MENTORING, EDUCATION, AND TRAINING CORNER John Del Valle, Section Editor
Developing a Fellowship Curriculum in Women’s Gastrointestinal Health Deepika Devuni and Reena V. Chokshi University of Connecticut Health Center, Farmington, Connecticut
A
ccording to the 2010 census, the 156 million women in the United States make up just over half (50.8%) of the nation’s population.1 However, there still exists a disparity in health care between the sexes. Sex and gender differences exist across all facets of health and disease. In 1985, a Public Health Service task force concluded that exclusion of women from clinical research was detrimental to women’s health.2 Because of this, the National Institutes of Health (NIH) adopted guidelines urging the inclusion of women in NIH-sponsored clinical research and the analysis of outcomes by gender.3,4 This eventually led to the establishment of the Office of Research on Women’s Health in 1990, an organization aimed at improving and expanding the study of women’s health. The Office of Research on Women’s Health recently released their third report in 2010, which outlines their vision and major goals for the advancement of women’s health research through 2020.5 In 1995, the directors of the American Board of Internal Medicine initiated a curriculum and developed competencies for teaching women’s health in internal medicine residency programs.6 This was followed by a groundbreaking report by the Institute of Medicine in 2001 concluding that the incidence and severity of diseases vary between sexes, and barriers to the advancement of knowledge about sex differences should be eliminated.7 Soon after, the Gastroenterology Leadership Council, composed of the 4 major gastroenterological societies, introduced in 2003 training in women’s digestive health into the Gastroenterology Core Curriculum.8 Today, attention to women’s gastrointestinal (GI) health has increased significantly, but challenges remain in integrating this topic into fellowship training. A 2011 study reported that both fellows and program directors feel that training in women’s GI health is insufficient across multiple domains, citing such barriers as
lack of faculty interest and poor collaboration between gastroenterology and obstetrics and gynecology.9
Sex and Gender Differences in GI Disease Sex and gender differences in digestive disorders are seen in all age groups (Table 1). Hormonal variation occurs with menstrual cycles, pregnancy, and menopause, and can impact GI function. Sex-based variation in drug metabolism may cause differences in medication side effects. Provider interaction with female patients requires an understanding of cultural and psychosocial factors and development of appropriate history-taking skills. Functional bowel disorders are among the most common reasons for outpatient gastroenterology visits. Irritable bowel syndrome, the most prevalent functional bowel disorder, has a notably higher prevalence in females compared with males. In addition, more American women than men seek health care services for irritable bowel syndrome, although this is not found in all cultures.10,11 GI motility may also vary between men and women. For example, it has been suggested that women have longer gastric emptying times for solids.12 Menopause is thought to negate this difference, unless a woman is on hormone replacement therapy.13 Pregnancy presents unique changes in digestive tract function. For example, increased progesterone levels lead to relaxation of the lower esophageal sphincter, thereby increasing the risk for gastroesophageal reflux disease.14 One study reported that 22.9% of pregnant women with gastroesophageal reflux disease required medication because of severe symptoms, with a significant reported impact on quality of life.15 Pregnancy is also associated with an increased incidence of gallstone disease through an increase in cholesterol saturation of bile, elevated ratio of cholic to chenoxycholic acid, increased secretion rate of cholesterol, and decreased gallbladder motility.16 Pregnancy-specific GI disorders are well-known and include hyperemesis gravidarum, acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy. Although © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.021
Gastroenterology 2014;146:1151–1155
MENTORING, EDUCATION, AND TRAINING CORNER Table 1.Sex differences in GI diseases Sex-based difference Diseases more commonly seen in women Diseases less commonly seen in women Pregnancy-related diseases (unique to pregnancy)
Pregnancy-related diseases (not unique to pregnancy) Diseases that can affect fertility Decreased female compliance with recommendations
