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Contraception Editorial February 2007

Securing the Future: A Case for Improving Clinical Education
in Reproductive Health

By: Cathy J. Lazarus, Shana Brown, and Lee Lee Doyle

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Over the past decade, it has become more widely recognized that reproductive health is an inextricable part of overall patient health and well-being.1 The need for high-quality reproductive health care in this country is reinforced by familiar statistics: nearly half of all pregnancies each year are unintended,2 an estimated 19 million new STIs occur annually,3 one in four individuals living with HIV is not aware of their status,4 and so on. The range of reproductive health care needs patients experience across the lifespan underscores the importance of training health care professionals to appropriately address these concerns in practice. Teaching reproductive health-specific content in medical schools, training programs for advanced practice clinicians, and other health profession institutions helps to ensure that future providers are well prepared to meet patients' comprehensive health care needs.5

Many providers do not routinely take a sexual health history from their patients — a critical first step in eliciting reproductive health concerns and establishing a comfortable environment for discussing these sensitive issues.6,7 Why is this? The number one reason cited by health care professionals is “lack of training”.8,9 Other common reasons, such as embarrassment or belief that sexual health is not relevant to the patient's visit, are also related to inadequate training. Research shows that providers' comfort with and practice of discussing sexual health issues with patients improve when they are trained on the “whys and hows” of sexual history taking.9,10

The skills and capabilities of health care professionals in addressing reproductive health events can profoundly affect the health outcomes of individual patients and the general public.11,12 So why, then, do educational institutions not devote curricular time to topics such as contraceptive counseling, abortion care and sexuality? Sadly, comprehensive reproductive health information is often missing from standard curricula. 13,14 And, when included, the time spent on these topics is minimal.14,15 Reasons for this are varied and include lack of time, competing curricular priorities, lack of trained faculty or appropriate training sites, and the belief that these issues are less important than training in other areas.14,16,17

Efforts to improve clinical education in reproductive health have been implemented over the years with varying degrees of success. In 2001, the pharmaceutical company Pfizer awarded unrestricted 2-year educational grants to seven US medical schools to develop sexual health curricula. Resultant publications show that these pilot programs were well received by students and faculty.7,18,19 However, experience with other time-limited initiatives shows that sustainability is almost always difficult to achieve once funding ends.20 Compounding the problem, curricula developed by and for one academic institution are not easily replicated in other settings due to huge variances in culture and process.

We can learn from the successful curricula improvement efforts that have been implemented in the field of gerontology. The need to prepare future health care professionals in this field emerged in response to the aging population and the recognition that all providers who see patients across the lifespan should be able to address specific health care needs in this demographic. An overcrowded curriculum was cited as the primary barrier to incorporating additional information into training programs. Yet sustainable, interdisciplinary gerontology programs have been implemented in all levels of health professions training.21,22,23 The John A. Hartford Foundation24 is one of the major driving forces behind this curricular enhancement. As a national organization with a mission to improve elder care in this country, the Hartford Foundation offers adaptable teaching materials, best practices and tips from other educators, and step-by-step guides to integrating gerontology information into existing curricula.25,26 These flexible, interdisciplinary approaches to improving the teaching of gerontology are helping to prepare future providers to deliver quality care to a specific population.

The lessons of the Pfizer and Hartford Foundation grant programs can help us understand the framework for improving the way future providers are trained to address reproductive health in practice. We know that the development of a specific curriculum by and for one particular educational program is hard to sustain and replicate at different academic institutions. We have seen how the involvement and support of a national organization in the development of curricula removes individual schools' dependence on funding and, thus, enhances the sustainability of the program. We have also learned that introducing new information into the curriculum is easier when materials are flexible and can be adapted to meet the varying needs of educators, students and administrators. These lessons form the basis of Association of Reproductive Health Professionals (ARHP) signature program for improving the way reproductive health information is taught to future providers: the Curriculum Initiative for Reproductive Health.

