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Clinical education
Clinical Education A presentation featuring Karen Johnson, MD, a psychiatrist and author from San Francisco; Joanna Cain, MD, an obstetrician-gynecologist on the faculty at the University of Washington Medical Center; and Judith B. Collins, RNC, MS, who teaches and directs the Health Policy Office at the Medical College of Virginia~Virginia Commonwealth University. The moderator was Ronald A. Chez, MD, professor of obstetrics-gynecology and professor of community and family health at the University of South Florida. mplementing an integrated approach to women's health care tends to be easier to work out in clinical practice than in academia. In practice, multispecialty providers, motivated by a philosophy that the interdisciplinary approach works best, share patients and possibly facilities and billing systems. To create training programs that reflect this integrated approach, however, it will be necessary for whole specialties---medical, nursing, and other health professions--to share core curricula and training opportunities. There is no getting around the fact that developing a holistic, comprehensive approach to women's health care calls for major changes in clinical education.
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W O M E N ' S HEALTH: A NEW INTERDISCIPLINARY SPECIALTY As the country's leading advocate for a new specialty in women's health, Dr. Karen Johnson has likened that objective to having "a room of one's o w n " - an allusion to Virginia Woolf's groundbreaking treatise on women's enfranchisement through the field of literature. Within a medical context, she sees the new specialty as a necessary step in providing women with the best possible health care. Only recently has medicine moved beyond the premise that women are just like men but for their reproductive organs. This latter view restricted research and also relegated women to a narrow form of medical treatment, one that failed to take into account their distinctive social, biologic, psychological, and hormonal attributes (and in doing so fell short of meeting their needs). Now the research gap is closing, but that alone is insufficient to provide women with the kind of care they need, in Dr. Johnson's view. She called for a cadre of specially trained providers. In her article published in this issue, she argues that a new specialty devoted to women's health is not only desirable, but inevitable--a movement born of practitioners' desires to set aside the "arbitrary divisions of medicine . . . to encompass the reality of women's experiences in which health, pain, and dysfunction cross conventional boundaries." As envisioned, such specialists would "not be constrained by the conventional biomedical model, but would recognize that prevention, education, health promotion, and psychosocial evaluation are integral components of the comprehensive care of women," similar to practice in the nation's approximately 1600 women's health WHI Vol. 3, No. 2 Summer 1993
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centers, where the entrepreneurial model has recently been joined by an academic model offering fertile training ground. "It is from t h e s e . . . c e n t e r s . . , that one model of postgraduate training in women's health, the 'de novo' interdisciplinary specialty, is likely to begin," she said. Dr. Johnson suggested that in its inception, the specialty of women's health will probably assume several different forms. A knowledge base is already emerging from the nation's major academic medical centers and professional organizations, which are developing core curricula and offering fellowships in women's health. (Depending on the institution, these are housed within internal medicine or obstetrics-gynecology departments.) Professional acceptance of such a discipline will take longer. Dr. Johnson suggests the new specialty be housed within obstetricsgynecology, albeit a dramatically made-over version of the specialty as it now stands. Whereas obstetrics-gynecology is now split between adopting a primary care role or protecting its surgical emphasis, Dr. Johnson envisions for it a challenging new future---one that would require a fundamental restructuring of medical education and residency training. As persuasion, she offers that many women already view their obstetrician-gynecologist as their primary care physician ("although there is little about their current training that warrants that perception") and that a formal continuation of that role would be mutually satisfying. Furthermore, the number of births are expected to decline after the 1990s, and the nation already is oversupplied with specialists and undersupplied with primary care physicians. Acknowledging that the transformation would mainly take place in residency education, and that many obstetrician-gynecologists would have no interest in providing primary care, Dr. Johnson suggested that those who are interested could be "grandfathered" into the new specialty. She cited a precedent for such change in the American Academy of General Practice's re-creation as the American Academy of Family Physicians. The American College of Obstetricians and Gynecologists, Dr. Johnson speculated, could become the "American College of Women's Health."
