Literature Review on Effective Sex- and Gender-Based Systems/Models of Care

January 30, 2007

Research Question 6: Approaches to Improving Care

6. How effective is a focus on clinical care at improving women's healthcare? How effective are systemic improvements (i.e. more women in professorships/research positions or emphasis on women's health in medical school curriculum) at improving women's healthcare? Are there other factors (e.g. continuity of care) that may be more important to women than to men or to women's outcomes vs. men's outcomes?

In this research question, we examine various aspects of healthcare in which interventions can take place to improve women's care. One of the most obvious places to intervene, and the focus of much of this report thus far, is clinical care. Here, we discuss clinical care interventions briefly, and highlight how such interventions can effectively and efficiently improve care. Another possible intervention is to increase the number of women in healthcare leadership positions, for example as doctors, professors, or administrators. We discuss the potential benefits of such a change and also provide a short discussion of the related benefits of increasing the number of ethnic minorities in similar leadership roles. To better understand the impact of such changes, we briefly discuss the literature on male vs. female doctors and gender interactions between doctors and patients. Next, we discuss changes in the medical school, public health, and pharmaceutical curriculums to include a more detailed discussion of the effects of sex and gender on health, as well as efforts to increase the knowledge of existing caregivers. Finally, we discuss other factors that may be related to effective sex- and gender-based care, such as differing preferences between male and female patients.

The clinical-care setting is the primary point of interaction between patients and medical providers. Changes in clinical care could improve the detection and treatment of sex- and gender-based differences in disease and would be especially beneficial in the provision of gender-appropriate preventive screenings. Elsewhere in this report, we have described common clinical care interventions such as women's health centers. Here, we offer some additional discussion of why the clinical setting is an excellent place to introduce concepts related to gender-based care.

The primary care setting is a "preferred option for the delivery of community health services," and implementing changes in the primary care setting could have "benefits for the economy, for the health care system, for communities, for users, and for practitioners" (Hills & Mullett, 2005). A strong primary health infrastructure is associated with "improved quality of health reflected in lower rates of mortality and morbidity and higher rates of use of preventive health services" (Hills & Mullett, 2005). Thus, the primary care setting is a natural place to implement changes that improve women's healthcare (e.g., by adopting a woman-centered approach to care). This approach can be accomplished through standalone women's health centers, but "incorporating women-centred care guidelines into primary health care planning and design might be a more effective strategy" (Hills & Mullett, 2005).

Multiple benefits could be achieved by integrating woman-focused care into a primary care setting. For example, providers who offer more complete services obtain better service ratings from their patients: "Male and female providers achieve higher ratings when they offer more comprehensive services to women patients. Thus, primary care providers should consider expanding their scope of services to include routine gynecologic care or consider being aligned with a clinical center or setting that offers these additional services (through either primary care or specialty care)" (Bean-Mayberry et al., 2006).

Additionally, when care is integrated and a multidisciplinary approach is used, it can improve quality "by facilitating accurate diagnosis, the basis for effective treatment. Quality of care, especially that relevant to psychosocial aspects of illness, may be further enhanced by offering familiar surroundings and tangible evidence of collaboration among multiple caregivers in the same physical setting" (Carlson, 2000). In addition to quality benefits, "co-location of core women's health services has great potential for decreasing inefficiency, improving access, and lowering costs" (Carlson, 2000). ⁹

Changes in the primary care setting also increase opportunities for patient education about upcoming preventive care needs. Additionally, integrated and coordinated care allows for a single source for informing patients of what care they may need in the future (e.g., mammography or colorectal screening), as well as streamlining the reminder process for preventive screenings. While such education does not have to be a gender-specific issue, it does allow for gender-specific patient education (e.g., about coronary heart disease risk or gender-specific cancers).

An emphasis on primary care settings that emphasize woman-oriented (or even gender-specific) care could include both changes in diagnosis procedures and care as well as doctor-patient interactions. For example, doctors can and should diagnose and treat diseases such as diabetes differently in men and women (Legato et al., 2006). At the same time, doctors need to educate their patients about gender-specific care, e.g., to explain why the care any given patient receives may differ from that of a spouse, friend, or sibling of the opposite sex.

In addition, however, changes to care can focus on interpersonal relationships. For example, providers following a gender-based model also would need to be attuned to the communication needs of their patients. In one study, "a single question, 'What would you really most of all want me to do for you today?' was more effective in eliciting responses from female patients than a series of medically oriented questions about the patient's diagnosis" (Khoury & Weisman, 2002). Asking appropriate questions such as this allows providers "to focus on gender-based problems of the patient, often of emotional origin, rather than on the symptoms of the problems alone" (Khoury & Weisman, 2002).

Changes in the way care is managed and delivered in the clinical setting have been shown to affect the delivery of services and to improve overall care. For example, a study of delivery of woman-specific services in the VA found that clinics with well-coordinated care between providers and specialists were more likely to offer breast cancer screenings (Goldzweig, Parkerton, Washington, Lanto, & Yano, 2004). Additionally, cervical cancer screenings were more likely to be offered in settings that saw a larger proportion of female patients and where the clinic had a quality improvement program (Goldzweig et al., 2004).

One of the widely held tenets of women's medicine is that women's leadership is crucial to success. Women have gained parity with men in terms of their representation as medical students; however, women are still underrepresented in positions of senior leadership. This section discusses trends in women's leadership positions. We also discuss barriers to women attaining leadership positions (e.g., overcoming the status quo), and recent efforts to address these barriers (e.g., mentorship programs).

