http://informahealthcare.com/pog ISSN: 0167-482X (print), 1743-8942 (electronic) J Psychosom Obstet Gynaecol, 2014; 35(2): 37–41 ! 2014 Informa UK Ltd. DOI: 10.3109/0167482X.2014.912210

ORIGINAL ARTICLE

National survey on psychosocial obstetrics and gynecology curriculum in US medical schools Jonathan Schaffir1, Valerie Waddell1, Dawn Watson1, and David Way2 1

Department of Obstetrics and Gynecology and 2Office of Education and Curricular Research Development, The Ohio State University College of Medicine, Columbus, OH, USA Abstract

Keywords

Introduction: This study sought to identify how psychosocial topics related to women’s health are taught and assessed in the obstetrics/gynecology program of American medical schools, and what issues may prevent or promote their instruction. Methods: A questionnaire was distributed to the ob/gyn clerkship director of every US medical school. Directors were asked whether each of four recommended topics were covered in their curricula. They were also asked about barriers to instructing topics not taught, and the importance of these topics. Results: Out of 136 US medical schools, 57 questionnaires were returned (response rate ¼ 40.4%). In all, 27 schools (48%) include formal training in pregnancy-related mood disorders, 33 (58%) include pre-menstrual syndrome/pre-menstrual dysphoric disorder, 29 (51%) include female sexual dysfunction and 45 (79%) include violence against women. Six schools (12%) listed none of these topics as taught. All but three of the clerkship directors agreed that psychosocial topics are important. The most common reason given for lack of instruction was insufficient time allotted. Conclusions: Despite agreement on their importance, many US medical schools do not teach psychosocial aspects of women’s health. Addressing the barriers to teaching these topics would help provide medical students with more opportunities to learn about these issues.

Medical education, medical school, psychosocial curriculum, women’s health

Introduction Undergraduate medical education involves shoehorning a huge amount of information into a finite amount of time. There is so much basic science, clinical skill, system-based practice and professional responsibility that need to be fit into medical school curriculum that many educators find it difficult to find room for them all. Some of the topics that often get short shrift involve aspects of behavioral medicine. Whether due to student perception of its relative unimportance, or low emphasis placed by medical faculty, instruction in psychosocial topics is often less than what is considered comprehensive or adequate [1,2]. In teaching about the health care of women, it is particularly important to recognize psychosocial issues. Women have a greater likelihood than men to receive a

Address for correspondence: Jonathan Schaffir, MD, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 493C McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210, USA. Tel: +1 614 293-9899. Email: jonathan.schaffir@ osumc.edu

History Received 18 January 2014 Revised 19 March 2014 Accepted 2 April 2014

mental health diagnosis during their lifetimes, and there are a wide variety of mood and anxiety disorders that are associated with hormonal changes through a woman’s lifespan (e.g. premenstrual changes, post-partum changes, menopausal changes). Despite the frequency and importance of these issues, physicians are graduating who feel ill-equipped to care for women with such problems. An Australian survey demonstrated that students in their final year of medical school tended to underestimate the prevalence of depression after childbirth and the duration of patient’s symptoms [3]. A survey of residents in a Massachusetts program asked its graduates to rate their preparedness for preventive counseling. While the majority was comfortable with discussing topics such as smoking, diet and exercise, only a minority felt prepared to counsel their patients about depression, substance abuse and domestic violence [4]. Though many agree on the importance of teaching future doctors about these issues, there is less agreement on when and how to convey this instruction. The psychiatric aspects of reproductive mental health, violence and trauma may be wellsuited to inclusion in a psychiatry clerkship [5]. However, because many psychological topics are female-specific and related to reproductive physiology, they should be taught in