DRAWING UPON THE "SCHOLARSHIP OF INTEGRATION" Teaching medical school graduates and undergraduates about women's health not only requires an interdisciplinary curriculum, but must also break the traditional mold of scholarship and teaching methodology within our academic institutions, according to Joanna Cain, MD. The endeavor "demands breaking very basic paradigms of the way we have taught medicine in this country," she said. "We are asking to incorporate a very rich context across boundaries that haven't been crossed easily in the past and have maintained their borders carefully because of money and power within the disciplines." As assistant professor of obstetrics and gynecology at the University of Washington Medical Center, Dr. Cain has focused on medical education, including curricula design and teaching ethics. She used an anecdote to illustrate what she means by the "rich context" of women's health care. A student in the gynecologic oncology clinic complained to her about a patient who was not cooperating with the treatment regimen. Although she was scheduled to undergo chemotherapy for cervical cancer, the woman said she couldn't be admitted, that her family needed her and she had to go home to her Indian reservation in the eastern part of the state. Dr. Cain happened to be acquainted with the woman, and after questioning the woman herself, she learned that the woman's aunt, brother, and sister had all "left her" (ie, died of cancer), the aunt only very recently. Also, the woman's sons were in college and one was having problems with alcohol use. At the end of their 72
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conversation, even though they had not discussed the impending chemotherapy, the woman announced she was willing to stay. "Thanks for sitting with me," she said to Dr. Cain. Afterwards, and only with a great deal of prompting, Dr. Cain was able to elicit from the medical student what the real barriers were in the previous interaction. They deduced that the woman was alone and wanted help, that "she wanted us to come in and listen to her context, to the richness of her life," Dr. Cain repeated. What happens in women's health care is "we fall to understand the code that w o m e n speak in," Dr. Cain explained. "Women quite often fear that one's experience, if spoken, will somehow be judged against them in the medical environment . . . . This very simple psychological fact keeps w o m e n talking in code." We don't teach medical students how to break the code or how to open that communication," she added. "But that is the sort of context and richness we must address if we are to build a curriculum in women's health care." The new educational paradigm that Dr. Cain is calling upon, the "scholarship of integration," was first postulated by Ernest L. Boyer, PhD, in a 1990 Carnegie Foundation report entitled, "Scholarship Revisited." Educators of this new mold would conform to Dr. Boyer's definition as "scholars with the ability to synthesize, to look for new relationships between parts and the whole, relate past, present, and future patterns of meaning that cannot be seen through traditional disciplinary lenses." Unfortunately, she added, this sort of scholarship is more apt to be found in book chapters than in peer-reviewed scientific articles, and among those who value teaching over a narrow research interest. In contrast, the type of activity rewarded in medical schools is the "scholarship of discovery"--ie, publishing original findings in a narrowly defined area. Therefore, the first shift to a new paradigm must occur in faculty selection and promotion practices. "Promoting women's health in that regard begins in the promotion and tenure committees of medical schools," she said. Women are no more inherently suited for this teaching role than are men, she added. In a telling study of obstetrics-gynecology residents, it was the female students, more than the males, who expected their patients to be "compliant" and "obedient." "What you're really looking for are people who are willing to continually assess their own a s s u m p t i o n s . . , tolerance and attitudes," Dr. Cain said, and who "respect the voice and the complexity" of patients. Because residents themselves tend to be violated in residency training, a "part of women's health care is treating both the student and the patient with the respect we would accord any colleague." A second major area of change would be core curriculum, where she suggested that curricula from different specialties be creatively merged. She suggested "integrating different paradigms to make a new paradigm," preserving any rethinking or revision of curricula that are already underway. Thus the new curricula would include obstetrics-gynecology curricula in preventive and primary care, and in reproductive ethics, would preserve family practice's new emphasis on studying family relationships, and would retain internal medicine's construct around disease and organ systems. Dr. Cain further proposed a way of integrating these curricula from different specialties into a model based on women's developmental stages, stretching from childhood through old age. It would begin with childhood on the premise that the manner in which girls grow to be women, and the societal and cultural messages they absorb en route, have a great deal to do with how they interact with the health care system. The model would highlight both basic care (ie, things you would expect any medical student to be WHI Vol. 3, No. 2 S u m m e r 1993
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able to do upon graduation) and more complex areas of risk assessment and counseling. The third area of change that is necessary, according to Dr. Cain, is the way students are taught. "Part of our respect for patients needs to be a new way of viewing student-patient relationships," she said. Patients no longer should be viewed as clinical material: "I would propose the student-patient relationship ought to be based on consent, and an idea of the patient as the expert a n d . . , teacher for the student," she said. One thing she recommends is the use of professional patients when teaching techniques such as sexual assault examination or breast examination. "They allow someone to become very proficient without ever putting a patient in a position of feeling powerless," she said, "and give the person who's learning a chance to view a patient as an expert." In addition, problem-based learning is very attractive because it teaches about the disease process within the patient's own context. Other tools of this sort include medical ethics taught by case example. In summary, "if we're going to look at curriculum for women's health care, we have to recognize that we have an interdependent system, and one that is different from what we have promoted for academic medicine," Dr. Cain said. Three major areas of change are required: 1) looking at who our educators are and how we promote them; 2) looking at curricula and creatively integrating very diverse paradigms into one; and 3) treating medical students with respect and expecting them to interact with patients and colleagues in a respectful way.
