Special Report: Entrustable Professional Activities in Sex- and Gender-Based Women's Health.

BACKGROUND: A set of core competencies in sex- and gender-based women's health (SGWH) has been endorsed by the Society of General Internal Medicine (SGIM), but many residencies lack the resources to implement curricula and clinical assessments that would support achievement of these competencies. AIM: Develop entrustable professional activities (EPA) to support implementation and assessment of clinical care for SGIM's SGWH Core Competencies. PROGRAM DESCRIPTION: Members of SGIM's SGWH Education Interest Group developed 18 SGWH EPAs for internal medicine residents. A team of clinician educators coordinated the preparation, drafting, quality control, and curriculum alignment of the SGWH EPAs through a rigorous process aligned with best practices for EPAs. All EPAs are mapped to the larger competency domains from the Accreditation Council for Graduate Medical Education (ACGME), for use with ACGME Milestones. The authors provide suggestions for the implementation of the EPAs into residency training. CONCLUSION: As residency education moves towards a competency-based structure, EPAs are needed to translate broad competencies into observable clinical skills. The SGWH EPAs provide a rigorously developed and ready-made tool for programs to link the SGWH core competencies to residency curriculum development, clinical assessment, and program evaluation.

Female Sexual Dysfunction: A Primer for Primary Care Health Professionals.

Introduction: Female sexual dysfunction (FSD) is common and associated with decreased quality of life, relationship satisfaction, and overall well-being. However, primary care practitioners report discomfort discussing, diagnosing, and treating FSD. Methods: We delivered two sessions on the approach to evaluation and treatment of FSD: a 60-minute didactic session and a 90-minute workshop. The intended audience was primary health care professionals who care for women. The workshop utilized interactive teaching methods including a large-group discussion, case-based discussions, debrief of an observed patient-physician discussion, and language drills to develop participants' knowledge and skills. Participants were surveyed about their practice patterns and attitudes toward FSD following the sessions on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Results: We collected 131 evaluations from a national Veterans Health Administration 60-minute didactic and four evaluations from the Society of General Internal Medicine Annual Meeting 90-minute workshop (response rates were 60% and 15%, respectively). One hundred thirty-five interdisciplinary trainees and practitioners from both audiences highly rated the workshop content (M = 4.1) and the overall session (M = 4.3). Didactic participants (n = 131) also reported high satisfaction (M = 4.5), increased knowledge and skills (M = 4.4), and improved interprofessional collaborative practice (M = 4.4) as a result of the training. Discussion: Our evaluation shows high satisfaction following interactive multimodal sessions on FSD. These adaptable resources can be used in multiple educational settings (didactic and workshop) and for multiple time frames to teach about FSD.

Position Paper: SGIM Sex- and Gender-Based Women's Health Core Competencies.

Women's health care has evolved significantly since it was first acknowledged as an integral part of internal medicine training more than two decades ago. To update and clarify core competencies in sex- and gender-based women's health for general internists, the Society of General Internal Medicine (SGIM) Women and Medicine Commission prepared the following Position Paper, approved by the SGIM council in 2023. Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education Program Requirements for Internal Medicine and the 2023 American Board of Internal Medicine Certification Examination Blueprint. These competencies are relevant to the care of patients who identify as women, as well as gender-diverse individuals to whom these principles apply. They align with pivotal advances in women's health and acknowledge the changing context of patients' lives, reaffirming the role of general internal medicine physicians in providing comprehensive care to women.

Managing Undesired Pregnancy After Dobbs.

Although both medication abortion (MAB) and aspiration procedures are safe and effective, the Supreme Court decision in Dobbs v. Jackson Women's Health Organization removed federal protection of access to abortion services. Abortion access is now illegal or severely limited in many states, leading to delays in abortion care for patients in all states. In this rapidly evolving landscape, primary care physicians (PCPs) must be familiar with laws surrounding abortion care in their own and neighboring states. PCPs must also be prepared to expedite abortion care by sharing resources, obtaining testing when needed, and counseling patients about expected outcomes following abortion.