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the context of learning about care of women. Rauchfuss et al. have described a curriculum that includes such topics in a gynecology training program [6]. In the United States, the guidelines for what educational topics merit inclusion in obstetrics and gynecology rotations are determined by the Association of Professors of Gynecology and Obstetrics (APGO). The Undergraduate Medical Education Committee of this organization has published a list of 58 educational topic areas that should be included in ob/gyn clerkships [7]. Among these are four topics that are exclusively psychosocial in nature: pregnancyrelated mood disorders, pre-menstrual dysphoric disorder, female sexuality and violence against women. The authors recognize that these topics are associated with substantial morbidity in female patients, and are equally deserving of instruction alongside clinical diagnoses such as abnormal uterine bleeding and labor disorders. Despite having these guidelines available, there is no literature available to demonstrate to what degree they are followed. If students and residents are uncomfortable with psychosocial topics in women’s health, it may be because these topics are not given sufficient attention in medical school. Awareness of how much time is devoted to these topics and what form such instruction takes could help individual institutions to improve their offerings on these subjects. Identifying barriers to providing sufficient psychosocial women’s health instruction could also help by inspiring solutions to overcome these barriers. The goal of this study is to gather information from ob/gyn clerkship directors about how these psychosocial topics are being taught in American medical schools. If shortcomings in their curricula are identified, it will help to target what issues may be better addressed for graduating physicians. The sharing of education strategies may allow for development of better resources to increase competency of medical students and residents in addressing psychosocial concerns.

Methods The study was conducted by Internet survey. Electronic correspondence was sent to the published e-mail address of the clerkship director of each US medical school’s obstetrics and gynecology department. This letter invited the recipient to participate in the survey by visiting a secure survey website (Survey Monkey). The letter explained the rationale for the research and the nature of the questionnaire. Clerkship directors were contacted twice electronically, and then nonresponders were sent a hard copy by regular mail. For institutions where the accuracy of the information on its internet site was in doubt, telephone calls were placed to the ob/gyn department to determine an accurate address. Subjects who visited the survey website were asked to complete a questionnaire in three parts. The first part inquired about the amount of instruction devoted to each of four psychosocial topics that APGO includes in its list of core competencies: peripartum mood disorders, pre-menstrual dysphoric disorder, female sexuality and violence against women. The questionnaire asked about what formats were used for teaching each subject, how many hours were devoted to the topic, and how mastery was assessed. For those

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institutions where the topic was not included in the rotation’s curriculum, subjects were also asked to state why the topic was not included. The second part included a series of statements about instruction of psychosocial topics. Subjects were asked to rank their degree of agreement with each statement on a five-point Likert scale. Finally, subjects were asked some general demographic information about themselves, such as their age, gender, time in practice and specialty. Each was also asked about the size and location of his or her medical school. The aggregate data were de-identified and statistically analyzed to demonstrate percentages for each response. Where appropriate, quantitative data were compared by t test or ANOVA for continuous variables and by contingency tables for categorical variables. As the intention was to recruit the number of subjects corresponding to the total number of US medical schools, no power calculation was performed in advance. The research was approved by the Institutional Review Board of the Ohio State University.

Results From the 136 medical schools contacted, 57 clerkship directors sent responses, yielding a response rate of 40.4%. Their average age was 46 (SD ¼ 8.9), and they had been in practice an average of 15.5 years (SD ¼ 9.9) with 5.1 (SD ¼ 4.8) of those years spent in the position of clerkship director. Regarding gender, 36 (63.2%) of the respondents were female, 18 (31.6%) were male and 3 did not provide data. The majority (73.7%) identified themselves as generalists, while 13 (22.8%) identified themselves as subspecialists. Most respondents were from medium sized schools with class sizes between 100 and 200; only 10 (17.6%) questionnaires were received from schools with enrollments of less than 100 per class and 7 (12.3%) from schools larger than 200 per class. Of the four topics of interest for the study, the one that was most frequently taught in ob/gyn rotations was violence against women. There were 45 schools (79%) that provided formal instruction in this topic, with 31 using lecture as a teaching method, 18 using small group discussions, 13 providing required reading, 10 giving instruction in a clinical setting and 4 using a computer-based module. [Note: Because respondents were allowed to choose more than one response, the total number of teaching methods is greater than the total number of programs.] Thirty-three (58%) of the schools offered formal instruction on premenstrual dysphoric disorder, with 16 using lecture as a teaching method, 13 each using small group discussions and required reading, 9 instructing in a clinical setting and 4 using computer-based modules. Sexual dysfunction is a topic taught formally in 29 (51%) schools, with 16 providing lectures, 12 providing required readings, 7 teaching the subject in a clinical setting, 5 using small group discussions and 4 using computer-based modules. Only 27, or just under half, of the schools included formal instruction on pregnancy-related mood disorders during the ob/gyn rotation. Sixteen provided lectures, 10 used required readings, 9 each reported instruction through small group discussions and clinical rounds and 3 used computer-based modules.