NURSING EDUCATION AND WOMEN'S HEALTH Judith B. Collins, RNC, MS, OGNP, described how nursing curricula and training can contribute to the interdisciplinary nature of women's health, and how nurses tend to serve in highly socialized roles as "interpreters" for physicians and advocates for patients. Overall, she characterized the philosophy of nursing education as one "based on a holistic approach . . . with a focus on the physical, psychological, and social dimensions" of care. "Caring versus curing," "health care versus medical care," and "high touch versus high tech" are all applicable descriptions. The didactic portion of nursing curricula usually has comprehensive core content that includes the nursing process and patient care planning, which represents considerable attention to communication skills plus patient education and counseling. In addition, she said, there is a major emphasis on prevention and wellness (as well as the disease process), as well as a multidisciplinary health care team approach. This foundation is then integrated throughout the rest of the curriculum as more focus is given to specific nursing skills, medicine, pharmacology, nutrition, etc. Students in nursing are exposed to patients not only in hospital settings, but also in clinic settings and home settings, Ms. Collins said. In addition, many nursing programs have instituted "follow-through" contact with patients so that nurses begin to see patients throughout different aspects of their illnesses and lives within the total context of their homes and families. This brings with it "a tremendous experience," she said. Above all, "a lot of time is spent looking at what the patient brings to this," she said. "I guess you could sum all this up in that nurses get a good dose of learning how to be a patient advocate." Partly because of their different educational experience, doctors and nurses tend to interact with what Ms. Collins described as a "creative tension." Nurses are predominantly women and "there's been a feminine model to our 74
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education," whereas physicians have been steeped in the medical model, which is traditionally hierarchical in orientation. These factors cause doctors and nurses to interact in what she perceives as a "game," in which the nurse, who is more attuned to the whole patient, tries to decipher her unspoken and spoken needs. (Ms. Collins referred to this as "decoding.") One reason patients tend to confide in nurses is because they're seen as more accessible than doctors, Mr. Collins said. "What we hear from patients is, 'we don't want to bother the doctor, but can I talk to you about this?' " Having extracted that information, nurses then "spend a tremendous amount of energy trying to persuade the doctor that he or she thought up what the patient wanted so we can get it done for the patient," Ms. Collins said. Rather than to view this game-playing as a weakness, Ms. Collins has turned it into a strength. "As I try to teach nurses how to be better politically, one of the things I say to them is 'we are the best politicians ever. We have learned how to negotiate and persuade, we are masters at this,' " she observes. Still, her dream is that "we don't have to play these games," she said. "We all need to be educated together" and "to recognize and value what every health care team member brings." "We really do have a lot to share," Ms. Collins said. "Nursing education, because of the focus that we bring to it, fits very well with trying to work in a model of teamwork."
DISCUSSION
Q. Given the fact that research into specific areas of women's health is overdue and unfinished, how would that affect the evolution of the new specialty? Marydale DeBor asked the question of Dr. Johnson, who alluded to pediatrics in its early stages. When physicians began talking about the need to have a specialty in pediatrics, the research into children's health was at about the same level as research into women's health is now, she said. The lack of designated physicians dedicated to the population being studied tends to inhibit the impact of research findings, Dr. Johnson pointed out, whereas when there is a group of dedicated physicians, there is an explosion in information because people are giving it their undivided attention. She referred to this as a "synergistic p h e n o m e n o n " - - t h e explosion and application of research findings.
Q. If there is to be a women's health specialty, why not one also for men's health? Carolyn Drummond directed this challenge to Dr. Johnson, who said she often gets asked it. "When you look at the way medicine has been constructed, that's precisely what we have," Dr. Johnson said, "we have men's health. What we're missing is a comprehensive view of women's health." She said 70% of the research on which physicians base recommendations for women has been conducted exclusively on males. Consequently, it's not known whether or not it's valid for women, Dr. Johnson said, "and that's a problem."
Q. What is the definition of an "adult woman"? Would adolescent women, and even younger women, be served under the definition of "women's health"? Dr. Chez asked this in the context of teenage pregnancy, because the ticket for so many young women to enter our health care system is through pregnancy. Dr. Johnson responded that there are going to be many different models of women's health in the beginning. Including adolescent care in
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some of them would be useful because, "on a continuum, the adolescent period is very powerful in a female person's life." She did express reservations about the possibility that "women's health care" might be framed as "maternal and child health care"--a mold that needs to be broken, in her view, in order to serve the approximately 20% of women who do not bear children, yet still have many health needs. There often is a conflict of interest "when you lump mothers' needs with children's needs in one category," she observed.
Q. How do family physicians view this proposal for a new specialty? Charlea T. Massion, MD, a family practitioner in Santa Cruz, California, responded. Informally specializing in women's health, she practices as part of a 65-physician multispecialty group that is currently exploring the possibility of starting a women's health center. Most family physicians oppose the concept of a women's health specialty, she said, because they view it as in conflict with the principles behind family practice (eg, cradle-to-grave care of the whole family). "It is true that it [women's health] is against the concept of family practice, and I think there will be resistance . . . because of our philosophy," Dr. Massion observed. She noted, however, that family practice itself was created by a government mandate, and not by a consensus among general physicians. "I don't hold any special stock in the philosophy of family practice, because I think it evolved after the specialty was invented," Dr. Massion said.
Q. Would obstetrics-gynecology be an appropriate home for a new specialty of women's health, and is obstetrics-gynecology evolving into a primary care specialty? Bonnie Connors Jellen specifically requested that Dr. Cain respond to Dr. Johnson's proposal. Dr. Cain first distinguished between two viewpoints: one, that obstetrics-gynecology represents a primary point of entry into health care for women, and two, that obstetrics-gynecology is a primary care specialty. "I think it can be [a primary care specialty]," Dr. Cain said, but "I don't see it as a bad thing for women's health to be interdisciplinary. In fact, I see it as a very positive step for medicine to learn to be interdisciplinary, and I'm not sure that we need another vertical line in the list of disciplines, to make another set of borders and boundaries that are so hard to cross."