Contraceptive Procedures in Internal Medicine Clinics and Resident Education: a Qualitative Study of Implementation Methods, Barriers, and Facilitators.

BACKGROUND: Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants are highly effective and increasingly popular. Internal Medicine (IM) clinics and residency curricula do not routinely include LARCs, which can limit patient access to these methods. In response, internists are integrating LARCs into IM practices and residency training. OBJECTIVE: This study examines the approaches, facilitators, and barriers reported by IM faculty to incorporating LARCs into IM clinics and resident education. DESIGN: We interviewed faculty who were prior or current LARC providers and/or teachers in 15 IM departments nationally. Each had implemented or attempted to implement LARC training for residents in their IM practice. Semi-structured interviews were used. PARTICIPANTS: Eligible participants were a convenience sample of clinicians identified as key informants at each institution. APPROACH: We used inductive thematic coding analysis to identify themes in the transcribed interviews. KEY RESULTS: Fourteen respondents currently offered LARCs in their clinic and 12 were teaching these procedures to residents. LARC integration into IM clinics occurred in 3 models: (1) a dedicated procedure or women's health clinic, (2) integration into existing IM clinical sessions, or (3) an interdisciplinary IM and family medicine or gynecology clinic. Balancing clinical and educational priorities was a common theme, with chosen LARC model(s) reflecting the desired priority balance at a given institution. Most programs incorporated a mix of educational modalities, with opportunities based upon resident interest and desired educational goals. Facilitators and barriers related to clinical (equipment, workflow), educational (curriculum, outcomes), or process considerations (procedural volume, credentialing). Participants reported that support from multiple stakeholders including patients, residents, leadership, and other departments was necessary for success. CONCLUSION: The model for integration of LARCs into IM clinics and resident education depends upon the clinical resources, patient needs, stakeholder support, and educational goals of the program.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment.

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Geographic distribution of California mental health professionals in relation to sociodemographic characteristics.

OBJECTIVE: To determine whether geographic access to licensed mental health providers in California is a barrier for underserved populations. METHOD: Data from the master file of the California Board of Psychology and Board of Behavioral Sciences were merged with U.S. Census data to determine the correlations between the concentration of providers and the corresponding sociodemographic characteristics of places in California. RESULTS: This article shows that the concentration of licensed mental health providers in the communities of California varies systematically with the racial, ethnic, age, education, and economic characteristics of those places. Specifically, licensed mental health providers are more concentrated in places that are wealthier, Whiter, older, and more educated. CONCLUSIONS: Policy and advocacy efforts in health service psychology can help assure more equitable distribution of mental health services. (PsycINFO Database Record

Explaining Breast Density Recommendations: An Introductory Workshop for Breast Health Providers.

Introduction: High breast density is an independent risk factor for breast cancer and can decrease the sensitivity of mammography. However, evidence surrounding recommendations for patient risk stratification and supplemental screening is evolving, and providers receive limited training on breast density counseling. Methods: We implemented an introductory, interactive workshop about breast density including current evidence behind supplemental screening and risk stratification. Designed for providers who counsel women on breast health, this workshop was evaluated with internal medicine providers, primary care residents, and radiology residents. We surveyed participants about knowledge and attitudes at baseline, postintervention (residents and providers), and 3-month follow-up (providers only). We compared baseline and postintervention scores and postintervention and 3-month follow-up scores using paired t tests and McNemar's tests. Results: Internal medicine providers had significant gains in knowledge when comparing baseline to postintervention surveys (6.5-8.5 on a 10-point scale, p < .0001), with knowledge gains maintained when comparing postintervention to 3-month follow-up surveys (p = .06). Primary care and radiology residents also had significant gains in knowledge when comparing baseline to postintervention surveys (p < .004 for both). All learner groups reported increases in their confidence regarding counseling women about breast density and referring for supplemental screening. Discussion: Through this breast density session, we showed trends for increased knowledge and change in attitudes for multiple learner groups. Because we aim to prepare providers with the best currently available recommendations, these materials will require frequent updating as breast density evidence and national consensus evolve.

Associations of medical student empathy with clinical competence.