US curriculum survey

DOI: 10.3109/0167482X.2014.912210

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Table 1. Level of agreement with statements regarding psychosocial education. Statement

# disagree (%)

It is important for all medical students to understand common mental health topics in women Psychosocial topics are important to the discipline of obstetrics and gynecology Faculty in my department have a strong interest in psychosocial issues related to women’s health Students in my program have a strong interest in learning about psychosocial issues related to women’s health Students who graduate from my medical school are well prepared to identify psychosocial issues that relate to women’s health Students who graduate from my medical school are well prepared to help a woman manage the psychosocial issues that relate to her health My department should devote more time to the instruction of psychosocial issues that relate to women’s health My medical school should devote more time to the instruction of psychosocial and behavioral issues in general

# neutral (%)

3 (5.6)

0

# agree (%) 51 (94.4)

3 (5.6) 11 (20.4)

0 12 (22.2)

51 (94.4) 31 (57.4)

7 (13.0)

19 (35.2)

28 (51.9)

4 (7.4)

20 (37.0)

30 (55.6)

6 (11.1)

26 (48.1)

22 (40.7)

8 (14.8)

13 (24.1)

33 (66.1)

11 (20.4)

13 (24.1)

30 (55.6)

Table 2. Comparison of clerkship directors who include all topics in curriculum versus including none. Characteristic ‘‘It is important for all medical students to understand . . .’’ Likert score ‘‘Psychosocial topics are important. . .’’ Likert score Age Years in practice Years as clerkship director Generalist?

Include all (n ¼ 15) 4.9 4.9 48.5 17.8 5.3 15

(0.35) (0.26) (8.5) (9.9) (4.7) (100%)

Include none (n ¼ 6) 3.7 3.7 38 8.2 1.7 3

(1.8) (1.8) (2.9) (6.4) (0.8) (50%)

p value 0.02 0.02 0.009 0.04 0.08 0.015

Responses given as mean (standard deviation).

The clerkship directors who did not include these topics in their courses gave varied reasons for their omission. The most common reason provided was insufficient time during the rotation to cover the topics, with other reasons being that the topics were covered in other rotations (most frequently in preclinical courses or in Psychiatry or Family Medicine rotations), that there were insufficient resources to provide training, or that they lacked faculty with the expertise to provide instruction. The statements for which clerkship directors were asked about their level of agreement are shown in Table 1. All but three respondents agreed with the statements regarding the importance of these topics for medical students. There was less agreement with the statements regarding interest in these topics. The lowest level of agreement (40.7% in agreement) was with the statement about medical school graduates being well-prepared to manage psychosocial issues. One of the objectives of this study was to identify predictors that may be associated with the inclusion of psychosocial topics in the clerkship curriculum. However, comparison between groups proved difficult due to the wide variety of patterns with some directors including certain topics but not others. To identify which demographic factors may be associated with inclusion of psychosocial topics, those directors who include all of these topics in their curriculum were compared with those who include none. Fifteen respondents oversee curricula where all four topics are included, and six include none of the four. The comparison is shown in Table 2. As would be expected, inclusive directors are more likely to agree that such topics are important. These directors were also found to be older, more experienced and more likely to be generalist practitioners.