Examples Irritable bowel syndrome Primary biliary cirrhosis Autoimmune hepatitis Barrett’s esophagus Esophageal adenocarcinoma Hepatocellular carcinoma Hyperemesis gravidarum Acute fatty liver of pregnancy Intrahepatic cholestasis of pregnancy Gastroesophageal reflux disease Constipation Gallstone disease Inflammatory bowel disease Celiac disease Colorectal cancer screening
trainees must learn the details of these disorders, it is important to note that more GI consultations in pregnant patients are sought for evaluation of disorders not unique to pregnancy. Based on one study, management of the majority of these patients can be altered in a positive way by involvement of a gastroenterologist.17 Certain digestive disorders can impact women’s reproductive cycles. A recent prospective study concluded, for example, that patients with inflammatory bowel disease (IBD) experience more frequent premenstrual GI symptoms than healthy controls. It further described significantly higher numbers of stools and loose stools as well as more severe abdominal pain among IBD patients during their menstrual cycles.18 This argues for consideration of time in menstrual cycle during symptom assessment in IBD patients. In addition, we know that IBD can affect fertility and pregnancy, especially with more active disease.19 Female patients with celiac disease also carry a risk of decreased fertility, along with potential for spontaneous abortions, preterm deliveries, and delivery of low birth weight infants.20 Like irritable bowel syndrome, some digestive and liver diseases are more common in women versus men. One notable example is primary biliary cirrhosis, which affects females at a ratio as high as 10:1.21 In contrast, female sex can have a protective effect in certain diseases. For example, both Barrett’s esophagus and esophageal adenocarcinoma are seen less frequently in women. Women tend to develop Barrett’s later than men and have a decreased rate of progression to high-grade dysplasia and cancer.22 Hepatocellular carcinoma is another such disease. The risk of developing hepatocellular carcinoma is higher among men, likely owing to the higher rate of certain risk factors, the protective effects of estrogen, and the detrimental effects of testosterone.23 Finally, special attention must be paid to women with regard to colorectal cancer screening. Despite colorectal
1152
cancer being common in both sexes, several studies have demonstrated a lower overall screening compliance in women versus men.24 Women are less likely to be referred for screening colonoscopy and often delay for reasons such as fear of pain, embarrassment, and inconvenience.24,25 Multiple studies have suggested that female patients prefer female endoscopists and are willing to wait for their procedures until one becomes available. 24,26 Technically, colonoscopic evaluation in women can be more difficult than in men, likely owing to longer, more tortuous anatomy and increased likelihood of previous abdominal surgeries, such as hysterectomy.26 This results in lower completion rates, longer procedure times, and greater sedation requirements, even in normal weight females.27
Curriculum Development in Women’s GI Health When establishing a curriculum in women’s GI health, several factors must be taken into account. First, adequate training in this topic extends beyond gastroenterology. This undertaking is a multidisciplinary effort and should include, if possible, representatives in such fields as obstetrics and gynecology, urology, surgery, nutrition, oncology, physical therapy, psychiatry, radiology, primary care, and geriatrics. Communication and collaboration among the women’s health faculty can enhance the experience for trainees. That said, key faculty members within the gastroenterology division are essential to leading the initiative. Next, curricular development requires a clear plan and objectives. These can be based on the Gastroenterology Core Curriculum developed by the American Gastroenterological Association, American College of Gastroenterology, American Association for the Study of Liver Diseases, and American Society for Gastrointestinal Endoscopy, which clearly describes goals for training in general women’s digestive health as well as specific health and disease states, including pregnancy.28 In addition, specific topics can also be promoted, such as corresponding digestive differences in men and/or differences in the lesbian, gay, bisexual, and transgender population. Performing a needs assessment at one’s own institution may be a helpful way to begin. At Brown University, where women’s GI health has been a focus since 1996, they began by conducting informal interviews of various practitioners to assess needs and develop foci for training.29 Learning objectives should be both didactic and clinical so that the curriculum can be built on both goals. Didactic sessions can include core lectures from faculty across specialties, small group conferences, simulations, and/or web-based modules. Clinical training should focus on inpatient and outpatient care of women at all stages along with procedural training, including endoscopy and manometry. How exactly an institution integrates women’s health into the GI curriculum depends heavily on the resources
