Continuing Medical Education
Family Planning Research Must Inform Clinician Training
SOURCE: AP/Rainier Ehrhardt
With a bold investment of federal resources into clinician education during their academic training years and throughout their careers, we can improve reproductive health care.
For clinicians to play their part in reducing unintended pregnancies, we must translate the best clinical and behavioral science available into innovative provider education. Much of the foundational research we rely on for effective clinical practice is funded by the federal government through the National Institutes of Health and other U.S. health agencies. But we miss the point of scientific data collection and analysis if it does not inform effective clinical practice with the ultimate goal of improving patient care. To make the most of that research investment, we have to expand and improve reproductive health training in schools and through continuing professional education. The need is clear, as the Association of American Medical Colleges reports that only 76 of 142 medical schools in the United States. and Canada claim that contraception and abortion education are part of their curriculum for medical students (with about two-thirds of schools reporting).[1]
With a bold investment of federal resources into clinician education during their academic training years and throughout their careers, we can improve reproductive health care—including family planning—and contribute significantly to the reduction of unintended pregnancy rates in the United States.
At the moment we lack a full picture of what students preparing for health professions are or are not learning about family planning. Understanding and improving education on reproductive health for clinicians-in-training will improve the care they can offer patients. Students have been strong advocates for these changes and are asking for more reproductive health training. For example, a 2006 study published in Contraception reported that “students requested that more time be devoted to teaching contraception.”[2] This education should include the linked issues of contraception, sexuality, abortion, HIV and sexually transmitted infections, pregnancy, and maternal and child health, among others.
The time is right to transform provider education in reproductive health and family planning. The president has challenged all Americans to work together to help reduce the need for abortion by, among other complementary goals, reducing unintended pregnancies in the country.
This idea is not new to the core reproductive health community. In a 1999 lecture at the annual clinical conference of the Association of Reproductive Health Professionals, Dr. Daniel Mishell focused on the pressing need to expand family planning curricula at U.S. medical schools. More recently, the National Campaign to Prevent Teen and Unintended Pregnancy and ARHP jointly convened a panel of experts to review and discuss barriers to effective contraception among young adults.
After a thorough literature review and two intensive meetings, the panel concluded that there is not a clear picture in the United State of the amount of contraceptive education health care providers receive at all levels of their training. Worse, it appears that much education is minimal or nonexistent, in spite of family planning training requirements in various specialties and disciplines.[3] The panel recommended expanding “broadly based, well-balanced and unbiased continuing education activities where practitioners could be exposed to evidence-based information in addition to practical hands-on experiences.”[4] Other research supports this conclusion:
- A 2007 editorial published in Contraception reports that lack of training is the number one reason cited by health care practitioners for not taking a sexual health history from patients on a routine basis, followed by clinician embarrassment and a belief that sexual health is not relevant to the patient’s visit.[5] Reasons for the small amount of time spent on contraceptive counseling, abortion care, and sexuality during training are listed as 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.
- A review published in the Journal of Sexual Medicine reinforces these conclusions, stating that “in all countries, medical students, house staff, and practicing physicians currently receive variable, nonstandardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There remain significant physician–patient barriers to discussing sexual issues; and patients feel that their physicians are reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between developments in sexual medicine and the clinical skills of practicing physicians.”[6]
- A study of contraceptive knowledge and attitudes among residents confirms that physician knowledge about contraceptives may not be optimal and is inconsistent across primary care specialties.[7] The authors recommend that “health care providers need ongoing education about new and effective methods of contraception, including long-acting methods. Support should be given to higher education institutions to provide students in the health and medical field with evidence-based information on the latest contraceptive methods. Grants should be available so that health care providers can pursue ongoing continuing medical education on the latest contraceptive methods.”
Our priority should be to expand research and invest heavily into its translation into academic and continuing education for all health care providers. For the reproductive health and family planning field, this means increasing provider knowledge, skills and understanding of contraception, family planning, abortion, sexuality, prepregnancy health, HIV and sexually transmitted infections, maternal and child health, and other issues associated with reproductive health. But it also means incorporating key research about human behavior to improve patient consultation skills, develop cultural competence, and increase awareness of and sensitivity to the potential impacts of provider and patient biases on reproductive health care.