Q. Does the discipline of medical anthropology (as exemplified by the work of Ludell Snozo at Michigan State University) have relevance for interacting zoith patients? Dr. Chez asked this in response to the clinical vignette given during Dr. Cain's presentation (eg, the Native American woman undergoing chemotherapy). Dr. Cain replied that in general our paradigms--regardless of what field--are highly culturally based. Medical ethics, as an example, relies heavily on the American concept of autonomy, whereas for some cultures, autonomy does not exist. It is not the patient who speaks for herself it is the husband or brother, Dr. Cain pointed out: "When that is the case, how do you interact with our system?"
Q. Why doesn't medicine integrate some of the educational experiences of students in different health care professions? Jaynelle Stichler commented that she is puzzled why learning opportunities are not shared among different health care professionals, such as nurses and physicians, social workers and clinical psychologists. She recalls one academic setting (University of Arizona), where graduate nursing students worked with medical students. "I felt that what came as an outcome of that experience was a real understanding of the likeness and differences of those particular 76
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professions, and most importantly, a higher caliber of collaboration between the two specialties," she said. She urged it be attempted as part of curriculum building "because it's going to be important f o r . . , health care professionals to work together more closely than ever before." Dr. Cain was in agreement.
Q. Why do nurses continue to "play a game" (ie, as an intermediary or "decoder" between physicians and patients)? Alice Dan, MD, asked this in response to the Collins presentation. Ms. Collins replied that "When your opinion is not valued . . . you find out soon enough what to do to get what you need for patients and their families. If you have to play the game, that's what you do," she said. She did acknowledge that in part this may be an outgrowth of nurses' socialization. Young men and women in nursing today are not as deferential, and are more apt to view themselves as equal professionals in relation to physicians, she said, so maybe this will change in time.
Q. Would it work to have nurses teach medical students? Dr. Wilbanks asked this question, which caused Dr. Cain to offer the following comment. "All of us who have been on clinical services know that nurses do help medical students learn and they help first-year residents," he said, "and there's some transition that takes place within each resident somewhere between the first, second, and third year, in which they [nurses] are no longer perceived as educators-mentors, but now as handmaidens." It would be worthwhile to analyze that phenomenon, he said, because in most programs the majority of residents leave without the understanding that nursing is truly a separate discipline with its own set of knowledge and skills brought to the therapeutic equation.
Q. What is the role of trust in professional interactions? Dr. Chez directed this topic to Howard McQuarrie, MD, because of his interest and past work. Medicine, in general, is "terribly dysfunctional," Dr. McQuarrie said, in that "we don't behave like other businesses, and our professional activity isn't manageable." Furthermore, the lack of trust is pervasive: "We don't trust our CEO [chief executive officer] or administrator, we don't trust our board of trustees," he continued. He postulated that the reason for this breakdown in trust is that "goals remain individual and egotistical." Building a women's center or service may be a way to change that, he said, an opportunity for integration when the mission of a project (medicine, for example) and the goals of the system override the individual preferences, expectations, and ego. Dr. Cain drew a parallel analogy in academic settings. She commented that her own experience in integrating different disciplines to establish a women's health center was to witness a marked interest in where the head of the center was going to come from (eg, obstetrics-gynecology, internal medicine, or family practice). "When our institution looked at women's health care, it was seen in terms of power meaning money, and therefore each separate department wanted to get its hands on it," she said. "That obviously is exactly the opposite of building trust between individual disciplines, and exactly the opposite of what we want to focus on in building a different sort of relationship and connection between disciplines," she said. WHI Vol. 3, No. 2 S u m m e r 1993
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Q. Again, is it really necessary to train the "renaissance" women's health provider in women's health, or is it possible for women's health providers to cross over the vertical integration of the specialties? Edward Linn, MD, in response to Dr. Johnson's call for a new specialty, commented that "I want all the health care providers to be educated in women's health, not just a unique specialty. I need surgeons who share my common philosophies and understanding about the woman's health process. I need neurologists and dermatologists and cardiologists who have these similar views." For that reason, Dr. Linn said he feels the "renaissance women's health center" needs to become the facilitator for this process of integration-to be a source of education, as well as health care provision--rather than have individuals trained in an exclusive specialty. Dr. Johnson responded to the debate over a new specialty by recalling a similar debate in the early 1970s about the need for colleges to establish departments of women's studies or, as an alternative, to bring women's information in every branch of academics (eg, English, history, anthropology, sociology). "The past 20 years have d e m o n s t r a t e d . . , that you need both," she said. "You must have departments of women's s t u d i e s . . , where scholars, who become your starter material, go to the other departments and educate your historians and sociologists . . . . You have to have