MENTORING, EDUCATION, AND TRAINING CORNER available. According to the GI Core Curriculum, 25% of all patients seen in each of the clinical settings, including continuity clinic and procedures, must be women.28 This can prove difficult in certain settings, such as a Veteran’s Administration hospital, so care should be taken to increase exposure in different ways. Conversely, trainees with access to a women’s hospital may have the added experience of seeing pregnancy consults and/or working with postpartum patients on pelvic floor care. Each institution must assess its own needs and utilize its resources to the fullest. At our institution, adding women’s GI health to the curriculum has occurred alongside the development of a women’s GI health clinic and an endoscopy day service dedicated to female patients and providers. Thus, along with monthly didactic sessions and motility study interpretation, fellows rotate through these weekly sessions. Some institutions have been able to organize full women’s GI health rotations and even dedicated fellowship tracks, complete with various specialty clinics, inpatient consults, anorectal motility training, didactic sessions, and research time. Again, these training opportunities depend on availability of expertise and other resources that help to guide curriculum development (Figure 1). Various teaching aids are at our disposal to “fill the gaps” of our institutions where needed. The American Gastroenterological Association includes topics in women’s digestive health and disease as part of its Digestive Diseases Self-Education Program30 and Gastroslides31 curricula. These resources provide background, PowerPoint slides, and test questions that can easily be integrated into didactic sessions. In addition, collections of women’s health-related studies can be supplemented by these resources to enhance the breadth of the trainees’ exposure. Case-based simulations provide clinical
scenarios that may be missing at a given institution. Currently, researchers at the University of Wisconsin Health Center, headed by Dr Sumona Saha, are working to build a module of cases based on the women’s digestive health section of the GI Core Curriculum that incorporates scores and real-time feedback for learners (personal communication with Dr Saha). When complete, these simulations will likely have far-reaching effects on the quality of the women’s GI health education for our fellows. With the foundation of the curriculum in place, attention can move toward competency assessment and scholarship. Assessment of fellows can come in various forms. Trainees’ competency should be assessed in clinical settings, possibly using mini-CEX or Objective Structured Clinical Examination formats, as well as during procedures. Questionnaires and/or board-type questions can be given both before and after rotations to evaluate progress. Fellows should also have opportunities for scholarly advancement in women’s GI health. Critical appraisal of the literature in women’s health topics can be included in the form of journal clubs and other didactic sessions. Opportunities for original research should be encouraged, as should involvement with faculty projects. At some institutions, the NIH sponsors a K12 career development award for junior faculty called Building Interdisciplinary Research Careers in Women’s Health. The goal of Building Interdisciplinary Research Careers in Women’s Health is to increase the number and skills of clinical investigators in women’s health through mentorship with other women’s health researchers. Knowledge of programs like this one can empower our fellows to seek grants and move forward as academic gastroenterologists with a focus on women’s GI health.
Figure 1. Sample curriculum components.
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MENTORING, EDUCATION, AND TRAINING CORNER Developing a women’s GI health curriculum can be an exciting and challenging task. There are clear differences in women’s digestive health and disease compared with men, and this provides us with a unique opportunity to improve the education of our trainees. Assessing institutional resources and collaborating between disciplines can initiate this undertaking of creating a curriculum, and supplemental resources are available. These efforts strengthen fellowship education and can serve as a backbone for the academic and clinical advancement of women’s GI health.