The number of women attending medical school continues to increase, so that women now make up about half of all medical students: "In 2000-2001, women constituted almost 46% of new entrants to the medical schools in the United States" (Franks & Bertakis, 2003). However, the number of women in academic leadership positions is still quite limited:

• "Data from Women in U.S. Academic Medicine Statistics [and in particular a survey of 126 U.S. allopathic medical schools] showed that women in general have an uphill battle in medical settings and still remain an underrepresented group. ... 30% of faculty members are women and at least 18 schools have no women serving as department chairs. This under-representation of female faculty is even more disconcerting when contrasted with a recent report ... [that] women represented the majority of medical school applicants. Of equal or perhaps greater importance, women are less likely than men to be promoted to the levels of associate or full professor and less likely to be appointed to search committees, which influence future faculty representation. ... Women comprise only 14% of tenured faculty and 12% of full professors, and ... the average number of female department chairs in the United States is just 1.7 per medical school" (King & Cubic, 2005).
• "Women are seriously underrepresented among the ranks of senior faculty and positions of leadership in academic medicine. In 1999, 27% of full-time medical school faculty were women, but only 15% of tenured faculty, 11% of full professors, and 6% of chairs of academic departments were women. Cohort studies comparing men and women medical school faculty have found that—even after adjusting for number of publications, amount of grant support, tenure versus other career track, number of hours worked, and specialty—women remain substantially less likely than men to be promoted to senior ranks" (Yedidia & Bickel, 2001).

Despite this lack of senior-level women leaders in academic medicine, some progress is being made in other sectors. For example, while still underrepresented, "women are succeeding in moving into the management hierarchy of the healthcare industry. One study found that the percentage of women in management positions increased from 13 to 36% in an 8-year span ending in 2001" (Neubert & Palmer, 2004).

The widely held assumption is that having women in positions of leadership will improve the quality of women's healthcare. To wit:

The early founders of women's health, and the federal bodies that supported its development, realized that their goals would be successful only if women's health had a structure, a source of funding, and a recognized place in academic institutions. Dedicated women's health offices or programs established at medical schools through federal or other sources of support have facilitated curriculum change and faculty development, and many play a key role in the recruitment and retention of women faculty. The importance of these functions cannot be overestimated because women students and faculty have been the driving force behind women's health curricular change at those institutions where it has occurred. These offices or programs are the repositories for the history of women's health ... and should be maintained until gender equity is attained at all levels of the education process (Henrich, 2004).

Put another way, the theory is that "as increasing numbers of women are being trained as physicians in the U.S., the needs of women are increasingly being integrated, at least into clinical training programs" (Strobino et al., 2002). This assertion seems logical, and certainly the prominence of the women's health movement has increased as women themselves have assumed greater positions of leadership. The evidence for this position is largely anecdotal, however:

Evidence supporting the link between women leaders in academic health sciences and women's health includes the historical observation that most major advances in women's health have been driven by women leaders, frequently those in academics. Furthermore, women's health research draws predominantly women investigators, as is evident from the gender composition of fellows in women's health training programs, attendees and presenters at clinical and scientific symposia on women's health, and principal investigators on proposals submitted to the NIH for research on diseases that occur predominantly or uniquely in women. This relationship between women's health and women leadership in academic medicine and other health science fields is underscored by the fact that the directors of 13 of the current 15 CoEs are women (Carnes et al., 2001).

Unfortunately, substantial barriers exist to the promotion of women to academic leadership positions in medicine. One study asked medical department chairs to identify such barriers:

The chairs we interviewed painted a broad tableau of factors constraining women's advancement to leadership positions in academic medicine, and they identified three sources of barriers: historical developments (e.g., shortage of women in the pipeline), broad social forces (e.g., gender roles and socialization patterns affecting women's status), and the expression of these forces in the medical environment (e.g., sexism in recruitment and promotion practices, a shortage of effective mentors for women) (Yedidia & Bickel, 2001).

Other barriers faced by women include more organizational resources being devoted to men, and increased family demands (e.g., women are much less likely to have a spouse who stays at home) (Committee on Maximizing the Potential of Women in Academic Science and Engineering, National Academy of Sciences, National Academy of Engineering, & Institute of Medicine, 2006). Moreover, women physicians face a very different set of life opportunities compared to their male peers because of these spousal differences. Since the workplace has been historically dominated by men with greater stay-at-home spousal support, medicine has been much slower to adapt to the needs of women, and specifically to women in dual career households (Bird, Lang, Amick, & Chertoff, 2002).

Unfortunately, there is no easy way to increase the number of women in leadership positions:

Common interventions to remedy this inequity often fail. One approach advocates mandating increased opportunities for women to lead, but this approach is bound to encounter resistance as only 53% of male healthcare executives favor this approach. Another typical approach is to proclaim the competitive advantage of "feminine" management, but despite near unanimous agreement across men and women of the unique contributions of women to leadership, this may have the unintentional consequence of increasing the strength and divisiveness of gender stereotypes. A more effective approach may be for organizations to promote a set of leadership competencies that have a valid link to important organizational outcomes (Neubert & Palmer, 2004).

Thus, despite widespread acknowledgment that these barriers exist, "it would appear that, in the absence of significant changes at the institutional level, ... women will continue to be underrepresented among the leadership in academic medicine" (Yedidia & Bickel, 2001).