OBJECTIVE: Empathy is a crucial skill for medical students that can be difficult to evaluate. We examined if self-reported empathy in medical students was associated with clinical competence. METHODS: This study combined cross-sectional data from four consecutive years of medical students (N=590) from the Boston University School of Medicine. We used regression analysis to evaluate if self-reported empathy (Jefferson Scale of Physician Empathy (JSPE)) predicted scores in clinical clerkships, United States Medical Licensing Examinations, and OBJECTIVE: Structured Clinical Examinations (OSCEs). We separately analyzed overall and OSCE communication scores based on interpersonal skills reported by standardized patients. We controlled for age, gender, debt, and specialty affinity. RESULTS: JSPE scores of medical students were positively associated with OSCE communication scores, and remained significant when controlling for demographics. We found that JSPE score was also predictive of overall OSCE scores, but this relationship was confounded by gender and age. JSPE scores were associated with performance in the Pediatrics clerkship, but not other clerkships or standardized tests. CONCLUSION: JSPE scores were positively associated with OSCE communication scores in medical students. PRACTICE IMPLICATIONS: This study supports that self-reported empathy may predict OSCE performance, but further research is needed to examine differences by gender and age.

Program Directors' Perceptions of Resident Education in Women's Health: A National Survey.

BACKGROUND: Despite professional societies' emphasis on women's health in internal medicine (IM) resident curricula, national implementation has varied. This study describes IM program directors' perceptions of women's health topics that residents should master and the current state of women's health education in IM residency programs. MATERIALS AND METHODS: We recruited 408 program directors of IM residency programs to complete an electronic cross-sectional survey. Participants were surveyed about expected resident mastery of twelve women's health topics in the context of their program's current characteristics, core curricula, and training opportunities. RESULTS: One hundred twelve IM program directors completed the survey (response rate 27%). The percentage of program directors who perceived that residents should master each of the twelve women's health topics ranged from 48% to 98%, with the most program directors expecting mastery of osteoporosis (N = 110, 98%), sexually transmitted infection (N = 110, 98%), and gender-specific cancer (N = 109, 97%). These topics, however, were not currently included in the core curricula of 6%-12% of programs. Programs offered varied opportunities in women's health, including dedicated women's health electives (N = 76, 68%), concentrations or tracks (N = 8, 7%), and continuity clinics (N = 15, 13%). Most program directors were interested (N = 90, 80%) in expanding women's health opportunities in their programs. CONCLUSION: While women's health topics were perceived by program directors as a priority for IM resident mastery, certain priority topics and training opportunities were limited. Additional studies are needed to explore barriers to expansion of resident education in women's health and potential solutions.

Toward the early recognition of psychosis among Spanish-speaking adults on both sides of the U.S.-Mexico border.

Lack of knowledge about psychosis, a condition oftentimes associated with serious mental illness, may contribute to disparities in mental health service use. Psychoeducational interventions aimed at improving psychosis literacy have attracted significant attention recently, but few have focused on the growing numbers of ethnic and linguistic minorities in countries with large immigrant populations, such as the United States. This paper reports on 2 studies designed to evaluate the effectiveness of a DVD version of La CLAve, a psychoeducational program that aims to increase psychosis literacy among Spanish-speaking Latinos. Study 1 is a randomized control study to test directly the efficacy of a DVD version of La CLAve for Spanish speakers across a range of educational backgrounds. Fifty-seven medical students and 68 community residents from Mexico were randomly assigned to view either La CLAve or a psychoeducational program of similar length regarding caregiving. Study 2 employed a single-subjects design to evaluate the effectiveness of the DVD presentation when administered by a community mental health educator. Ninety-three Spanish-speakers from San Diego, California completed assessments both before and after receiving the DVD training. Results from these 2 studies indicate that the DVD version of La CLAve is capable of producing a range of psychosis literacy gains for Spanish-speakers in both the United States and Mexico, even when administered by a community worker. Thus, it has potential for widespread dissemination and use among underserved communities of Spanish-speaking Latinos and for minimizing disparities in mental health service use, particularly as it relates to insufficient knowledge of psychosis.