a home base where somebody does the scholarship in women's studies. "We need precisely the same thing in medicine . . . a home base. We need scholars who devote their undivided attention to women, who will then be available to educate orthopedists, urologists, gastroenterologists, cardiologists, obstetricians-gynecologists, etc, and they will, again, be synergistic." According to Dr. Johnson, the experience in women's studies has shown that those institutions that tried only to integrate it into existing disciplines failed, and those in which women's studies remained isolated failed. It worked when departments of women's studies were integrated into the larger institution. "It has to be both, not either/or," she concluded. "Frankly," she added, "this is a moving train that's not going to be stopped. When I sit here and listen to all of you starting up women's health centers across the United S t a t e s . . . I know there are going to be young men and women who come through those institutions. You are going to train them, and they're going to come out the other end and say to you, 'I want to practice women's health!' "
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W O M E N ' S HEALTH: A NEW INTERDISCIPLINARY SPECIALTY As the country's leading advocate for a new specialty in women's health, Dr. Karen Johnson has likened that objective to having "a room of one's o w n " - an allusion to Virginia Woolf's groundbreaking treatise on women's enfranchisement through the field of literature. Within a medical context, she sees the new specialty as a necessary step in providing women with the best possible health care. Only recently has medicine moved beyond the premise that women are just like men but for their reproductive organs. This latter view restricted research and also relegated women to a narrow form of medical treatment, one that failed to take into account their distinctive social, biologic, psychological, and hormonal attributes (and in doing so fell short of meeting their needs). Now the research gap is closing, but that alone is insufficient to provide women with the kind of care they need, in Dr. Johnson's view. She called for a cadre of specially trained providers. In her article published in this issue, she argues that a new specialty devoted to women's health is not only desirable, but inevitable--a movement born of practitioners' desires to set aside the "arbitrary divisions of medicine . . . to encompass the reality of women's experiences in which health, pain, and dysfunction cross conventional boundaries." As envisioned, such specialists would "not be constrained by the conventional biomedical model, but would recognize that prevention, education, health promotion, and psychosocial evaluation are integral components of the comprehensive care of women," similar to practice in the nation's approximately 1600 women's health WHI Vol. 3, No. 2 Summer 1993
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centers, where the entrepreneurial model has recently been joined by an academic model offering fertile training ground. "It is from t h e s e . . . c e n t e r s . . , that one model of postgraduate training in women's health, the 'de novo' interdisciplinary specialty, is likely to begin," she said. Dr. Johnson suggested that in its inception, the specialty of women's health will probably assume several different forms. A knowledge base is already emerging from the nation's major academic medical centers and professional organizations, which are developing core curricula and offering fellowships in women's health. (Depending on the institution, these are housed within internal medicine or obstetrics-gynecology departments.) Professional acceptance of such a discipline will take longer. Dr. Johnson suggests the new specialty be housed within obstetricsgynecology, albeit a dramatically made-over version of the specialty as it now stands. Whereas obstetrics-gynecology is now split between adopting a primary care role or protecting its surgical emphasis, Dr. Johnson envisions for it a challenging new future---one that would require a fundamental restructuring of medical education and residency training. As persuasion, she offers that many women already view their obstetrician-gynecologist as their primary care physician ("although there is little about their current training that warrants that perception") and that a formal continuation of that role would be mutually satisfying. Furthermore, the number of births are expected to decline after the 1990s, and the nation already is oversupplied with specialists and undersupplied with primary care physicians. Acknowledging that the transformation would mainly take place in residency education, and that many obstetrician-gynecologists would have no interest in providing primary care, Dr. Johnson suggested that those who are interested could be "grandfathered" into the new specialty. She cited a precedent for such change in the American Academy of General Practice's re-creation as the American Academy of Family Physicians. The American College of Obstetricians and Gynecologists, Dr. Johnson speculated, could become the "American College of Women's Health."
DRAWING UPON THE "SCHOLARSHIP OF INTEGRATION" Teaching medical school graduates and undergraduates about women's health not only requires an interdisciplinary curriculum, but must also break the traditional mold of scholarship and teaching methodology within our academic institutions, according to Joanna Cain, MD. The endeavor "demands breaking very basic paradigms of the way we have taught medicine in this country," she said. "We are asking to incorporate a very rich context across boundaries that haven't been crossed easily in the past and have maintained their borders carefully because of money and power within the disciplines." As assistant professor of obstetrics and gynecology at the University of Washington Medical Center, Dr. Cain has focused on medical education, including curricula design and teaching ethics. She used an anecdote to illustrate what she means by the "rich context" of women's health care. A student in the gynecologic oncology clinic complained to her about a patient who was not cooperating with the treatment regimen. Although she was scheduled to undergo chemotherapy for cervical cancer, the woman said she couldn't be admitted, that her family needed her and she had to go home to her Indian reservation in the eastern part of the state. Dr. Cain happened to be acquainted with the woman, and after questioning the woman herself, she learned that the woman's aunt, brother, and sister had all "left her" (ie, died of cancer), the aunt only very recently. Also, the woman's sons were in college and one was having problems with alcohol use. At the end of their 72