Discussion Among ob/gyn clerkship directors in the US, there is agreement that psychosocial topics are an important aspect of women’s health and worthy of instruction. However, several of the topics recommended by APGO’s Undergraduate Medical Education Committee are not formally included in medical school training. The results suggest a failure on the part of many American medical schools to adequately train their graduates about important issues such as mood disorders, sexual dysfunction and domestic violence as they relate to women’s clinical health. Failure to include these topics is most often ascribed to a lack of time during the limited timeframe of the rotation, or a lack of resources and faculty with expertise. Although this is the first study to globally survey ob/gyn clerkship directors about psychosocial topics in general, there have been surveys regarding specific topics. A 2003 survey sought information about human sexuality education in medical schools in the US and Canada. This study found that 83% of the schools surveyed offered didactic instruction on issues related to sexuality, but this primarily occurred during the preclinical phase of medical education. In 55% of the schools surveyed, there was some opportunity for students to get clinical experience dealing with sexuality issues during a clerkship rotation as well [8]. A review of the literature regarding sexuality education reveals that this is a significant improvement over time, since only three medical schools offered any curriculum on sexuality in 1964, and less than half incorporated instruction on sexual dysfunction in 1980 [9]. Similarly, there have been improvements in getting issues of domestic violence taught in American medical schools.

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A review of education on this topic reveals that in 1989, 53% of schools did not offer any formal training on adult domestic violence, while a 1999 survey indicated that all US medical schools offered training on interpersonal violence ‘‘in some form’’ [10]. Again, the majority of education was given in the classroom years before any clinical exposure. There have been no surveys of schools that indicate the frequency with which peripartum or menstrually related mood disorders are included in formal curricula. With an incidence of 10–15% of births and the potential to impact the health of mothers and babies [11], post-partum depression is a topic with greater frequency and impact than many of the pathological conditions routinely taught in obstetrics rotations. Yet the current study indicates that there is formal training in less than half of the programs surveyed. Although mood disorders related to pregnancy or menstruation may overlap with mood disorders reviewed in psychiatry rotations, these issues are very specific to women’s health and deserve attention in the obstetrics and gynecology rotation. A focus group of psychiatry clerkship leaders in 2002 identified these topics as important for inclusion in psychiatry rotations, though they acknowledged that learning objectives from their institutions were unlikely to specify these issues [5]. Based on these reports, there is an increasing interest in including psychosocial issues related to women’s health in medical school curricula. However, many of these subjects are taught in the first 2 years of medical school when clinical exposure is minimal and students do not have the opportunity to recognize their clinical importance. Educators in our survey acknowledge that there is frequently insufficient time during a clinical rotation for students to receive formal training. To achieve the objective of having students understand these issues in a clinical context, it is important for curriculum planners to reserve time for such instruction, whether by integrating clinical experience into the first 2 years when these subjects are taught, or by including didactic resources and expert faculty in the clinical rotations. Some educators have described innovative teaching methods to circumvent these concerns. For example, at the University of Texas Medical School at San Antonio, faculty have created an Objective Structured Clinical Exam (OSCE) that focuses on psychosocial issues in women’s health [12]. This exercise provides an opportunity for education and feedback for a group of students in a single day. At the University of Massachusetts, domestic violence is taught in an ‘‘interclerkship’’, which concentrates the topic in a 2-day exercise that occurs in between the traditional rotations, involving educators from multiple disciplines [13]. Such innovative ideas for leveraging the expertise and time availability of multiple faculty may serve as models for how other psychosocial topics can be introduced into the busy clinical curriculum. By focusing our survey only on ob/gyn curriculum leaders, the study was limited in not identifying all of the aspects of medical school in which these subjects may receive formal recognition. However, the APGO guidelines on which the survey was based are intended to serve as a yardstick for training within the obstetrics and gynecology department. Even if such topics are taught elsewhere, this professional

