi-square = 26.36; p < 0.0002. Note: 5 of 133 internists did not complete the demographicsection of the questionnaire. tFourteen internists reported having 0 to 20% women patients.
637
JOURNALOFGENERALINTERNALMEDICINE.Volume7 (November/December), t992
tween subspecialists and general internists. Multiple regression analysis was performed to assess independence of correlations among variables. Statistical significance was set at the p < 0.01 level.
RESULTS Responses were received from 159 of 325 internists (48.5%). Twelve surveys were returned uncompleted. The 147 completed surveys included 37 women (67% of the women internists surveyed) and 1 1 0 men internists (42% of the men internists surveyed). The physicians averaged 15 + 12 years (mean + SD) of clinical practice since completion of residency. While complete demographic data were not provided on all questionnaires, the majority of respondents (n = 107) indicated that their residencies had been at university medical centers or Veterans Administration hospitals, while 38 had trained exclusively at community hospitals. During residency, most had rotated through more than one hospital. One hundred thirty-eight were graduates of American medical schools, six were foreign medical graduates, and four had graduated from unspecified schools. The respondents included 102 general internists and 24 internal medicine subspecialists, plus 11 who did not specify a subspecialty. Thirty-three respondents worked in an academic setting (23%), 52 in group practice or clinics (36%), and 24 in health maintenance organizations (16%), while 36 were solo practitioners (25%). The percentages of women patients by physician gender are listed in Table 1. For evaluation purposes, we excluded the 14 internists who reported having less than 20% women patients. This group worked primarily at the Veterans Administration hospital. The survey results are based, therefore, on completed responses from the 133 practicing physicians with at least 20% women patients. Overall the internists reported relatively little training in residency to manage many common problems in women's health and outpatient gynecology (Table 2). The internists' average response was that they had received minimal or no training (Likert score < 2.5, Table 2) during residency in 14 of the 25 gynecologic problems surveyed. In none of these 25 assessed areas did the internists, on average, feel that they had been reasonably or very well prepared during residency (Likert score > 3.5, Table 2). The frequency with which these problems were encountered in practice was compared with residency preparation in caring for each condition (Table 2). Areas of significant disparity (where training in residency was reported as being less than the frequency with which the problem was encountered in practice) included safe-sex counseling, cancer screening in
TABLE ~. Internists' Reported PracticeActivity and ResidencyTraining Encountered in
Preparation in
Practice (Mean)* Residency(Mean)t Diagnosisand managementof diabetes mellitus Diagnosisand managementof coronary artery disease Cancer screeningin women Ability to perform Pap tests Ability to detect pelvicmass Diagnosisand managementof osteoporosis Diagnosisand managementof menopause Diagnosisand managementof vaginitis Diagnosisand managementof breast lumps Diagnosisand managementof valvular heart disease Safe-sexcounseling Diagnosisand managementof sexuallytransmitted diseases Diagnosisand managementof urinary incontinencein women Diagnosisand managementof sepsis Diagnosisand managementof pelvic pain Diagnosisand managementof dysmenorrhea How to prescribe birth control pills Diagnosisand managementof abnormal vaginal bleeding Diagnosisand managementof pelvic inflammatory disease When to switch birth-control pills and how to do it Diagnosisand management of acute renal failure Diagnosisand managementof amenorrhea Diagnosisand managementof dyspareunia Medicalconditions in pregnancy Diagnosisand managementof abnormal breast discharge Counselingon family planning options Counselingon abortion Evaluationof infertility Fitting of a diaphragm Counselingon use of morningafter pill
4.3
4.6*
4.3 4.2* 4. I* 3.6§
4.7* 3.4 3.5 3.1
3.6*
2.0
3.5*
3.0
3.4
3.1
3.3§
3.0
3.3 3.0*
4.3* 2.1
2.9
3.2*
2.8,
2.3
2.7
4.5*
2.7
2.6
2.6
2.4
2.6
2.3
2.5
2.6
2.3
3. I t
2.3§
2.0
2.3
4.1,
2.2
2.4
2.1 2.1
1.9 2.4§
2.0
2.4*
2.0 1.8 1.8 1.6
1.8 1.6 1.8 1.S
1.3
1.3
*Based on Likert scale ranging from 1 (never encountered)to 5 (encounteredon most days of practice). tBased on Likert scale ranging from 1 (no training) to 5 (very substantial training [structured teaching of frequent cases]). ~tp< 0.001 (comparing residencypreparation and practiceexperience for eachskill). §p < 0.01 (comparing residency preparation and practice experience for eachskill).