The Initiative was born at the American Medical Women's Association when the Reproductive Health Initiative (RHI) was established in 1994. Working collaboratively with other organizations and prominent leaders in the field, RHI produced the Reproductive Health Model Curriculum in 1996 to provide medical schools with content for teaching about comprehensive reproductive health issues. An accompanying booklet, A Medical Student's Guide to Improving Reproductive Health Curricula, was published with Medical Students for Choice® shortly thereafter, as a way to help students become advocates for curricular change at their individual institutions. These resources and the vision for improving clinical education in reproductive health were adopted by ARHP in 2005, and ARHP's Curriculum Initiative for Reproductive Health was established.

The goal of the Initiative is to improve the way comprehensive, evidence-based reproductive health information is taught in US medical schools, residency programs and advanced practice training programs. The Initiative is guided by an expert advisory committee and a panel of peer reviewers, all of whom are respected specialists and committed to improving the way reproductive health is taught to future providers. A unique feature of this effort is the collaborative inter-professional expertise represented on the advisory committee, which includes ob/gyn physicians, family medicine practitioners, internists, nurse practitioners, nurse-midwives, physician assistants, pharmacists, public health professionals and other specialists. The depth and breadth of the Initiative's curricular materials make them well suited for use in a variety of disciplines and across levels of learners (students, residents, practicing clinicians).

ARHP leaders and staff recognize that it takes novel strategies, an authentically collaborative approach and an investment of time to effect the kind of curricular change that is needed. With this in mind and following the lessons learned above, the broad-based Initiative team has developed the following three strategies.

Strategy 1: Providing Educational Content. ARHP offers up-to-date, evidence-based reproductive health information in different formats to fit a variety of educational settings. ARHP's newest and most exciting resource is CORE, the Curricula Organizer for Reproductive Health Education. CORE is an interactive online tool that can help users create complete curricula and customized educational presentations on numerous reproductive health topics. Featuring thousands of PowerPoint slides and accompanying handouts, learning activities, case studies and other resources, CORE is a living repository of peer-reviewed materials suitable for teaching in any health professions setting. See all that CORE has to offer at /core.

Strategy 2: Conducting Outreach. In collaboration with organizations such as Medical Students for Choice® and coalitions like the Training and Access Working Group (TAWG), ARHP is working to build a cadre of professionals who are committed to improving the way reproductive health is taught in health professions programs. Currently, ARHP co-manages the Curriculum Reform Working Group with Ibis Reproductive Health, which fosters the exchange of ideas and resources among professionals interested in these issues..

Strategy 3: Identifying Platforms for Change. ARHP helps educators, administrators, students and professionals identify ways to initiate and promote reproductive health curricula reform at their institution or practice. ARHP offers materials for students to help them advocate for curricular change and explore international reproductive health issues through targeted field placement programs. ARHP also provides individualized support, where ARHP leaders, staff and collaborators work with academic institutions on a one-on-one basis to cultivate “champions” of reproductive health curricula reform. ARHP does this by conducting curricular needs assessments, identifying gaps and offering tailored models for integrating appropriate topics into the curricula with suggested educational content. This personal, customizable approach reflects ARHP's commitment to helping others ensure that future providers are trained to provide respectful, empathic reproductive health care to women and men of all ages.

Many education and advocacy organizations in the field are committed to this issue and are doing wonderful work to advance the cause. The Women's Health Care Competencies, developed by the Association of Professors of Gynecology and Obstetrics, provides medical educators with a framework for developing interdisciplinary curricula that address women's and reproductive health topics.27 Physicians for Reproductive Choice and Health® are working to integrate evidence-based reproductive health information into residency training programs in all disciplines through their Residency Education Initiative.28 The Reproductive Options Education Consortium for Nursing (the ROE Consortium), a project of the Abortion Access Project, is doing the same thing with nursing programs.29 ARHP's Curriculum Initiative for Reproductive Health is well positioned to enhance the work of others and to help lead the way toward improving clinical education in reproductive health. Today's students are tomorrow's health care providers. We must work together to make a place for reproductive health training in clinical education programs.

Cathy J. Lazarus
Chicago Medical School at Rosalind Franklin University of Medicine and Science
North Chicago, IL

Shana Brown
Association of Reproductive Health Professionals
Washington, DC

Lee Lee Doyle
University of Arkansas for Medical Sciences
Little Rock, AR

References

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Used with permission from Elsevier, Inc.