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association endorses additional inclusion of education about psychosocial topics within the clinical arena. The study was also limited by its use of an Internet survey. Though great care was taken to verify the accuracy of addresses and provide multiple opportunities for response, the response rate was still less than half of the total number of medical schools. There may be a response bias in that clerkship directors who have an interest in these topics may have been more likely to respond. If this is the case, the results may be skewed to demonstrating a greater interest and presence in formal curriculum than there actually is. Furthermore, the survey was not validated, and its statements are open to interpretation. Free responses that were included, however, indicated that respondents did understand what was being asked, and interpretation bias was thought to be low. Overall, the study demonstrated a strong level of agreement among educators that psychosocial topics should be included in medical student education that pertains to women’s health. The finding that those who are most supportive of including these topics were also older and more experienced suggests that this sentiment is related to the wisdom and perspective that such additional experience will bring. Given the interest in ensuring that medical students receive training in these topics, educators should work to remove barriers that might prevent such education. Some of the tactics suggested by our findings would include the use of independent study modules that students could consult without using up valuable clinical time, and the development of a standardized instruction guide from experts that may overcome an institution’s lack of expertise in a given area. Without such efforts to improve medical school curricula, it is likely that a substantial number of American physicians will lack the training to recognize and treat morbidity related to behavioral issues in their female patients. Untreated mood disorders, sexual disorders and unrecognized cycles of violence are sources of suffering for a significant portion of female patients, and add to burgeoning health care costs as well. By preparing their students to deal with these disorders, American medical schools will successfully be able to graduate students who become competent and humanistic physicians, able to care for all the health needs of women.

Declaration of interest The authors have received no financial support for this study, and they report no declarations of interest.

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6. Rauchfuss M, Kentenich H, Siedentopf F, Danzer G. New challenges in medical education: the psychosomatic training program for gynecologists in Germany. J Psychosom Obstet Gynecol 2005;26:85–91. 7. Hammoud MM, Casey PM, Chuang AW, et al. APGO Medical Student Educational Objectives, 9th ed. Crofton, MD: Association of Professors of Gynecology and Obstetrics; 2009. 8. Solursh DS, Ernst JL, Lewis RW, et al. The human sexuality education of physicians in North American medical schools. Int J Impot Res 2003;15:S41–5. 9. Shindel AW, Parish SJ. Sexuality education in North American medical schools: current status and future directions. J Sex Med 2013;10:3–18.

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10. Hamberger LK. Preparing the next generation of physicians: medical school and residency-based intimate partner violence curriculum and evaluation. Trauma Violence Abuse 2007;8: 214–25. 11. Seyfried LS, Marcus SM. Postpartum mood disorders. Int Rev Psychiatry 2003;15:231–42. 12. Schillerstrom JE, Lutz ML, Ferguson DM, et al. The Women’s Health Objective Structured Clinical Exam: a multidisciplinary collaboration. J Psychosom Obstet Gynaecol 2013;34: 145–9. 13. Jonassen JA, Pugnaire MP, Mazor K, et al. The effect of a domestic violence interclerkship on the knowledge, attitudes and skills of third-year medical students. Acad Med 1999;74:821–8.

ä Current knowledge on this subject  Educators agree that medical students should learn about psychosocial topics that relate to women’s health.  In the United States, the Association of Professors of Obstetrics and Gynecology has published a guideline to identify important topics.  It is unclear how often this advice is followed by those who design medical curriculum. ä What this study adds  Psychosocial topics are often left out of the curriculum in obstetrics/gynecology clerkships in US medical schools.  Formal training in peripartum mood disorders is included in less than half of these programs.  Medical educators agree on their importance but cite lack of time and expertise as barriers to including these topics in the curriculum.

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National survey on psychosocial obstetrics and gynecology curriculum in US medical schools.

This study sought to identify how psychosocial topics related to women's health are taught and assessed in the obstetrics/gynecology program of Americ...
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