Coodley et al., IM GYNECOLOGYTRAINING
638
TABLE 3 Areas of Significant Practice Differences between Men and Women Internists* Men Internists Women Internists Ability to perform Pap test Diagnosis and management of vaginitis Safe-sex counseling Diagnosis and management of dysmenorrhea Diagnosis and management of sexually transmitted diseases How to prescribe birth control pills Diagnosis and management of abnormal vaginal bleeding When to switch birth-control pills and how to do it Diagnosis and management of amenorrhea Counseling on family planning options Diagnosis and management of sepsis Fitting of a diaphragm Counseling on abortion Evaluation of infertility
significantly differ with trainee gender for any of the 30 clinical problems. However, the situation in practice was different. Table 3 lists those problems where women internists reported managing problems in ambulatory gynecology significantly more than did their male counterparts (Table 3). In contrast, the men internists saw significantly more (p < 0.01) coronary artery disease and sepsis. Women internists had a higher percentage of women patients (Table 1). However, the reported difference in frequencies of encountering problems reflected physician gender and was independent of the percentage of women patients.
4,0
4.6t
3.2 2.8
4.1 t 3.6*
2.3
3.4t
2.8 2.4
3.4t 3.4*
2.4
3.0$
2.0
3.0*
DISCUSSION
2.1
2.7*
1.9
2.6t
2.8t 1,3 1.6 1.6
2.3 2.3* 2.2* 2.2t
Internal medicine residency appears to provide inadequate preparation in many common outpatient gynecologic problems. Practicing internists indicated relatively little residency training in the diagnosis and management of several gynecologic conditions, in contrast to their perceived strong training in the five nongynecologic problems surveyed. This limited preparation is in contrast to the relative frequency with which these gynecologic problems were encountered in clinical practice. Previous studies provide limited information about internal medicine residents' training and the skills used in practice with regard to gynecology.3, 4 A large survey of general internists suggests that gynecologic procedures, such as pelvic examinations and obtaining wet mounts of vaginal discharge, were a part of the majority of practices.3 Wigton et al. questioned program directors about their residents' ability to do these procedures. While residency directors felt that these skills were important, they were less likely to feel that their residents had mastered these procedures. 4 Other studies have suggested that recent graduates felt underprepared in pelvic examination and reported inadequate training in nonmedical subspecialties, including gynecology. H-Is Kiel and colleagues found that residents trained in primary care residencies reported significantly superior preparation in gynecology, including pelvic examination, than did traditional internal medicine graduates. 16 The only study that actually tested skills reported that ten of 30 internal medicine residents were unable to detect an adnexal mass on a synthetic pelvic mode. 17 Our results suggest that internists may receive inadequate preparation in managing a wide range of common gynecologic problems. Major differences were not seen in either the residency preparations or the practice patterns of internists trained during different time periods. This suggests that instruction in ambulatory gynecology may not have changed significantly over the past 15 years despite the recent emphasis on women's health issues. 18While the 23% of respondents who were academic internists may exceed the proportion of academics among internists,
*Based on Likert scale ranging from 1 (never encountered) to 5 (encountered on most clays of practice). t p < 0.01 (comparing men versus women internists' practice experiences). tp < 0.001 (comparing men versus women internists' practice experiences).