References 1. Howden LM and Meyer JA. Age and sex composition: 2010. 2010 Census Briefs, United States Census Bureau, May 2011. Available at: http://www.census.gov/prod/ cen2010/briefs/c2010br-03.pdf. Accessed February 25, 2014. 2. Women’s health. Report of the Public Health Service Task Force on Women’s Health Issues. Public Health Rep 1985;100:73–106. 3. National Institutes of Health. NIH guide for grants and contracts. Bethesda, MD: National Institutes of Health, 1986. 4. National Institutes of Health Revitalization Act of 1993. Public Law 103-43, 1993. Available at: http://grants.nih. gov/grants/olaw/pl103-43.pdf. 5. Pinn VW, Clayton JA, Begg L, et al. Public partnerships for a vision for women’s health research in 2020. J Womens Health (Larchmt) 2010;19:1603–1607. 6. Day SC, Cassel CK, Kimball HR. Training internists in women’s health: recommendations for educators. American Board of Internal Medicine Committee on General Internal Medicine. Am J Med 1996;100: 375–379. 7. Institute of Medicine Committee on Understanding the Biology of Sex and Gender Differences, Board on Health Sciences Policy. Exploring the biological contributions to human health: does sex matter? J Womens Health Gend Based Med 2001;10:433–439. 8. American Association for the Study of Liver Diseases; American College of Gastroenterology; American Gastroenterological Association; American Society for Gastrointestinal Endoscopy. Training the gastroenterologist of the future: the Gastroenterology Core Curriculum. Gastroenterology 2003;124:1055–1104. 9. Saha S, Roberson E, Richie K, et al. Women’s health training in gastroenterology fellowship: a national survey of fellows and program directors. Dig Dis Sci 2011; 56:751–760. 10. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography and health impact. Dig Dis Sci 1993;38:1569–1580. 11. Camilleri M. Management of the irritable bowel syndrome. Gastroenterology 2001;120:652–668. 12. Knight LC, Parkman HP, Brown KL, et al. Delayed gastric emptying and decreased antral contractility in normal
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13.
14.
15.
16.
17.
18.
19.
20.
21. 22.
23.
24.
25.
26.
27.
28.
premenopausal women compared with men. Am J Gastroenterol 1997;92:968–975. Hutson WR, Roehrkasse RL, Wald A. Influence of gender and menopause on gastric emptying and motility. Gastroenterology 1989;96:11–17. Malfertheiner SF, Malfertheiner MV, Kropf S, et al. A prospective longitudinal cohort study: evolution of GERD symptoms during the course of pregnancy. BMC Gastroenterol 2012;12:131. Fill Malfertheiner S, Malfertheiner MV, Mönkemüller K, et al. Gastroesophageal reflux disease and management in advanced pregnancy: a prospective survey. Digestion 2009;79:115–120. Kern F Jr, Everson GT, DeMark B, et al. Biliary lipids, bile acids, and gallbladder function in the human female. Effects of pregnancy and the ovulatory cycle. J Clin Invest 1981;68:1229–1242. Saha S, Manlolo J, McGowan CE, et al. Gastroenterology consultations in pregnancy. J Womens Health (Larchmt) 2011;20:359–363. Lim SM, Nam CM, Kim YN, et al. The effect of the menstrual cycle on inflammatory bowel disease: a prospective study. Gut Liver 2013;7:51–57. Bortoli A, Pedersen N, Duricova D, et alEuropean Crohn-Colitis Organisation (ECCO) Study Group of Epidemiologic Committee (EpiCom). Pregnancy outcome in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 20032006. Aliment Pharmacol Ther 2011;34:724–734. Ludvigsson JF, Montgomery SM, Ekbom A. Celiac disease and risk of adverse fetal outcome: a populationbased cohort study. Gastroenterology 2005; 129:454–463. Kaplan MM, Gershwin ME. Primary biliary cirrhosis. N Engl J Med 2005;353:1261–1273. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett’s esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011; 103:1049–1057. El-Serag HB. Epidemiology of viral hepatitis and hepatocellular carcinoma. Gastroenterology 2012; 142:1264–1273. Jimenez B, Palekar N, Schneider A. Issues related to colorectal cancer and colorectal cancer screening practices in women. Gastroenterol Clin North Am 2011; 40:415–426. Ritvo P, Myers RE, Paszat L, et al. Gender differences in attitudes impeding colorectal cancer screening. BMC Public Health 2013;13:500. Wolf JL. Uniquely women’s issues in colorectal cancer screening. Am J Gastroenterol 2006;101(12 Suppl): S625–S629. Czwornog J, Austin GL. Body mass index, age, and gender affect prep quality, sedation use, and procedure time during screening colonoscopy. Dig Dis Sci 2013; 58:3127–3133. Training in women’s health issues in digestive diseases. In: The gastroenterology core curriculum, 3rd ed. 2007. Available at: http://www.gastro.org/gi-fellowship/gicore-curriculum. Accessed December 15, 2013.