Contraceptive use in women undergoing bariatric surgery.

INTRODUCTION: Contraceptive counselling in women undergoing bariatric surgery is crucial due to increased risk of foetal growth restriction postoperatively. We evaluate if women undergoing bariatric surgery are being counselled about and using contraception. METHODS: A 36-question survey was sent electronically to patients at the Miriam Hospital Bariatric Center in Providence, Rhode Island. RESULTS: Of the thirty-five women included in our study, 85.7% and 80% reported receiving contraceptive counselling and advice to avoid pregnancy in the 12-24 months following surgery, respectively. Only 65.7% were using contraception. More women using contraception reported receiving counselling (95.7% vs. 66.7%) and knew to avoid pregnancy postoperatively (82.6% vs. 75%) than women not using contraception. Contraceptive use declined over time following surgery. CONCLUSION: We have identified an important opportunity for healthcare providers to promote ongoing compliance with contraception for women undergoing bariatric surgery.

Interpreter-mediated neuropsychological testing of monolingual Spanish speakers.

The primary objective of this study was to investigate empirically whether using an interpreter to conduct neuropsychological testing of monolingual Spanish speakers affects test scores. Participants included 40 neurologically normal Spanish speakers with limited English proficiency, aged 18-65 years (M = 39.7, SD = 13.9), who completed the Vocabulary, Similarities, Block Design, and Matrix Reasoning subtests of the Wechsler Adult Intelligence Scale-III in two counterbalanced conditions: with and without an interpreter. Results indicated that interpreter use significantly increased scores on Vocabulary and Similarities. However, scores on Block Design and Matrix Reasoning did not differ depending on whether or not an interpreter was used. In addition the findings suggested a trend toward higher variability in scores when an interpreter was used to administer Vocabulary and Similarities; this trend did not show up for Block Design or Matrix Reasoning. Together the results indicate that interpreter use may significantly affect scores for some tests commonly used in neuropsychological practice, with this influence being greater for verbally mediated tests. Additional research is needed to identify the types of tests that may be most affected as well as the factors that contribute to the effects. In the meantime neuropsychologists are encouraged to avoid interpreter use whenever practically possible, particularly for tests with high demands on interpreter abilities and skills, with tests that have not been appropriately adapted and translated into the patient's target language, and with interpreters who are not trained professionals.

Association of leisure physical activity and sleep with cardiovascular risk factors in postmenopausal women.

OBJECTIVE: The aim of this study was to examine the individual and combined associations of leisure-time physical activity and sleep with cardiovascular risk factors in postmenopausal women. METHODS: We analyzed 48-month cross-sectional follow-up data from 393 participants of the Women on the Move Through Activity and Nutrition Study, a behavioral weight loss trial. Leisure-time physical activity data were collected with the past-year Modifiable Activity Questionnaire, whereas sleep data were collected with the Pittsburgh Sleep Quality Index. We compared physical activity and sleep categories using analysis of variance, post hoc Scheffe tests, and multivariate analyses based on groups above/below the median leisure-time physical activity level, above/below the sleep quality value of 5, and above/below the sleep duration of 7 hours/day. RESULTS: The average sleep quality and sleep duration did not significantly differ between women with high and women with low physical activity levels. When women with good sleep quality were compared, higher physical activity levels were associated with lower body mass index (2.0 kg/m; 25, 75 quartiles, 0.3, 3.6), waist circumference (6.3 cm; 1.7, 10.9), and total body fat (2.1%; 0.3, 4.0; P < 0.05). When participants with poor sleep quality were compared, highly active women had lower trunk fat, total body fat, and insulin levels than less active women did (P < 0.05). In multivariate analysis, physical activity was significantly associated with high-density lipoprotein level, trunk fat, and total body fat after controlling for sleep quality, sleep duration, age, hormone therapy and smoking status, and body mass index. CONCLUSIONS: The combined associations of leisure-time physical activity and sleep suggest that cardiovascular risk factors are more favorable in highly active women relative to less active women regardless of sleep.