women, when and how to switch birth-control pills, the ability to perform a Pap test, and the ability to detect a pelvic mass, as well as the diagnosis and management of menopause, breast lumps, urinary incontinence (in women), and osteoporosis (all p < 0.01). In contrast, internists reported more training than practice experience for the diagnosis and management of sexually transmitted diseases, pelvic inflammatory disease, medical conditions in pregnancy, and all five nongynecologic areas surveyed (p < 0.01) (Table 2). The year of completion of residency training did not correlate with the frequency with which internists encountered most of the clinical problems or with amount of residency preparation. The more recently trained internists reported significantly more clinical experience in practice only for safe-sex counseling and the diagnosis and management of sexually transmitted diseases and more residency training only for safe-sex counseling, detection of pelvic masses, and management of sepsis (p < 0.01). The general internists encountered women's health problems far more often in practice than did the subspecialists (p < 0.001 for 17/25 problems listed in Table 2). However, general internists and subspecialists did not exhibit significant demographic differences or report differences in their amounts of training in women's health. Finally, data were analyzed on the basis of physician gender. Preparation in women's health did not
JOURNALOF GENERALINTERNALMEDICINE, Volume7 (November/December), 1992
this probably reduced the overall frequency with which common gynecologic problems were encountered in practice (due to smaller practices in academic medicine), actually reducing the differences reported between residency and practice experiences. The perceived weaknesses reported by internists in ambulatory gynecology training may indicate overall weaknesses in ambulatory training. Although some of the nongynecologic comparison topics chosen have both inpatient and ambulatory components, the reported superior training in these areas may reflect a long-term history of greater emphasis on inpatient training. Further studies are needed to assess whether primary care training programs, with their increased emphasis on ambulatory care, offer training in ambulatory gynecology equal to the demands of clinical practice. In our study, women internists appear to manage problems in women's health more often, independent of the percentage of women in their practices. The higher response rate from women internists (67% vs. 42% for men internists) may reflect increased interest in, or awareness of, women's health issues. The more frequent management of gynecologic problems by women internists was independent of their percentages of women patients. Thus, women physicians seem both to see more women patients and to manage more gynecologic problems among the women patients seen. The patient distribution data may reflect this practice pattern or patient preferences. Two prior reports have suggested that women patients may prefer women physicians, particularly for the management of gynecologic problems.19, 2o Further study is needed to determine whether the increased number of gynecologic problems seen by women physicians reflects higher physician interest, increased patient willingness to bring these issues to women physicians, or a combination of both. Our study has several potential limitations. The response rate was relatively low. It is possible that nonresponders may be significantly different from responders. While we cannot rule out this possibility, there is no evidence that those physicians with the least training in gynecology would reply more frequently than those with greater training. Our study relied solely on self-assessment, rather than skills testing. Future studies may want to incorporate additional instruments to assess how well internists' self-assessment compares with some additional objective testing. The physicians surveyed also represented a limited geographic area, the metropolitan Portland area, and the results may not be generalizable to other metropolitan or rural areas. Our findings suggest that training in ambulatory gynecology is deficient compared with the demands of
639
practice. Our results provide an initial needs assessment and can help guide curriculum development. Further studies are warranted to confirm these findings and define what experiences are required so that trainees perceive that their training is adequate and commensurate with practice requirements. The results indicate that expanded training in gynecology is needed to prepare graduates for internal medicine practice.
The authors acknowledge the wonderful assistance and patience of Darlene Coffey, Sue Simmons, and Marcella Loprinzi and the invaluable advice and suggestions of Dr. Marcia K. Coodley, for without their help, the study would have been impossible.