MENTORING, EDUCATION, AND TRAINING CORNER 29. Saha S, Esposti SD. Meeting the need for women’s health training in gastroenterology: creation of a women’s digestive disorders program at Brown University. J Womens Health (Larchmt) 2010;19:1409–1415. 30. Rose S. Women’s issues in gastroenterology and hepatology, in DDSEP VII. Bethesda: American Gastroenterological Association, 2013. 31. Rose S (senior author). Digestive health and disease in women. In: GastroSlides. Bethesda: American Gastroenterological Association; 2009. Available at:
http://www.gastroslides.org/Main/deck_intro.asp?tpc¼20. Accessed January 7, 2014.
Reprint requests Address requests for reprints to: Reena V. Chokshi, MD, Assistant Professor of Medicine, Division of Gastroenterology & Hepatology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, Connecticut 06030-1845. e-mail: [email protected]. Conflicts of interest The authors declare no conflicts of interest.
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Developing a Fellowship Curriculum in Women’s Gastrointestinal Health Deepika Devuni and Reena V. Chokshi University of Connecticut Health Center, Farmington, Connecticut
A
ccording to the 2010 census, the 156 million women in the United States make up just over half (50.8%) of the nation’s population.1 However, there still exists a disparity in health care between the sexes. Sex and gender differences exist across all facets of health and disease. In 1985, a Public Health Service task force concluded that exclusion of women from clinical research was detrimental to women’s health.2 Because of this, the National Institutes of Health (NIH) adopted guidelines urging the inclusion of women in NIH-sponsored clinical research and the analysis of outcomes by gender.3,4 This eventually led to the establishment of the Office of Research on Women’s Health in 1990, an organization aimed at improving and expanding the study of women’s health. The Office of Research on Women’s Health recently released their third report in 2010, which outlines their vision and major goals for the advancement of women’s health research through 2020.5 In 1995, the directors of the American Board of Internal Medicine initiated a curriculum and developed competencies for teaching women’s health in internal medicine residency programs.6 This was followed by a groundbreaking report by the Institute of Medicine in 2001 concluding that the incidence and severity of diseases vary between sexes, and barriers to the advancement of knowledge about sex differences should be eliminated.7 Soon after, the Gastroenterology Leadership Council, composed of the 4 major gastroenterological societies, introduced in 2003 training in women’s digestive health into the Gastroenterology Core Curriculum.8 Today, attention to women’s gastrointestinal (GI) health has increased significantly, but challenges remain in integrating this topic into fellowship training. A 2011 study reported that both fellows and program directors feel that training in women’s GI health is insufficient across multiple domains, citing such barriers as
lack of faculty interest and poor collaboration between gastroenterology and obstetrics and gynecology.9
Sex and Gender Differences in GI Disease Sex and gender differences in digestive disorders are seen in all age groups (Table 1). Hormonal variation occurs with menstrual cycles, pregnancy, and menopause, and can impact GI function. Sex-based variation in drug metabolism may cause differences in medication side effects. Provider interaction with female patients requires an understanding of cultural and psychosocial factors and development of appropriate history-taking skills. Functional bowel disorders are among the most common reasons for outpatient gastroenterology visits. Irritable bowel syndrome, the most prevalent functional bowel disorder, has a notably higher prevalence in females compared with males. In addition, more American women than men seek health care services for irritable bowel syndrome, although this is not found in all cultures.10,11 GI motility may also vary between men and women. For example, it has been suggested that women have longer gastric emptying times for solids.12 Menopause is thought to negate this difference, unless a woman is on hormone replacement therapy.13 Pregnancy presents unique changes in digestive tract function. For example, increased progesterone levels lead to relaxation of the lower esophageal sphincter, thereby increasing the risk for gastroesophageal reflux disease.14 One study reported that 22.9% of pregnant women with gastroesophageal reflux disease required medication because of severe symptoms, with a significant reported impact on quality of life.15 Pregnancy is also associated with an increased incidence of gallstone disease through an increase in cholesterol saturation of bile, elevated ratio of cholic to chenoxycholic acid, increased secretion rate of cholesterol, and decreased gallbladder motility.16 Pregnancy-specific GI disorders are well-known and include hyperemesis gravidarum, acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy. Although © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.021