Several efforts are under way to overcome existing barriers and to promote women's leadership, although it remains to be seen how successful these efforts will be. For example, NIH has a set of strong recommendations to promote leaders at all levels who are women and to move toward greater representation and inclusiveness (Pinn et al., 2006). Additionally, NIH (as described in our discussion of question 5) has a program to promote career development and mentoring in the field of women's health (Pinn, 2005). Several of these efforts capitalize on the women's health movement as a logical venue to promote the achievement of women. Women's health is seen as "an opportune field in which to nurture the academic careers of women. It is an ideal venue to fill the pipeline with talented women who may become academic leaders in positions where they can promote positive change as well as mentor other women" (Carnes et al., 2001). An exclusive focus on promoting women as leaders only in women's health may have the unintentional effect of stereotyping women, however.

The creation of inclusive mentorship programs is one way to promote the advancement of women (King & Cubic, 2005). Another recommendation, from the report Increasing Women's Leadership in Academic Medicine, is that "medical schools, teaching hospitals, and academic societies emphasize faculty diversity and the development of women faculty in department reviews, target the career development needs of women within the context of helping all faculty, and enhance the effectiveness of search committees in attracting women candidates" (as cited in King & Cubic, 2005).

The inclusion of racial and ethnic minority leaders in medicine, like the inclusion of women, is generally believed to result in better overall healthcare. In this section of the report, we briefly describe trends in minority medical leadership.

Ideally, "care providers should reflect the diversity of the population served" (Jackson et al., 2001). At present, however, the U.S. population is not served by a diverse group of care providers. For example, "only 2.9 percent of U.S. doctors in 1999 were black" (Williams, 2005). These discrepancies exist at the physician level and continue all the way to the faculty level, where disparities are most pronounced for underrepresented minorities (Wong et al., 2001).

Despite the relative absence of racial and ethnic minorities in care settings, there is evidence that including minorities leads to better care outcomes, especially for low-income and minority patients. Benefits include the following:

• "Race-concordant visits averaged two minutes longer than race-discordant encounters among both black and white patients. Patients in race-concordant visits also reported higher levels of satisfaction and judged physicians' participatory decision-making style more positively. Moreover, independent ratings of audiotapes of the encounters indicated that race-concordant visits had a more positive emotional context (as indicated by voice tone) and a slower pace" (Williams, 2005).
• "Black and Hispanic physicians are more likely than others to care for the uninsured and those covered by Medicaid, and to practice in underserved urban and rural areas" (Williams, 2005).
• "Diversity among health professionals is critical to excellence in the delivery of clinical services. Reasons cited include representation from different cultural perspectives, social equity, and improved access and health outcomes in underserved communities. ... Minority physician faculty help break down cross-cultural communication barriers through teaching of curricula that address sociocultural issues. ... In addition, studies have shown that many patients prefer women and minority physicians" (Wong et al., 2001).
• Minority doctors are more likely to adopt patient-centered care practices: "Thirty percent of minority physicians (black, Hispanic, or Asian) rated high on the patient-centered adoption scale, compared with 19% of white, non-Hispanic physicians (p<.05)" (Audet, Davis, & Schoenbaum, 2006).

Gender is an important variable at the level of the physician, especially as it relates to interpersonal interactions with patients. Men and women have well-documented differences in how they communicate. Not surprisingly, these differences also extend to how male and female physicians interact with their patients.

Several large studies have shown key differences in how male and female doctors communicate with their patients. Female doctors tend to spend more time interacting with patients, resulting in longer visits, and have a less dominant interaction style. A comprehensive literature review of studies based on audiotapes, videotapes, or direct observations found the following:

Medical visits with female physicians were, on average, two minutes (10%) longer than those of male physicians. During this time, female physicians engaged in significantly more communication that can be considered patient-centered. They engaged in more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. Moreover, the patients of female physicians spoke more overall, disclosed more biomedical and psychosocial information, and made more positive statements to their physicians than did the patients of male physicians (Roter & Hall, 2004).

By way of explanation, Roter and Hall (2004) offered the following accounting of their findings:

The pattern of results was almost entirely consistent with what one might expect from the nonmedically related literature regarding gender differences in communication. Female physicians spend more time during a typical visit talking with their patients than do male physicians. During this time, they engage in communication that more broadly relates to the larger life context of the patient's condition by addressing psychosocial issues through related questioning and counseling and through greater use of emotional talk, positive talk, and active enlistment of patient input. In contrast to the higher levels of psychosocial and socioemotional exchange, there is little evidence that physician gender is related to the more task-specific communication elements of care. Physician gender was not related to the provision of biomedical information (including discussion of the diagnosis, prognosis, and medical treatment). ... Patient behavior largely reciprocates gender-linked physician behaviors. Like their physicians, patients of female doctors talk more overall, make more positive statements, discuss more psychosocial information, and express more partnership building than do patients of male physicians.

Other studies have reported similar findings:

• "Female family physicians ... provide more counseling, have longer consultation time, spend more time listening to their patients, and give selective attention to preventive healthcare and female health issues than male physicians" (Ahmad, Steward, Cameron, & Hyman, 2001).
• "Female physicians adopt a less dominant interaction style with their patients than male physicians do and for female physicians it seems to be especially important to behave in a gender-congruent way and not to express much dominance if they want satisfied patients. Male physicians seem to have more latitude in their behavior" (Mast, 2004).
• "The fact that women doctors often exhibit more patient-centered behaviors and are more concerned about psychosocial health issues than are men is consistent with other evidence indicating that female clinicians generally are more interpersonally oriented, more concerned about emotional and social aspects of health, and more interested in the patient's input and partnership. Men, on the other hand, may take a more individualistic and instrumental approach to health management. Thus, whether as clinicians or patients, men may spend proportionately more time focusing on biomedical issues, offering advice, expressing opinions, and independently making recommendations for the other to accept or reject" (Street, 2002).