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conversation, even though they had not discussed the impending chemotherapy, the woman announced she was willing to stay. "Thanks for sitting with me," she said to Dr. Cain. Afterwards, and only with a great deal of prompting, Dr. Cain was able to elicit from the medical student what the real barriers were in the previous interaction. They deduced that the woman was alone and wanted help, that "she wanted us to come in and listen to her context, to the richness of her life," Dr. Cain repeated. What happens in women's health care is "we fall to understand the code that w o m e n speak in," Dr. Cain explained. "Women quite often fear that one's experience, if spoken, will somehow be judged against them in the medical environment . . . . This very simple psychological fact keeps w o m e n talking in code." We don't teach medical students how to break the code or how to open that communication," she added. "But that is the sort of context and richness we must address if we are to build a curriculum in women's health care." The new educational paradigm that Dr. Cain is calling upon, the "scholarship of integration," was first postulated by Ernest L. Boyer, PhD, in a 1990 Carnegie Foundation report entitled, "Scholarship Revisited." Educators of this new mold would conform to Dr. Boyer's definition as "scholars with the ability to synthesize, to look for new relationships between parts and the whole, relate past, present, and future patterns of meaning that cannot be seen through traditional disciplinary lenses." Unfortunately, she added, this sort of scholarship is more apt to be found in book chapters than in peer-reviewed scientific articles, and among those who value teaching over a narrow research interest. In contrast, the type of activity rewarded in medical schools is the "scholarship of discovery"--ie, publishing original findings in a narrowly defined area. Therefore, the first shift to a new paradigm must occur in faculty selection and promotion practices. "Promoting women's health in that regard begins in the promotion and tenure committees of medical schools," she said. Women are no more inherently suited for this teaching role than are men, she added. In a telling study of obstetrics-gynecology residents, it was the female students, more than the males, who expected their patients to be "compliant" and "obedient." "What you're really looking for are people who are willing to continually assess their own a s s u m p t i o n s . . , tolerance and attitudes," Dr. Cain said, and who "respect the voice and the complexity" of patients. Because residents themselves tend to be violated in residency training, a "part of women's health care is treating both the student and the patient with the respect we would accord any colleague." A second major area of change would be core curriculum, where she suggested that curricula from different specialties be creatively merged. She suggested "integrating different paradigms to make a new paradigm," preserving any rethinking or revision of curricula that are already underway. Thus the new curricula would include obstetrics-gynecology curricula in preventive and primary care, and in reproductive ethics, would preserve family practice's new emphasis on studying family relationships, and would retain internal medicine's construct around disease and organ systems. Dr. Cain further proposed a way of integrating these curricula from different specialties into a model based on women's developmental stages, stretching from childhood through old age. It would begin with childhood on the premise that the manner in which girls grow to be women, and the societal and cultural messages they absorb en route, have a great deal to do with how they interact with the health care system. The model would highlight both basic care (ie, things you would expect any medical student to be WHI Vol. 3, No. 2 S u m m e r 1993
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able to do upon graduation) and more complex areas of risk assessment and counseling. The third area of change that is necessary, according to Dr. Cain, is the way students are taught. "Part of our respect for patients needs to be a new way of viewing student-patient relationships," she said. Patients no longer should be viewed as clinical material: "I would propose the student-patient relationship ought to be based on consent, and an idea of the patient as the expert a n d . . , teacher for the student," she said. One thing she recommends is the use of professional patients when teaching techniques such as sexual assault examination or breast examination. "They allow someone to become very proficient without ever putting a patient in a position of feeling powerless," she said, "and give the person who's learning a chance to view a patient as an expert." In addition, problem-based learning is very attractive because it teaches about the disease process within the patient's own context. Other tools of this sort include medical ethics taught by case example. In summary, "if we're going to look at curriculum for women's health care, we have to recognize that we have an interdependent system, and one that is different from what we have promoted for academic medicine," Dr. Cain said. Three major areas of change are required: 1) looking at who our educators are and how we promote them; 2) looking at curricula and creatively integrating very diverse paradigms into one; and 3) treating medical students with respect and expecting them to interact with patients and colleagues in a respectful way.