REFERENCES 1. Mandel JH, Rich EC, Luxenberg MG, et al. Preparation for practice in internal medicine. Arch Intern Med. 1988; 148: 853 -6. 2. The Task Force on the Future Internist, American Board of Internal Medicine. Ann Intern Med. 1988;108:139-41. 3. Wigton RS, Nicolas JA, Blank LL. Procedural skills of the general internist. Ann Intern Med. 1989;111:1023-34. 4. Wigton RS, Blank LL, NicolasJA, Tape TG. Procedural skills training in internal medicine residencies: a survey of program directors. Ann Intern Med. 1989;I 11:932-8. 5. HillardJT, Jang WL. Medical students' gynecologic examination skills. J Reprod Med. 1986; 31:491-6. 6. Stenchevers MA, O'Toole B, Irby D. Evaluating student performance in an obstetrics and gynecology clerkship. Am J Obstet Gynecol. 1979;134:235-7. 7. Pecorari D. Teaching and training in obstetrics and gynecology. Clin Exp Obstet Gynecol. 1990;17:1-4. 8. Kowlowitz V, Curtis P, Sloane PD. The procedural skills of medical students: expectations and experiences. Acad Med. 1990;65:656-8. 9. Goroll AH, May LA, Mulley AG. Primary care medicine. Philadelphia: J. B. Lippincott, 1981. 10. Barker LR, Burton JR, Zieve PD. Principles of ambulatory medicine. Baltimore: Williams and Wilkins, 1986. 11. Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DG, Parrino TA. Preparation for practice in internal medicine. Arch Intern Med. 1988;148:853-6. 12. Linn LS, Brook RH, Clark VA, Fink A, Kosecoff T. Evaluation of ambulatory care training by graduates of internal medicine residencies. J Med Educ. 1986;61:293-302. 13. Martin GJ, Curry RH, Yarnold PR. The content of internal medicine training and its relevance to the practice of medicine: implications for primary care curricula. J Gen Intern Med. 1989;4:304-8. 14. Kantor SM, Griner PF. Educational needs in general internal medicine as perceived by prior residents. J Med Educ. 1981;56:748-56. 15. Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA. 1985;254:70-6. 16. Kiel DP, O'Sullivan PS, Ellis PJ, Wartman SA. Alumni perspectives comparing a general internal medicine program and a traditional medicine program. J Gen Intern Med. 1991 ;6:544-52. 17. Ferris AK, Schapiro MM, Young MJ. Accuracy of pelvic examination. Ann Intern Med. 1991;114:522. 18. HealyB.Women'shealth, publicaffairs.JAMA. 1991;266:566-8. 19. GraffyJ. Patient choice in a practice with men and women general practices. BrJ Gen Pract. 1991;40:13-5. 20. Waller K. Women doctors for women patients? BrJ Med Psychol. 1988;61:125-35.
7:636-639.
AMBULATORY INTERNAL MEDICINE PRACTICE involves managing p r o b l e m s outside traditional medical training, including outpatient gynecology. 1.2 Previous studies have d o c u m e n t e d that internal m e d i c i n e training m a y be deficient in certain k n o w l e d g e and skills req u i r e d in clinical practice, t, 3, 4 However, there are f e w data about h o w well residency p r o g r a m s p r e p a r e graduates to manage gynecologic p r o b l e m s . To date, inquiries c o n c e r n i n g a m b u l a t o r y g y n e c o l o g y teaching have focused on o b s t e t r i c s / g y n e c o l o g y residents or students during o b s t e t r i c s / g y n e c o l o g y clerkships. 5"8 In v i e w of the evidence that internal m e d i c i n e training has not always correlated w i t h the d e m a n d s of a m b u l a t o r y practice and the r e c o m m e n d a t i o n that internists manage c o m m o n g y n e c o l o g i c p r o b l e m s , w e evaluated internists' p e r c e p t i o n s of their residency preparations in g y n e c o l o g y as c o m p a r e d with their clinical practice experiences. We sought to identify specific areas w h e r e i m p r o v e m e n t in training m i g h t be warranted. In addition, w e e x a m i n e d the characteristics of physicians and their practice settings to observe h o w d e m o g r a p h i c data m i g h t relate to the n u m b e r and s p e c t r u m of w o m e n ' s health p r o b l e m s seen.
Received from the Division of General Medicine, Oregon Health Sciences University, Portland, Oregon. Supported in part by DHHS#5 D28 PE 10061-01. Address correspondence and reprint requests to Dr. Coodley: Oregon Health Sciences University, L475, 3181 SWSamJackson Park Road, Portland, OR 97201-3098.