A critical question is whether these differing interaction styles impact care outcomes. There are some quality-of-care differences that have been associated with physician gender: "Women who use female generalist providers are more likely to receive routine gynecologic and mammography services and more gender-specific counseling compared to women who use male generalists" (Bean-Mayberry et al., 2006). Likewise:

After multivariate adjustment, the patients of female physicians were more likely to receive scheduled follow-up visits and referrals to other physicians than were the patients of male physicians. The patients of female physicians were also more likely to receive preventive services, such as breast and pelvic examinations, Pap tests, mammograms, rectal examinations, and blood pressure measurements, supporting the findings of previous studies. Female physicians appear to be more prevention oriented, particularly for female prevention. For nongender-related prevention interventions, such as blood pressure measurement, cholesterol testing, and sigmoidoscopy, only blood pressure testing showed a modest physician gender effect (Franks & Bertakis, 2003).

Such clinical differences appear to be rare, however. Moreover, while there are clear gender differences in communication patterns, these differences are "small in magnitude," and "male and female clinicians are generally more similar than different in their communication" (Street, 2002). Thus, while

research to date indicates that women health care providers generally tend to conduct longer consultations, give more information, engage in more partnership-building, are less directive, express more interest in psychosocial aspects of health (e.g. emotions, lifestyle, family), and are more explicitly reassuring and encouraging than are male clinicians ... to infer that women are more patient-focused and better health care providers than men would be an extremely simplistic generalization (Street, 2002).

This is partly because, as we will discuss in more detail, there is not a universal female advantage. For example, in a study on care for depression, it was found that while "female providers were more likely to counsel on anxiety," male providers were more likely to counsel on alcohol and drug use (Chan et al., 2006). The authors concluded that physicians of both genders provided similar care for depression.

Moreover, physician gender differences can be overcome. From the patient perspective:

By actively participating in their consultations, patients can attenuate and even erase communicative behaviors stemming from a clinician's style or preconceived attitudes and stereotypes. Health care providers usually accommodate a patient who asks questions, offers opinions, and expresses concerns either because they now have a better understanding of how to address the patient's needs or because they feel some obligation to adhere to norms governing conversational conduct. ... The evidence to date indicates that patients will indeed gain more information, support, and involvement in decision-making the more they actively participate in the consultation (Street, 2002).

Even from the provider perspective, such differences are not absolute. For example, "obtaining gynecologic care or being involved with a women's clinic setting improved the ratings of male providers" (Bean-Mayberry et al., 2006).

In addition to gender differences between male and female doctors, the gender match between doctors and patients also may affect care. The reasons for these differences are complex. Partly, they are the result of patient preferences (e.g., studies consistently show that patients prefer a doctor of the same sex for sensitive examinations). Other differences may be due to doctors' perceptions or comfort levels. These differences impact quality of care, but the effect is not always consistent—gender concordance influences care outcomes both positively and negatively.

Numerous studies have shown that patients prefer to receive care from a same-sex physician for sensitive examinations. For example:

• "For genital and rectal examinations, patients have been shown to prefer a physician of the same gender" (Franks & Bertakis, 2003).

• A VA study of older women found that women would be less willing to undergo a full-body skin examination if it was performed by a male physician (Federman, Kravetz, Haskell, Ma, & Kirsner, 2006).

• A study in the Netherlands found that "the physician's gender is particularly salient under conditions in which examination require complete disrobing, extensive body probing or examination of the genitalia" (Kerssens, Bensing, & Andela, 1997).

Interestingly, doctors also may be somewhat reluctant to perform sensitive examinations on members of the opposite sex. A study of students in their final year of medical school at Monash University found that students

were more comfortable with and said that they were more attuned to the concerns of patients of their own gender. They were also more comfortable dealing with personal issues as opposed to sexual matters in the consultation, and again, more so with patients of their own gender. They were ... uncomfortable performing the more body-intimate examinations on patients of the opposite gender (Zaharias, Piterman, & Liddell, 2004).

Sometimes, having physician-patient gender concordance leads to better care outcomes. For example, "female physicians considered depression more often, particularly with female patients" (Stoppe et al., 1999). Medical visits also may be longer when doctors and patients are the same sex:

Female physicians had significantly longer visits with their female patients than any other physician-patient dyad. The next longest visits occurred between male physicians and their male patients. When visits with pelvic and breast examinations were excluded, there was no overall physician gender effect on visit length. It would appear that the observation that female physicians have significantly longer visits than their male colleagues is associated with the performance of gender-specific (breast and pelvic) physical examinations. As previously noted, female patients differentially see female physicians, and these patients may make their selection based on a preference for a physician of the same gender to perform their breast and pelvic examinations. When visits with pelvic and breast examinations were excluded, visit duration was related to gender congruence between physician and patient. Gender-congruent visits were longer than gender-discordant visits (Franks & Bertakis, 2003).

Additionally, Chan, Bird et al. (2006) did a study on gender concordance and detection and care for mental health problems in primary care settings. They found that females were more likely to receive counseling with a female provider, although no other gender-concordance differences were found (Chan et al., 2006).