In addition to learning about family planning essentials, clinicians need to improve their communication skills with their patients. Discomfort about discussing sexuality can interfere with effective reproductive health care. A 2003 ARHP survey of women and primary care providers in the United States concludes that providers can be as uncomfortable as patients when discussing specific issues such as sexuality, vaginal health, sexually transmitted infections, and other related issues. Sex and sexuality must be addressed in any discussion about pregnancy prevention.[8] An analysis published in the Journal of the National Medical Association in 2006 on sexually transmitted disease prevention programs also addresses this point, concluding that “it is essential to train all healthcare providers to lead discussions, educate patients and provide treatment in hopes that sexual health promotion will become as important as other socially accepted healthcare concerns.”[9]
But reproductive health care, including patient counseling, can be time intensive. A 2000 report focusing on contraceptive counseling for teens concludes that “prescribing and reviewing contraceptive methods with adolescents involves a significant amount of time and resources. Health care providers need to be familiar with how teens think about sex and birth control, what their beliefs are, and how individual teens may make different choices based on their lifestyles.”[10] An investment in provider education on family planning and reproductive health is in order to meet these needs.
From the patient’s perspective, an untrained or unavailable health care provider can negatively impact contraceptive care. In an analysis of contraceptive use and nonuse published in Perspectives in Sexual and Reproductive Health, the authors found that many women experiencing problems with their contraceptive methods believe that contraceptive service providers are not readily available to answer method-related questions.[11] Another study completed by Motivational Educational Entertainment Corporation in 2004 found that among a group of urban, African-American teens in the United States, experiences with the health system (including family planning services) were among the most distressing encounters they experienced with any human services system at all.[12]
Of course, this work will not exist in a vacuum. The investment in provider education will only work in concert with an equivalent surge in new research, health care reform, patient education and advocacy, and a healthier economy. The concept of ramping up family planning education is only one of a handful of linked efforts that, when combined, can help reduce U.S. unintended pregnancy rates.
In a 2007 article on the state of U.S. family planning published in Obstetrics and Gynecology, the authors conclude that “a comprehensive approach requires policy change to improve funding for and access to family planning.”[13] To accomplish this goal, the time is right for significant federal investment in provider training and continuing education on reproductive health and family planning.
Wayne C. Shields is president and CEO of the Association of Reproductive Health Professionals. This article is adapted from an editorial in the journal Contraception: An International Reproductive Health Journal.
Notes
[1] Association of American Medical Colleges. AAMC Curriculum Management & Information Tool. http://www.aamc.org/currmit 2009.
[2] Cwiak CA, Emmons SL, Khan IM, Edelman AB. A comparison of different contraceptive curriculums and their impact on knowledge retention and learning skills of medical students. Contraception. 2006; 73: 609–612.
[3] Providers’ perspectives: perceived barriers to contraceptive use in youth and young adults, Final report, March 17, 2008. http://www.arhp.org/.
[4] Brown S, Burdette L, Rodriguez P. Looking inward: provider-based barriers to contraception among teens and young adults. Contraception. 2008; 78: 355–357.
[5] Lazarus C, Brown S, Doyle LL. Securing the future: a case for improving clinical education in reproductive health. Contraception. 2007; 75: 81–83
[6] Parish SJ, Clayton AH. Sexual medicine education: review and commentary. J Sex Med. 2007; 4: 259–267.
[7] Schreiber CA, Harwood BJ, Switzer GE, et al. Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents. Contraception. 2006; 73: 618–622.
[8] Association of Reproductive Health Professionals. Vagina dialogues survey, August 8, 2003. /Publications-and-Resources/Studies-and-Surveys/Vagina-Dialogues. Accessed May 26, 2009.
[9] Williams C, Wimberly Y. Sexually transmitted disease prevention in adolescents and young adults. J Natl Med Assoc. 2006; 98: 275–276.
[10] Brill SR, Rosenfeld WD. Contraception. Med Clin North Am. 2000; 84: 907–925.
[11] Frost JL, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007; 39: 90–99.
[12] In: Motivational Educational Entertainment, National Campaign to Prevent Teen and Unplanned Pregnancy. Key findings: this is my reality: the price of sex, an inside look at black urban youth sexuality and the role of media. 2004; p. 1–8.
[13] Espey E, Cosgrove E, Ogburn T. Family planning American style: why it’s so hard to control birth in the US. Obstet Gynecol Clin North Am. 2007; 34: 1–17 vii.
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