636
METHODS We surveyed the initial 325 internists from the O r e g o n Medical Association's (OMA's) list of 6 0 0 Portland, Oregon, area internists, organized b y zip codes. The list included all physicians w h o classified their specialty as internal medicine. Data w e r e collected b y a mailed a n o n y m o u s questionnaire using standard survey methodology. Anonymity of individual replies was assured b y a cover letter. The survey instrument listed c o m m o n gynecologic p r o b l e m s suggested as curricula for residency training in p r i m a r y care internal m e d i c i n e at the Oregon Health Sciences University. Additional clinical p r o b l e m s w e r e added from topics contained in p r i m a r y care medicine textbooks.9, l0 The questionnaire was divided into three sections: questions about physician demographics, questions a b o u t residency training, and queries c o n c e r n i n g internists' clinical practice experiences. Internists w e r e asked to evaluate the f r e q u e n c y of 25 c o m m o n gynecologic and five nongynecologic medical p r o b l e m s e n c o u n t e r e d in their medical practices using a Likert scale of assessment, ranging from 1 (never e n c o u n t e r e d in practice) to 3 ( e n c o u n t e r e d at least m o n t h l y ) to 5 ( e n c o u n t e r e d on most days in practice). For each of these 3 0 clinical problems, the physicians also rated their preparations in residency for that condition on a scale ranging from 1 (no training) to 5 (very substantial training [structured teaching or freq u e n t care]). Statistical analysis included assessment of means and i n d e p e n d e n t g r o u p t-tests for continuous variables and chi-squares for categorical variables. Pearson's correlation coefficient was used to d e t e r m i n e relationships b e t w e e n variables. The data w e r e analyzed by s u b g r o u p to assess for significant differences by year of residency completion, by physician gender, and be-
TABLE 1
Percentagesof Women Patients by PhysicianGender* Percentage of Women Patientst 80-100% 60-80% 40-60% 20-40%
Men Physicians (n = 97) I 24 69 3
( i %) (25%) (71%) (3%)
Women Physicians (n = 31) 7 (23%) 13 (42%) 10 (33%) 1 (3%)
*Chi-square = 26.36; p < 0.0002. Note: 5 of 133 internists did not complete the demographicsection of the questionnaire. tFourteen internists reported having 0 to 20% women patients.
637
JOURNALOFGENERALINTERNALMEDICINE.Volume7 (November/December), t992
tween subspecialists and general internists. Multiple regression analysis was performed to assess independence of correlations among variables. Statistical significance was set at the p < 0.01 level.
RESULTS Responses were received from 159 of 325 internists (48.5%). Twelve surveys were returned uncompleted. The 147 completed surveys included 37 women (67% of the women internists surveyed) and 1 1 0 men internists (42% of the men internists surveyed). The physicians averaged 15 + 12 years (mean + SD) of clinical practice since completion of residency. While complete demographic data were not provided on all questionnaires, the majority of respondents (n = 107) indicated that their residencies had been at university medical centers or Veterans Administration hospitals, while 38 had trained exclusively at community hospitals. During residency, most had rotated through more than one hospital. One hundred thirty-eight were graduates of American medical schools, six were foreign medical graduates, and four had graduated from unspecified schools. The respondents included 102 general internists and 24 internal medicine subspecialists, plus 11 who did not specify a subspecialty. Thirty-three respondents worked in an academic setting (23%), 52 in group practice or clinics (36%), and 24 in health maintenance organizations (16%), while 36 were solo practitioners (25%). The percentages of women patients by physician gender are listed in Table 1. For evaluation purposes, we excluded the 14 internists who reported having less than 20% women patients. This group worked primarily at the Veterans Administration hospital. The survey results are based, therefore, on completed responses from the 133 practicing physicians with at least 20% women patients. Overall the internists reported relatively little training in residency to manage many common problems in women's health and outpatient gynecology (Table 2). The internists' average response was that they had received minimal or no training (Likert score < 2.5, Table 2) during residency in 14 of the 25 gynecologic problems surveyed. In none of these 25 assessed areas did the internists, on average, feel that they had been reasonably or very well prepared during residency (Likert score > 3.5, Table 2). The frequency with which these problems were encountered in practice was compared with residency preparation in caring for each condition (Table 2). Areas of significant disparity (where training in residency was reported as being less than the frequency with which the problem was encountered in practice) included safe-sex counseling, cancer screening in
TABLE ~. Internists' Reported PracticeActivity and ResidencyTraining Encountered in
Preparation in