However, there are cases in which gender discordance leads to better care outcomes. For example:

• "During prenatal visits, Roter et al. observed that female physicians actually spent less time with patients, engaged in less facilitative communication, and made fewer expressions of concern than did the male doctors. Contrary to expectations, Huston et al. found that male doctors more often discussed hormone replacement therapy with their women patients than did female physicians" (Street, 2002).
• "Female physicians are significantly more likely than males to refer a patient with BPH [benign prostatic hypertrophy] to a urologist (37.5% vs. 24.9%, p , 0.001). Male physicians are significantly more likely to recommend that a woman with vaginal itching and discharge have an office visit (52.7% vs. 40.6%, p , 0.001). ... The results may suggest that physicians use fewer resources to treat the genital-specific conditions of patients who share their sex" (Boulis & Long, 2004).
• "Overall, the accuracy of the male and female cardiologists in diagnosing CAD [coronary artery disease] was identical (both 79%), although there were some noteworthy differences. ... The specificity to assess female patients by the female cardiologists (48%) and male patients by the male cardiologists (59%) was relatively low compared with the specificity to assess female patients by the male cardiologists (74%) and male patients by the female cardiologists (70%). Thus, the cardiologists tended to assess patients of the opposite gender with a greater specificity" (Wegmann et al., 2003).

One of the most logical places to introduce concepts relate to sex- and gender-based medicine is via the curriculum of medical, pharmaceutical, public health, and nursing schools. Historically, medical curriculums have overlooked such teaching in favor of a model that assumes a male norm (Alexanderson, 1999). Or, put another way, "it is ironic that it is in medical education, where would-be-physicians presumably learn the most about human biology and behavior, that they are taught to ignore fundamental gender differences" (Lazarus, 2001). Now, however, information on gender differences is gradually being introduced. In this section, we discuss how such information is incorporated into an existing curriculum as well as where changes are occurring.

Part of the context of this discussion is an ongoing call for such changes. For example, "the American Board of Internal Medicine ... has made specific recommendations for training in women's health. These recommendations are based on the premise that 'the knowledge base and clinical skills required to provide care for women are best addressed within the context of general skills acquired' by trainees of internal medicine" (Nicolette & Jacobs, 2000).

Frequently, changes in the curriculum at individual medical schools have happened through the joint efforts of students and faculty. Such a process has been described in detail for the Department of Medicine at Stanford University School of Medicine. A student-faculty team analyzed the existing medical school curriculum in internal medicine for the third-year clerkship, and the team sees this process as illustrative of "the value of medical students' contributions to medical education" (Nicolette & Jacobs, 2000). Here is one example of their process:

In our analysis of the pulmonary medicine module, we found that four out of the five cases described male patients. This is consistent with traditional male imagery in medical education, including textbook and lecture illustrations, as well as case examples. Discussions involving female patients have traditionally been relegated to reproductive health, mental illness, and pregnancy-related illness. This may affect trainees of medicine in two ways: encouraging the misperception of men's health as the "norm" in medicine with women's health as a deviation from this standard, and contributing to the designation of a disproportionate number of female patients' complaints to mental, rather than systemic, illness. To avoid propagating these erroneous notions, the learning module's cases were altered so that three of the five patients were women (Nicolette & Jacobs, 2000).

While helpful, note that this change is primarily cosmetic, and does not represent changes to include gender-based approaches to medicine.

In general, curriculum changes are "difficult and slow" and require "leadership and support; senior faculty or administrative leaders and designated women's health programs or centers may facilitate this process" (Henrich & Viscoli, 2006).

In recent years, there has been a "marked increase in the number of schools with an office or program responsible for integration of women's health and gender-specific content into curricula" (Giardina et al., 2006). For example, there is now a major two-volume medical textbook on sex and gender differences; Principles of Gender-Specific Medicine is a collection of "articles detailing sex and gender differences throughout the life cycle, including early development, the central nervous system, cardiology, pulmonology, gastroenterology, reproductive biology, oncology, nutrition, drug metabolism, infectious disease, bone, immunology/rhematology, and aging" (Legato, 2004). Even with such changes, however, "progress toward integrating women's health and gender-specific content into medical school curricula has been uneven" (Henrich & Viscoli, 2006).

One study looked at the content of medical school curriculums as they relate to women's health and gender, and found that

few medical schools in this study offered interdisciplinary women's health courses or clerkships; most were elective or selective clinical rotations that, as a result of limited enrollments, benefited a small number of students. The majority of schools that provided detailed information in CurrMIT [the Association of American Medical Colleges' Curriculum Management and Information Tool] included important women's health topics in their curricula; however, there was considerably less emphasis on gender-specific information about many conditions that cause the greatest morbidity and mortality in women, a pattern that has persisted for a decade (Henrich & Viscoli, 2006).

More than half of the schools taught at least 11 of 18 identified women's health topics, but fewer than a third included gender-specific topics. A designation as a CoE, having a women's health program, and having a female dean were all associated with teaching more women's health or gender topics (Henrich & Viscoli, 2006). A tension with adding such curriculum materials is whether to teach them separately as a specialty (allowing for greater focus, but reaching only a subset of students) or whether to fully integrate them across the curriculum (exposing all students to these materials, but perhaps in less depth).