Gastroenterology 2014;146:1151–1155
MENTORING, EDUCATION, AND TRAINING CORNER Table 1.Sex differences in GI diseases Sex-based difference Diseases more commonly seen in women Diseases less commonly seen in women Pregnancy-related diseases (unique to pregnancy)
Pregnancy-related diseases (not unique to pregnancy) Diseases that can affect fertility Decreased female compliance with recommendations
Examples Irritable bowel syndrome Primary biliary cirrhosis Autoimmune hepatitis Barrett’s esophagus Esophageal adenocarcinoma Hepatocellular carcinoma Hyperemesis gravidarum Acute fatty liver of pregnancy Intrahepatic cholestasis of pregnancy Gastroesophageal reflux disease Constipation Gallstone disease Inflammatory bowel disease Celiac disease Colorectal cancer screening
trainees must learn the details of these disorders, it is important to note that more GI consultations in pregnant patients are sought for evaluation of disorders not unique to pregnancy. Based on one study, management of the majority of these patients can be altered in a positive way by involvement of a gastroenterologist.17 Certain digestive disorders can impact women’s reproductive cycles. A recent prospective study concluded, for example, that patients with inflammatory bowel disease (IBD) experience more frequent premenstrual GI symptoms than healthy controls. It further described significantly higher numbers of stools and loose stools as well as more severe abdominal pain among IBD patients during their menstrual cycles.18 This argues for consideration of time in menstrual cycle during symptom assessment in IBD patients. In addition, we know that IBD can affect fertility and pregnancy, especially with more active disease.19 Female patients with celiac disease also carry a risk of decreased fertility, along with potential for spontaneous abortions, preterm deliveries, and delivery of low birth weight infants.20 Like irritable bowel syndrome, some digestive and liver diseases are more common in women versus men. One notable example is primary biliary cirrhosis, which affects females at a ratio as high as 10:1.21 In contrast, female sex can have a protective effect in certain diseases. For example, both Barrett’s esophagus and esophageal adenocarcinoma are seen less frequently in women. Women tend to develop Barrett’s later than men and have a decreased rate of progression to high-grade dysplasia and cancer.22 Hepatocellular carcinoma is another such disease. The risk of developing hepatocellular carcinoma is higher among men, likely owing to the higher rate of certain risk factors, the protective effects of estrogen, and the detrimental effects of testosterone.23 Finally, special attention must be paid to women with regard to colorectal cancer screening. Despite colorectal
1152
cancer being common in both sexes, several studies have demonstrated a lower overall screening compliance in women versus men.24 Women are less likely to be referred for screening colonoscopy and often delay for reasons such as fear of pain, embarrassment, and inconvenience.24,25 Multiple studies have suggested that female patients prefer female endoscopists and are willing to wait for their procedures until one becomes available. 24,26 Technically, colonoscopic evaluation in women can be more difficult than in men, likely owing to longer, more tortuous anatomy and increased likelihood of previous abdominal surgeries, such as hysterectomy.26 This results in lower completion rates, longer procedure times, and greater sedation requirements, even in normal weight females.27
Curriculum Development in Women’s GI Health When establishing a curriculum in women’s GI health, several factors must be taken into account. First, adequate training in this topic extends beyond gastroenterology. This undertaking is a multidisciplinary effort and should include, if possible, representatives in such fields as obstetrics and gynecology, urology, surgery, nutrition, oncology, physical therapy, psychiatry, radiology, primary care, and geriatrics. Communication and collaboration among the women’s health faculty can enhance the experience for trainees. That said, key faculty members within the gastroenterology division are essential to leading the initiative. Next, curricular development requires a clear plan and objectives. These can be based on the Gastroenterology Core Curriculum developed by the American Gastroenterological Association, American College of Gastroenterology, American Association for the Study of Liver Diseases, and American Society for