Practice (Mean)* Residency(Mean)t Diagnosisand managementof diabetes mellitus Diagnosisand managementof coronary artery disease Cancer screeningin women Ability to perform Pap tests Ability to detect pelvicmass Diagnosisand managementof osteoporosis Diagnosisand managementof menopause Diagnosisand managementof vaginitis Diagnosisand managementof breast lumps Diagnosisand managementof valvular heart disease Safe-sexcounseling Diagnosisand managementof sexuallytransmitted diseases Diagnosisand managementof urinary incontinencein women Diagnosisand managementof sepsis Diagnosisand managementof pelvic pain Diagnosisand managementof dysmenorrhea How to prescribe birth control pills Diagnosisand managementof abnormal vaginal bleeding Diagnosisand managementof pelvic inflammatory disease When to switch birth-control pills and how to do it Diagnosisand management of acute renal failure Diagnosisand managementof amenorrhea Diagnosisand managementof dyspareunia Medicalconditions in pregnancy Diagnosisand managementof abnormal breast discharge Counselingon family planning options Counselingon abortion Evaluationof infertility Fitting of a diaphragm Counselingon use of morningafter pill
4.3
4.6*
4.3 4.2* 4. I* 3.6§
4.7* 3.4 3.5 3.1
3.6*
2.0
3.5*
3.0
3.4
3.1
3.3§
3.0
3.3 3.0*
4.3* 2.1
2.9
3.2*
2.8,
2.3
2.7
4.5*
2.7
2.6
2.6
2.4
2.6
2.3
2.5
2.6
2.3
3. I t
2.3§
2.0
2.3
4.1,
2.2
2.4
2.1 2.1
1.9 2.4§
2.0
2.4*
2.0 1.8 1.8 1.6
1.8 1.6 1.8 1.S
1.3
1.3
*Based on Likert scale ranging from 1 (never encountered)to 5 (encounteredon most days of practice). tBased on Likert scale ranging from 1 (no training) to 5 (very substantial training [structured teaching of frequent cases]). ~tp< 0.001 (comparing residencypreparation and practiceexperience for eachskill). §p < 0.01 (comparing residency preparation and practice experience for eachskill).
Coodley et al., IM GYNECOLOGYTRAINING
638
TABLE 3 Areas of Significant Practice Differences between Men and Women Internists* Men Internists Women Internists Ability to perform Pap test Diagnosis and management of vaginitis Safe-sex counseling Diagnosis and management of dysmenorrhea Diagnosis and management of sexually transmitted diseases How to prescribe birth control pills Diagnosis and management of abnormal vaginal bleeding When to switch birth-control pills and how to do it Diagnosis and management of amenorrhea Counseling on family planning options Diagnosis and management of sepsis Fitting of a diaphragm Counseling on abortion Evaluation of infertility
significantly differ with trainee gender for any of the 30 clinical problems. However, the situation in practice was different. Table 3 lists those problems where women internists reported managing problems in ambulatory gynecology significantly more than did their male counterparts (Table 3). In contrast, the men internists saw significantly more (p < 0.01) coronary artery disease and sepsis. Women internists had a higher percentage of women patients (Table 1). However, the reported difference in frequencies of encountering problems reflected physician gender and was independent of the percentage of women patients.
4,0
4.6t
3.2 2.8
4.1 t 3.6*
2.3
3.4t
2.8 2.4
3.4t 3.4*
2.4
3.0$
2.0
3.0*
DISCUSSION
2.1
2.7*
1.9
2.6t
2.8t 1,3 1.6 1.6
2.3 2.3* 2.2* 2.2t
Internal medicine residency appears to provide inadequate preparation in many common outpatient gynecologic problems. Practicing internists indicated relatively little residency training in the diagnosis and management of several gynecologic conditions, in contrast to their perceived strong training in the five nongynecologic problems surveyed. This limited preparation is in contrast to the relative frequency with which these gynecologic problems were encountered in clinical practice. Previous studies provide limited information about internal medicine residents' training and the skills used in practice with regard to gynecology.3, 4 A large survey of general internists suggests that gynecologic procedures, such as pelvic examinations and obtaining wet mounts of vaginal discharge, were a part of the majority of practices.3 Wigton et al. questioned program directors about their residents' ability to do these procedures. While residency directors felt that these skills were important, they were less likely to feel that their residents had mastered these procedures. 4 Other studies have suggested that recent graduates felt underprepared in pelvic examination and reported inadequate training in nonmedical subspecialties, including gynecology. H-Is Kiel and colleagues found that residents trained in primary care residencies reported significantly superior preparation in gynecology, including pelvic examination, than did traditional internal medicine graduates. 16 The only study that actually tested skills reported that ten of 30 internal medicine residents were unable to detect an adnexal mass on a synthetic pelvic mode. 17 Our results suggest that internists may receive inadequate preparation in managing a wide range of common gynecologic problems. Major differences were not seen in either the residency preparations or the practice patterns of internists trained during different time periods. This suggests that instruction in ambulatory gynecology may not have changed significantly over the past 15 years despite the recent emphasis on women's health issues. 18While the 23% of respondents who were academic internists may exceed the proportion of academics among internists,
*Based on Likert scale ranging from 1 (never encountered) to 5 (encountered on most clays of practice). t p < 0.01 (comparing men versus women internists' practice experiences). tp < 0.001 (comparing men versus women internists' practice experiences).