Another study examined the gender topics most likely to be included in a medical school curriculum. It found that women's reproductive health topics were most common, with limited information on gender-specific disease factors:

Most schools included information on sexual and reproductive function, medical interviewing and examination skills, and diagnostic tests specific to women. Fewer schools incorporated gender-specific information on heart disease, lung cancer, and stroke—leading causes of death in women—or chronic medical disorders that disproportionately affect women, such as temporomandibular joint disease, interstitial cystitis, and fibromyalgia (Henrich, 2004).

Yet another study cites as a critique of existing curriculum

the limited attention to how the social context of women's lives affect their health. Examples of topics that need to be integrated into the curriculum of medical schools include the effect of stress related to the multiple roles of women, the importance to women of relationships with their partners and their children, the social and economic circumstances of low income women, particularly those living in households with no other adult present, and the importance of cultural sensitivity in providing services to women from varied ethnic backgrounds (Strobino et al., 2002).

Several factors have slowed the speed at which curriculum changes are adopted. These include the following:

• "Uncertainty about the impact of women's health and what should be included in a curriculum, a lack of practical guidelines for implementation, reluctance to train faculty, and institutional resistance to change" (Giardina et al., 2006).
• "A lack of awareness of data on gender differences, the lesser importance generally placed on this information, or the difficulties schools face in adding new information to already overloaded curricula" (Henrich & Viscoli, 2006).

Fortunately, the emphasis on including sex and gender factors in the medical school curriculum will only increase as knowledge and understanding of such differences increases (Giardina et al., 2006).

Pharmacists represent another important professional group to educate about sex- and gender-based medical differences. One recent study found that women's health is increasingly being taught at such schools:

Women's health instruction was specifically mentioned (in fall 2004) by just under 40 percent (n=34) of the 89 U.S. colleges and schools of pharmacy. At those institutions, some of which have multiple courses with women's health content, 48 courses were identified: 21 didactic elective courses dedicated to women's health issues, two elective experiential courses dedicated to women's health; 3 didactic electives in which women's health was one of a broad array of component content areas; and 22 required courses in which women's health content was incorporated. Among those 22 required courses, 18 were courses in pharmacotherapeutics; two were pharmacokinetics/dose optimization courses; one was a pharmacy practice course, and one was a first-year orientation course on practice trends. Given the variability across colleges and schools in how course descriptions are worded and the level of detail provided, it is likely that women's health issues are included, at the very least, in the pharmacotherapeutics courses in more colleges and schools than identified in this review (Health Resources and Services Administration, 2005a).

Another important group to reach with this information is public health students. A recent study involving focus groups with public health faculty members and an online survey of students and/or recent graduates found that:

1. Sex and gender differences, diversity within gender, social determinants of health, and a lifespan perspective should provide the foundation efforts to incorporate women's health into the MPH [master's in public health] core curriculum. Women's health faculty proposed that the current focus in public health on health disparities and cultural competency should serve as the backdrop and rationale for inclusion of women's health concepts in the educational core curricula of MPH students. There was substantial agreement among core course faculty, as well as among students surveyed, that these women's health concepts were important. Moreover, the students and recent alumni surveyed overwhelmingly indicated that they anticipated needing women's health knowledge in their professional careers. 2. There should be greater emphasis on women's health in the MPH core curriculum through integration into core courses rather than by requiring a separate course specific to women's health. The main themes identified for integration into core courses included sex and gender differences, health disparities, and cultural competence. 3. The principles identified as important by women's health faculty currently are incorporated into the core MPH curriculum to at least a moderate degree. Overall, about one-third of the participating faculty believed that the concepts and principles identified as essential already received full exposure when they considered the entire array of course offerings for their MPH programs. Student survey results appear to confirm these faculty reports. The systematic review of 2003 SPH course catalogues and follow-up with each school representative identified a total of 324 women's health-related courses. Slightly less than 20 percent (60 of 324) of the total number of courses identified appeared to have a focus on women's health beyond reproductive health, maternal and child health, or nutrition. ... Not surprisingly, the elective courses were more frequently offered in the largest schools. Only two schools did not offer courses in the categories named (Health Resources and Services Administration, 2006).

Thus, while progress is being made, Schools of Public Health continue to teach women's health as mainly maternal/child health. This overlooks many important issues to women's health, especially later life issues and the appropriate conveyance of gender- and evidence-based preventive strategies.

A study of nursing curriculums is more encouraging. The report, Women's Health in the Baccalaureate Nursing School Curriculum: Report of a Survey and Recommendations, found that "entry-level courses and evidence-based interventions do address women's health issues" (Health Resources and Services Administration, 2001). The report found that "virtually all schools require their students to take courses that address issues such as breast cancer; contraception and fertility management; normal and abnormal female anatomy and physiology; and sexually transmitted diseases and prevention of risk" (Health Resources and Services Administration, 2001). In addition, "four-fifths of the responding schools teach cultural competency as part of women's health communications" (Health Resources and Services Administration, 2001).

In addition to training students, there is also work to be done to train researchers on sex- and gender-based differences. To this end, an online course titled The Basic Science and the Biological Basis for Sex- and Gender-Related Differences has recently been developed (National Institutes of Health, 2006a). It includes six sections: Understanding the Importance of Sex and Gender in Biomedical Research; Legislative Process Framework; Cell Physiology; Developmental Biology; Pharmacodynamics and Pharmacokinetics; and Clinical Applications of Genomics. The course was

developed as a collaborative effort between the Office of Research on Women's Health, Office of the Director, National Institutes of Health (NIH) and the Office of Women's Health, Food and Drug Administration (FDA). ... [It] was developed for researchers, clinicians, and members of academia to gain a basic scientific understanding of the major physiological differences between the sexes, the influences these differences have on illness and health outcomes, and the implications for policy, medical research, and health care (National Institutes of Health, 2006a).