Gastrointestinal Endoscopy, which clearly describes goals for training in general women’s digestive health as well as specific health and disease states, including pregnancy.28 In addition, specific topics can also be promoted, such as corresponding digestive differences in men and/or differences in the lesbian, gay, bisexual, and transgender population. Performing a needs assessment at one’s own institution may be a helpful way to begin. At Brown University, where women’s GI health has been a focus since 1996, they began by conducting informal interviews of various practitioners to assess needs and develop foci for training.29 Learning objectives should be both didactic and clinical so that the curriculum can be built on both goals. Didactic sessions can include core lectures from faculty across specialties, small group conferences, simulations, and/or web-based modules. Clinical training should focus on inpatient and outpatient care of women at all stages along with procedural training, including endoscopy and manometry. How exactly an institution integrates women’s health into the GI curriculum depends heavily on the resources
MENTORING, EDUCATION, AND TRAINING CORNER available. According to the GI Core Curriculum, 25% of all patients seen in each of the clinical settings, including continuity clinic and procedures, must be women.28 This can prove difficult in certain settings, such as a Veteran’s Administration hospital, so care should be taken to increase exposure in different ways. Conversely, trainees with access to a women’s hospital may have the added experience of seeing pregnancy consults and/or working with postpartum patients on pelvic floor care. Each institution must assess its own needs and utilize its resources to the fullest. At our institution, adding women’s GI health to the curriculum has occurred alongside the development of a women’s GI health clinic and an endoscopy day service dedicated to female patients and providers. Thus, along with monthly didactic sessions and motility study interpretation, fellows rotate through these weekly sessions. Some institutions have been able to organize full women’s GI health rotations and even dedicated fellowship tracks, complete with various specialty clinics, inpatient consults, anorectal motility training, didactic sessions, and research time. Again, these training opportunities depend on availability of expertise and other resources that help to guide curriculum development (Figure 1). Various teaching aids are at our disposal to “fill the gaps” of our institutions where needed. The American Gastroenterological Association includes topics in women’s digestive health and disease as part of its Digestive Diseases Self-Education Program30 and Gastroslides31 curricula. These resources provide background, PowerPoint slides, and test questions that can easily be integrated into didactic sessions. In addition, collections of women’s health-related studies can be supplemented by these resources to enhance the breadth of the trainees’ exposure. Case-based simulations provide clinical
scenarios that may be missing at a given institution. Currently, researchers at the University of Wisconsin Health Center, headed by Dr Sumona Saha, are working to build a module of cases based on the women’s digestive health section of the GI Core Curriculum that incorporates scores and real-time feedback for learners (personal communication with Dr Saha). When complete, these simulations will likely have far-reaching effects on the quality of the women’s GI health education for our fellows. With the foundation of the curriculum in place, attention can move toward competency assessment and scholarship. Assessment of fellows can come in various forms. Trainees’ competency should be assessed in clinical settings, possibly using mini-CEX or Objective Structured Clinical Examination formats, as well as during procedures. Questionnaires and/or board-type questions can be given both before and after rotations to evaluate progress. Fellows should also have opportunities for scholarly advancement in women’s GI health. Critical appraisal of the literature in women’s health topics can be included in the form of journal clubs and other didactic sessions. Opportunities for original research should be encouraged, as should involvement with faculty projects. At some institutions, the NIH sponsors a K12 career development award for junior faculty called Building Interdisciplinary Research Careers in Women’s Health. The goal of Building Interdisciplinary Research Careers in Women’s Health is to increase the number and skills of clinical investigators in women’s health through mentorship with other women’s health researchers. Knowledge of programs like this one can empower our fellows to seek grants and move forward as academic gastroenterologists with a focus on women’s GI health.