NURSING EDUCATION AND WOMEN'S HEALTH Judith B. Collins, RNC, MS, OGNP, described how nursing curricula and training can contribute to the interdisciplinary nature of women's health, and how nurses tend to serve in highly socialized roles as "interpreters" for physicians and advocates for patients. Overall, she characterized the philosophy of nursing education as one "based on a holistic approach . . . with a focus on the physical, psychological, and social dimensions" of care. "Caring versus curing," "health care versus medical care," and "high touch versus high tech" are all applicable descriptions. The didactic portion of nursing curricula usually has comprehensive core content that includes the nursing process and patient care planning, which represents considerable attention to communication skills plus patient education and counseling. In addition, she said, there is a major emphasis on prevention and wellness (as well as the disease process), as well as a multidisciplinary health care team approach. This foundation is then integrated throughout the rest of the curriculum as more focus is given to specific nursing skills, medicine, pharmacology, nutrition, etc. Students in nursing are exposed to patients not only in hospital settings, but also in clinic settings and home settings, Ms. Collins said. In addition, many nursing programs have instituted "follow-through" contact with patients so that nurses begin to see patients throughout different aspects of their illnesses and lives within the total context of their homes and families. This brings with it "a tremendous experience," she said. Above all, "a lot of time is spent looking at what the patient brings to this," she said. "I guess you could sum all this up in that nurses get a good dose of learning how to be a patient advocate." Partly because of their different educational experience, doctors and nurses tend to interact with what Ms. Collins described as a "creative tension." Nurses are predominantly women and "there's been a feminine model to our 74
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education," whereas physicians have been steeped in the medical model, which is traditionally hierarchical in orientation. These factors cause doctors and nurses to interact in what she perceives as a "game," in which the nurse, who is more attuned to the whole patient, tries to decipher her unspoken and spoken needs. (Ms. Collins referred to this as "decoding.") One reason patients tend to confide in nurses is because they're seen as more accessible than doctors, Mr. Collins said. "What we hear from patients is, 'we don't want to bother the doctor, but can I talk to you about this?' " Having extracted that information, nurses then "spend a tremendous amount of energy trying to persuade the doctor that he or she thought up what the patient wanted so we can get it done for the patient," Ms. Collins said. Rather than to view this game-playing as a weakness, Ms. Collins has turned it into a strength. "As I try to teach nurses how to be better politically, one of the things I say to them is 'we are the best politicians ever. We have learned how to negotiate and persuade, we are masters at this,' " she observes. Still, her dream is that "we don't have to play these games," she said. "We all need to be educated together" and "to recognize and value what every health care team member brings." "We really do have a lot to share," Ms. Collins said. "Nursing education, because of the focus that we bring to it, fits very well with trying to work in a model of teamwork."
DISCUSSION
Q. Given the fact that research into specific areas of women's health is overdue and unfinished, how would that affect the evolution of the new specialty? Marydale DeBor asked the question of Dr. Johnson, who alluded to pediatrics in its early stages. When physicians began talking about the need to have a specialty in pediatrics, the research into children's health was at about the same level as research into women's health is now, she said. The lack of designated physicians dedicated to the population being studied tends to inhibit the impact of research findings, Dr. Johnson pointed out, whereas when there is a group of dedicated physicians, there is an explosion in information because people are giving it their undivided attention. She referred to this as a "synergistic p h e n o m e n o n " - - t h e explosion and application of research findings.
Q. If there is to be a women's health specialty, why not one also for men's health? Carolyn Drummond directed this challenge to Dr. Johnson, who said she often gets asked it. "When you look at the way medicine has been constructed, that's precisely what we have," Dr. Johnson said, "we have men's health. What we're missing is a comprehensive view of women's health." She said 70% of the research on which physicians base recommendations for women has been conducted exclusively on males. Consequently, it's not known whether or not it's valid for women, Dr. Johnson said, "and that's a problem."
Q. What is the definition of an "adult woman"? Would adolescent women, and even younger women, be served under the definition of "women's health"? Dr. Chez asked this in the context of teenage pregnancy, because the ticket for so many young women to enter our health care system is through pregnancy. Dr. Johnson responded that there are going to be many different models of women's health in the beginning. Including adolescent care in
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some of them would be useful because, "on a continuum, the adolescent period is very powerful in a female person's life." She did express reservations about the possibility that "women's health care" might be framed as "maternal and child health care"--a mold that needs to be broken, in her view, in order to serve the approximately 20% of women who do not bear children, yet still have many health needs. There often is a conflict of interest "when you lump mothers' needs with children's needs in one category," she observed.
Q. How do family physicians view this proposal for a new specialty? Charlea T. Massion, MD, a family practitioner in Santa Cruz, California, responded. Informally specializing in women's health, she practices as part of a 65-physician multispecialty group that is currently exploring the possibility of starting a women's health center. Most family physicians oppose the concept of a women's health specialty, she said, because they view it as in conflict with the principles behind family practice (eg, cradle-to-grave care of the whole family). "It is true that it [women's health] is against the concept of family practice, and I think there will be resistance . . . because of our philosophy," Dr. Massion observed. She noted, however, that family practice itself was created by a government mandate, and not by a consensus among general physicians. "I don't hold any special stock in the philosophy of family practice, because I think it evolved after the specialty was invented," Dr. Massion said.
Q. Would obstetrics-gynecology be an appropriate home for a new specialty of women's health, and is obstetrics-gynecology evolving into a primary care specialty? Bonnie Connors Jellen specifically requested that Dr. Cain respond to Dr. Johnson's proposal. Dr. Cain first distinguished between two viewpoints: one, that obstetrics-gynecology represents a primary point of entry into health care for women, and two, that obstetrics-gynecology is a primary care specialty. "I think it can be [a primary care specialty]," Dr. Cain said, but "I don't see it as a bad thing for women's health to be interdisciplinary. In fact, I see it as a very positive step for medicine to learn to be interdisciplinary, and I'm not sure that we need another vertical line in the list of disciplines, to make another set of borders and boundaries that are so hard to cross."
Q. Does the discipline of medical anthropology (as exemplified by the work of Ludell Snozo at Michigan State University) have relevance for interacting zoith patients? Dr. Chez asked this in response to the clinical vignette given during Dr. Cain's presentation (eg, the Native American woman undergoing chemotherapy). Dr. Cain replied that in general our paradigms--regardless of what field--are highly culturally based. Medical ethics, as an example, relies heavily on the American concept of autonomy, whereas for some cultures, autonomy does not exist. It is not the patient who speaks for herself it is the husband or brother, Dr. Cain pointed out: "When that is the case, how do you interact with our system?"