The course itself is free, and the content for this course is in the public domain to further enhance access to this information (National Institutes of Health, 2006a).

The United States is not the only country struggling with these issues. A recent European Union research project "evaluated all European medical curricula for the extent and integration of gender-specific teaching offered" (Rieder, 2006). The study found that

across Europe no such teaching model exists, within the scope of medical education. The lack of basic reference texts in this field has spurred the production of textbooks to underpin study, such as Principles of Gender Medicine and our own textbook in the German language Gender Medizin, which aims to investigate which gender specific similarities or differences are clinically relevant, irrelevant or known, what scientific and clinical evidence is currently available and whether this influences clinical diagnosis, therapy and outcome, and finally to identify whether practical recommendations may be made and what these are (Rieder, 2006).

Another review found similar problems in the Netherlands, although efforts are now being made to address these issues (e.g., adding the question: "What will you do when the patient is a man/woman?" to medical textbooks as appropriate) (Verdonk, Mans, & Lagro-Janssen, 2005).

Even among practicing physicians, there are substantial knowledge gaps regarding sex- and gender-based differences in medical care. Given the rapid growth in medical knowledge, it is not surprising that practicing doctors also require additional training. In this section, we briefly describe some of the treatment differences practicing physicians should be aware of, as well as some of the key sex- and gender-related differences in patient communication. Finally, we discuss the emergence of gender-specific guidelines for the treatment of various diseases.

Several studies have found that physicians may lack important knowledge about sex and gender differences in medical care. For example, "the ability of clinicians to accurately diagnose many conditions in women is compromised by large gaps in the biomedical knowledge base, owing to a longstanding cultural focus on a male norm for health and disease" (Carlson, 2000). Reaching these physicians is difficult, however. Some areas where providers may need more sex- and gender-based training include:

• "Most cardiologists are unaware of race and gender disparities in treatment" (Redberg, 2005). Women also present with different symptoms than men, and providers may not be aware of these differences (Gold & Krumholz, 2006).
• Nursing home staff may need more information on the different needs of men and women with Alzheimer's disease (Buchanan et al., 2004).
• Providers need more information on "stroke symptoms, risk factors and available therapies and interventions (acute and preventive) for women" (Bushnell et al., 2006).
• Women with diabetes "are more likely to encounter difficulties engaging in effective self-care activities than are men" (McCollum, Hansen, Lu, & Sullivan, 2005). Providers may not be aware of these differences.

Physicians may also require training about the differences in communication styles between male and female patients. Some research indicates that physicians may be "more likely to interpret men's symptoms as organic and women's as psychosocial" (Hamberg, Risberg, Johansson, & Westman, 2002). Likewise, a study of medical students found that "male patients are taken more seriously" (Hamberg et al., 2002).

Part of the explanation for this finding is that male and female patients present their symptoms differently. For example, in a linguistic analysis of chest pain, Vodopiutz, Poller et al. (2002) found:

Male patients presented themselves as interested in the cause of the chest pain, observing and describing their pain concretely, whereas female patients presented themselves as prevailingly pain enduring and describing their pain diffusely. ... Male language behavior seems to match the physicians' expectations better than the female language behavior. Clear descriptions of symptoms with exact chronological data appear to be considered more relevant, whereas female self-presentation as pain enduring combined with less concrete pain descriptions seems to make it more difficult for physicians to reconstruct pain development.

Another study on chest pain found that "women reportedly use stronger words, such as 'terrifying,' 'tiring,' and 'intolerable,' to describe their symptoms and appear to be exaggerating, whereas men seem more stoic and, when complaining, are believed to be sick" (Wegmann et al., 2003). In response to such findings, there has been some call for additional training for physicians on these differences:

Training in gender-specific language attitudes and preferences to obtain satisfying results when taking the clinical history might be suitable for educating physicians and healthcare professionals in general and especially those working in emergency rooms. ... When taking the clinical history of patients with chest pain, especially female patients, pain description should be supported by enhancing the patient's ability to describe the kind and course of the symptoms. If patients play down their symptoms, the physician should encourage them to take their disease seriously. If patients describe their pain only diffusely, the physician should encourage them to a more concrete description by making them aware that in this setting, the patients rather than the physicians are experts in describing their pain (Vodopiutz et al., 2002).

One way to reach physicians with relevant sex- and gender-based information is through the development and dissemination of evidence-based clinical guidelines. The creation of gender-specific guidelines is emerging as a part of a new medical emphasis on evidence-based medicine. One barrier to the creation of such guidelines is the perception that they are not needed and will not uncover anything new. For example, the landmark Women's Health Initiative (National Institutes of Health, 2007) was critical to informing clinicians and women about the costs and benefits of hormone therapy. The study was originally perceived by some as unnecessary because it was assumed that such therapy was universally beneficial, an assumption that was contradicted by study results. Thus, the experience of the Women's Health Initiative speaks to why such guidelines are critical to ensuring quality care.