Figure 1. Sample curriculum components.
1153
MENTORING, EDUCATION, AND TRAINING CORNER Developing a women’s GI health curriculum can be an exciting and challenging task. There are clear differences in women’s digestive health and disease compared with men, and this provides us with a unique opportunity to improve the education of our trainees. Assessing institutional resources and collaborating between disciplines can initiate this undertaking of creating a curriculum, and supplemental resources are available. These efforts strengthen fellowship education and can serve as a backbone for the academic and clinical advancement of women’s GI health.
References 1. Howden LM and Meyer JA. Age and sex composition: 2010. 2010 Census Briefs, United States Census Bureau, May 2011. Available at: http://www.census.gov/prod/ cen2010/briefs/c2010br-03.pdf. Accessed February 25, 2014. 2. Women’s health. Report of the Public Health Service Task Force on Women’s Health Issues. Public Health Rep 1985;100:73–106. 3. National Institutes of Health. NIH guide for grants and contracts. Bethesda, MD: National Institutes of Health, 1986. 4. National Institutes of Health Revitalization Act of 1993. Public Law 103-43, 1993. Available at: http://grants.nih. gov/grants/olaw/pl103-43.pdf. 5. Pinn VW, Clayton JA, Begg L, et al. Public partnerships for a vision for women’s health research in 2020. J Womens Health (Larchmt) 2010;19:1603–1607. 6. Day SC, Cassel CK, Kimball HR. Training internists in women’s health: recommendations for educators. American Board of Internal Medicine Committee on General Internal Medicine. Am J Med 1996;100: 375–379. 7. Institute of Medicine Committee on Understanding the Biology of Sex and Gender Differences, Board on Health Sciences Policy. Exploring the biological contributions to human health: does sex matter? J Womens Health Gend Based Med 2001;10:433–439. 8. American Association for the Study of Liver Diseases; American College of Gastroenterology; American Gastroenterological Association; American Society for Gastrointestinal Endoscopy. Training the gastroenterologist of the future: the Gastroenterology Core Curriculum. Gastroenterology 2003;124:1055–1104. 9. Saha S, Roberson E, Richie K, et al. Women’s health training in gastroenterology fellowship: a national survey of fellows and program directors. Dig Dis Sci 2011; 56:751–760. 10. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography and health impact. Dig Dis Sci 1993;38:1569–1580. 11. Camilleri M. Management of the irritable bowel syndrome. Gastroenterology 2001;120:652–668. 12. Knight LC, Parkman HP, Brown KL, et al. Delayed gastric emptying and decreased antral contractility in normal
1154
13.
14.
15.
16.
17.
18.
19.
20.
21. 22.
23.
24.
25.
26.
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28.
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Reprint requests Address requests for reprints to: Reena V. Chokshi, MD, Assistant Professor of Medicine, Division of Gastroenterology & Hepatology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, Connecticut 06030-1845. e-mail: [email protected]. Conflicts of interest The authors declare no conflicts of interest.
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