Q. Why doesn't medicine integrate some of the educational experiences of students in different health care professions? Jaynelle Stichler commented that she is puzzled why learning opportunities are not shared among different health care professionals, such as nurses and physicians, social workers and clinical psychologists. She recalls one academic setting (University of Arizona), where graduate nursing students worked with medical students. "I felt that what came as an outcome of that experience was a real understanding of the likeness and differences of those particular 76
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professions, and most importantly, a higher caliber of collaboration between the two specialties," she said. She urged it be attempted as part of curriculum building "because it's going to be important f o r . . , health care professionals to work together more closely than ever before." Dr. Cain was in agreement.
Q. Why do nurses continue to "play a game" (ie, as an intermediary or "decoder" between physicians and patients)? Alice Dan, MD, asked this in response to the Collins presentation. Ms. Collins replied that "When your opinion is not valued . . . you find out soon enough what to do to get what you need for patients and their families. If you have to play the game, that's what you do," she said. She did acknowledge that in part this may be an outgrowth of nurses' socialization. Young men and women in nursing today are not as deferential, and are more apt to view themselves as equal professionals in relation to physicians, she said, so maybe this will change in time.
Q. Would it work to have nurses teach medical students? Dr. Wilbanks asked this question, which caused Dr. Cain to offer the following comment. "All of us who have been on clinical services know that nurses do help medical students learn and they help first-year residents," he said, "and there's some transition that takes place within each resident somewhere between the first, second, and third year, in which they [nurses] are no longer perceived as educators-mentors, but now as handmaidens." It would be worthwhile to analyze that phenomenon, he said, because in most programs the majority of residents leave without the understanding that nursing is truly a separate discipline with its own set of knowledge and skills brought to the therapeutic equation.
Q. What is the role of trust in professional interactions? Dr. Chez directed this topic to Howard McQuarrie, MD, because of his interest and past work. Medicine, in general, is "terribly dysfunctional," Dr. McQuarrie said, in that "we don't behave like other businesses, and our professional activity isn't manageable." Furthermore, the lack of trust is pervasive: "We don't trust our CEO [chief executive officer] or administrator, we don't trust our board of trustees," he continued. He postulated that the reason for this breakdown in trust is that "goals remain individual and egotistical." Building a women's center or service may be a way to change that, he said, an opportunity for integration when the mission of a project (medicine, for example) and the goals of the system override the individual preferences, expectations, and ego. Dr. Cain drew a parallel analogy in academic settings. She commented that her own experience in integrating different disciplines to establish a women's health center was to witness a marked interest in where the head of the center was going to come from (eg, obstetrics-gynecology, internal medicine, or family practice). "When our institution looked at women's health care, it was seen in terms of power meaning money, and therefore each separate department wanted to get its hands on it," she said. "That obviously is exactly the opposite of building trust between individual disciplines, and exactly the opposite of what we want to focus on in building a different sort of relationship and connection between disciplines," she said. WHI Vol. 3, No. 2 S u m m e r 1993
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Q. Again, is it really necessary to train the "renaissance" women's health provider in women's health, or is it possible for women's health providers to cross over the vertical integration of the specialties? Edward Linn, MD, in response to Dr. Johnson's call for a new specialty, commented that "I want all the health care providers to be educated in women's health, not just a unique specialty. I need surgeons who share my common philosophies and understanding about the woman's health process. I need neurologists and dermatologists and cardiologists who have these similar views." For that reason, Dr. Linn said he feels the "renaissance women's health center" needs to become the facilitator for this process of integration-to be a source of education, as well as health care provision--rather than have individuals trained in an exclusive specialty. Dr. Johnson responded to the debate over a new specialty by recalling a similar debate in the early 1970s about the need for colleges to establish departments of women's studies or, as an alternative, to bring women's information in every branch of academics (eg, English, history, anthropology, sociology). "The past 20 years have d e m o n s t r a t e d . . , that you need both," she said. "You must have departments of women's s t u d i e s . . , where scholars, who become your starter material, go to the other departments and educate your historians and sociologists . . . . You have to have a home base where somebody does the scholarship in women's studies. "We need precisely the same thing in medicine . . . a home base. We need scholars who devote their undivided attention to women, who will then be available to educate orthopedists, urologists, gastroenterologists, cardiologists, obstetricians-gynecologists, etc, and they will, again, be synergistic." According to Dr. Johnson, the experience in women's studies has shown that those institutions that tried only to integrate it into existing disciplines failed, and those in which women's studies remained isolated failed. It worked when departments of women's studies were integrated into the larger institution. "It has to be both, not either/or," she concluded. "Frankly," she added, "this is a moving train that's not going to be stopped. When I sit here and listen to all of you starting up women's health centers across the United S t a t e s . . . I know there are going to be young men and women who come through those institutions. You are going to train them, and they're going to come out the other end and say to you, 'I want to practice women's health!' "
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