At present there appear to be more guidelines for women's health than for gender-specific medicine. Two recent examples of gender-specific guidelines include the gender-specific practice guidelines for coronary artery bypass surgery (Society of Thoracic Surgeons (STS), 2004), and the Evidence-Based Guidelines for Cardiovascular Disease Treatment in Women (Mosca et al., 2004). Many more such guidelines are needed, however. For example:

Antipsychotic prescription guidelines do not differentiate between male and female patients, yet human studies have shown that the pharmacokinetics and the pharmacodynamics of drugs differ between the two sexes. Women's bodies, on average, contain 25% more adipose tissue than those of men, and most antipsychotic drugs are lipophilic—i.e., accumulate in lipid stores (Seeman, 2004).

Finally, we look at what factors may matter more to women than to men (or the reverse). Several such differences have been detected as they relate to primary care. Women's preferences also appear to change somewhat over the lifespan.

Women appear to value different components of care than men. While both sexes place a high value on time spent with doctor,

aside from this item in common, women and men appear to find different aspects of visit content to be important to their overall satisfaction. For women, satisfaction with the doctor's ability to answer questions clearly, with how well the doctor knew what happened at other visits, and with nursing care are significant predictors of overall visit satisfaction. These items might be construed as reflecting, respectively, the technical content of communication, continuity of care, and the multidisciplinary nature (i.e., the importance of nonphysician providers) of the care process. For men, satisfaction with the personal interest shown in them and their medical problems significantly predicts overall satisfaction. This item might be construed as reflecting the affective content of communication (Weisman et al., 2000).

These effects may be more pronounced for lower-income and less-educated women, who place "an even higher value on specific aspects of primary care such as comprehensiveness of services, coordination of specialty care, and cultural similarity of provider, than did higher income and more educated women" (O'Malley & Forrest, 2002).

Women's preferences for care also may vary throughout the lifespan:

Younger women (ages 18 to 34) often reported extreme role overload (due to parenting as well as working or schooling) and therefore wanted health care providers who could see them promptly when they needed care, did not keep them waiting, provided services efficiently, and were willing to provide information or prescriptions by telephone. Older women (ages 55 and over) frequently had done considerable shopping around to find providers with whom they were comfortable, and they thought that women had to select physicians carefully. Midlife women (ages 35 to 54) were the most vocal about the need for providers who are sensitive to women's specific health care needs and for services that are not merely replications of male-modeled care. Midlife women also were most likely to identify organizational or system issues related to health care quality, rather than focus solely on provider issues (Scholle et al., 2000).

The intention of this research question was to examine where interventions to improve women's health and sex- and gender-based care can be most effective. Options considered were improvements to clinical care, increases in the number of women leaders in medicine, changes to various curriculums related to medical training, and other changes such as enhanced doctor-patient communications or improved continuity of care. Unfortunately, we found that hard data to address the effectiveness of these various efforts are lacking.

We have reported elsewhere in this report that clinical care interventions to create women's health centers appear to be effective in improving women's preventive care. Likewise, there is anecdotal evidence that increasing the number of women leaders in healthcare improves care for women, and substantial evidence that male and female doctors communicate and interact with patients in different ways. While limited efforts are being made to increase the amount of gender-specific information in various curriculums, we found no data to demonstrate the effectiveness of this approach in improving overall care. Finally, we found evidence that women have different care preferences than men, but again no data to suggest whether attention to these areas will substantially improve care for women.

This is not to say that these interventions are without merit. Indeed, it appears that all or almost all of these kinds of interventions will be critical to the success of any effort to fully realize the goal of sex- and gender-based medical care. However, efforts to provide this kind of care are still, for the most part, limited in scope, and large-scale efficacy results are not yet available.

Increasingly, however, there is a demand for such work, and this is a demand that we echo. Some of the more recent calls to action include the following:

• "Gender-specific matters have increasing relevance for day-to-day practice and research findings have the potential to bring about policy changes. It is, therefore, vital that clinical research, medical education practical applications of research findings and public health take a gender-based approach. Gender-specific medicine has a major responsibility to meet societal needs and to contribute to societal values of health research" (Rieder, 2006).
• "We are urging the systematic development of evidence-based recommendations in all the subspecialties of medicine, which will provide guidelines for optimal gender-specific care to patients. We have finished developing the first of such recommendations for the diabetic patient. But as important as it will be to put these guidelines into practice, that is only half the task: we must also develop effective instruments for documenting patient outcome so that we can test whether or not such care actually improves or prolongs the sick patient's life" (Legato, 2006c).
• "The past 15 years have produced enormous advances in our understanding of the unique features of biological sex. Nevertheless, important and different tasks remain. One of these is to address the difficulties inherent in including premenopausal women in prospective, randomized trials characterizing the impact of new drugs and new interventions. A second compelling mandate is to expand our knowledge of men using the same concentration on the unique features of male biology as we have used in studying women. The inclusion of men in our scientific investigations is a natural evolution of our development of the discipline of gender-specific medicine and will yield the same rich harvest as has our work in women's health" (Legato, 2006c).

Much of the burden of achieving the goal of gender-specific medicine will fall to physicians. To truly provide comprehensive gender-based care, physicians will need both "interdisciplinary training at an early clinical level" (Henrich et al., 2003) and the regular experience of treating both men and women "to keep up to date with ... rapidly changing information" (McNeil & Hayes, 2003). To accomplish this mission will undoubtedly require changes in clinical care; increasing parity in terms of women and minority medical leadership; better training for the entire medical community on sex- and gender-based differences; and attention to other aspects of care, such as communication and expectations that may differ in important ways between male and female patients.

Thus, to truly implement a system of gender-based care in the United States will require interventions at multiple levels. These include approaches to reach providers as well as systems-level approaches and patient education efforts.

Current as of March 2007