women, when and how to switch birth-control pills, the ability to perform a Pap test, and the ability to detect a pelvic mass, as well as the diagnosis and management of menopause, breast lumps, urinary incontinence (in women), and osteoporosis (all p < 0.01). In contrast, internists reported more training than practice experience for the diagnosis and management of sexually transmitted diseases, pelvic inflammatory disease, medical conditions in pregnancy, and all five nongynecologic areas surveyed (p < 0.01) (Table 2). The year of completion of residency training did not correlate with the frequency with which internists encountered most of the clinical problems or with amount of residency preparation. The more recently trained internists reported significantly more clinical experience in practice only for safe-sex counseling and the diagnosis and management of sexually transmitted diseases and more residency training only for safe-sex counseling, detection of pelvic masses, and management of sepsis (p < 0.01). The general internists encountered women's health problems far more often in practice than did the subspecialists (p < 0.001 for 17/25 problems listed in Table 2). However, general internists and subspecialists did not exhibit significant demographic differences or report differences in their amounts of training in women's health. Finally, data were analyzed on the basis of physician gender. Preparation in women's health did not
JOURNALOF GENERALINTERNALMEDICINE, Volume7 (November/December), 1992
this probably reduced the overall frequency with which common gynecologic problems were encountered in practice (due to smaller practices in academic medicine), actually reducing the differences reported between residency and practice experiences. The perceived weaknesses reported by internists in ambulatory gynecology training may indicate overall weaknesses in ambulatory training. Although some of the nongynecologic comparison topics chosen have both inpatient and ambulatory components, the reported superior training in these areas may reflect a long-term history of greater emphasis on inpatient training. Further studies are needed to assess whether primary care training programs, with their increased emphasis on ambulatory care, offer training in ambulatory gynecology equal to the demands of clinical practice. In our study, women internists appear to manage problems in women's health more often, independent of the percentage of women in their practices. The higher response rate from women internists (67% vs. 42% for men internists) may reflect increased interest in, or awareness of, women's health issues. The more frequent management of gynecologic problems by women internists was independent of their percentages of women patients. Thus, women physicians seem both to see more women patients and to manage more gynecologic problems among the women patients seen. The patient distribution data may reflect this practice pattern or patient preferences. Two prior reports have suggested that women patients may prefer women physicians, particularly for the management of gynecologic problems.19, 2o Further study is needed to determine whether the increased number of gynecologic problems seen by women physicians reflects higher physician interest, increased patient willingness to bring these issues to women physicians, or a combination of both. Our study has several potential limitations. The response rate was relatively low. It is possible that nonresponders may be significantly different from responders. While we cannot rule out this possibility, there is no evidence that those physicians with the least training in gynecology would reply more frequently than those with greater training. Our study relied solely on self-assessment, rather than skills testing. Future studies may want to incorporate additional instruments to assess how well internists' self-assessment compares with some additional objective testing. The physicians surveyed also represented a limited geographic area, the metropolitan Portland area, and the results may not be generalizable to other metropolitan or rural areas. Our findings suggest that training in ambulatory gynecology is deficient compared with the demands of
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practice. Our results provide an initial needs assessment and can help guide curriculum development. Further studies are warranted to confirm these findings and define what experiences are required so that trainees perceive that their training is adequate and commensurate with practice requirements. The results indicate that expanded training in gynecology is needed to prepare graduates for internal medicine practice.
The authors acknowledge the wonderful assistance and patience of Darlene Coffey, Sue Simmons, and Marcella Loprinzi and the invaluable advice and suggestions of Dr. Marcia K. Coodley, for without their help, the study would have been impossible.
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