Context and objectives
The training programme was developed by four GPs with expertise in and a commitment to gender issues. They synthesized and outlined the training programme in close collaboration with the department of Women's Studies Medicine at Radboud University Medical Centre. The group worked on the specific areas to be covered and educational methods to be used. The experts have been guided by the following questions:
1. Is the topic relevant for and frequently seen by GPs?
2. Does the topic have gender-specific aspects that impact practice?
3. Is there underlying evidence for the gender-specific aspects?
They selected cross-disciplinary topics: cardiovascular disease, depression/anxiety disorders, urinary incontinence, addiction to alcohol or benzodiazepines, domestic and sexual violence. They also included communicative aspects in the training programme. In addition, for each topic they defined a set of objectives, and translated the relevant information and evidence from literature into educational material based on the principles of problem-based learning. Our framework for gender needs assessment is partially based on gender concepts written by Phillips [21
After the course, GP registrars will be able to:
1. consider the ways in which gender aspects and differences have an impact on health and illness, and an understanding of how gender-related issues may bias the provision of healthcare.
2. consider gender aspects and gender differences in epidemiology, presentation, diagnostic management, and treatment strategies in primary care.
3. understand the impact of doctors' gender in relationships and communication, and model reflective practice around gender issues.
Learning and teaching methods
Teaching and learning in general practice takes place primarily at work. The key to productive learning in postgraduate training is to focus on the experiences of GP registrars in their practice and to connect theoretical education to these experiences[22
] The tutorials are founded on adult learning theory and emphasize interaction, application, reflection, and problem-centred learning. Recent new insights in effective medical education support this strategy. [23
] For our training programme it means that we interrelate and clarify gender issues for health conditions in actual contact with patients (e.g., knowledge, judgement, norms). We try to identify and discuss factors that impede change in behaviour toward gender issues (e.g., gender stereotyped perceptions). We promote discussion about approaches to provide appropriate gender sensitive care. In the tutorials we propose that identification and removal of gender-related barriers (e.g. resistance) are important steps toward improving change. Substantial evidence supports interactive and clinically integrated teaching over other teaching methods. [24
Reflection on gender issues supports GP registrars to understand complex situations by considering them in a larger context, and to identify their particular needs. [25
] Reflection is a key feature of our training programme. We use reflection to know what registrars do, or neglect to do, with the role of sex and gender in daily practice. Reflection is used in a way of gaining access to perceptions and judgements on gender issues that often escape our awareness.
We work in small-group sessions with 10 to 15 GP registrars who are familiar with each other to facilitate comfort. We used a mix of video-consultations, paper cases, role plays with simulated patients, and reading gender-related articles or narratives. We choose different methods of learning over time as a variety of educational experiences can be more stimulating.
Our GP-supervisors have special skills and specific expertise in teaching gender-specific medicine. They know available resources on gender-specific medicine. Furthermore, they are familiar with resistance and know how to cope with defensive postures of GP registrars when they touch gender issues.
The training programme consists of five 3-hours tutorials. An introductory tutorial discusses the intent of the course including the basic concepts of gender, and four specific tutorials address clinical topics in general practice. The sequence used within the tutorials proceeds from an introduction of the topic and an icebreaker exercise, followed by reflection upon experiences and stimulation of self-assessment, to an interactive assignment with a plenary discussion. Typically, the tutorial ends with an overview of the knowledge acquired.
Content of the curriculum
Tutorial one and two of our training programme are followed in first year (general practice), tutorial three in second year (hospital, psychiatric department, and nursery home), and tutorial four and five in third year (general practice) of GP training. The key features of each tutorial are shortly outlined hereafter and the main factors are presented in table .
The main factors of the gender-specific medicine curriculum in GP training
Tutorial one, gender and socialization, introduces the concepts of gender and sex. The purpose is to initiate a gender issue perspective into GP registrars' medical encounters. For example, gender differences in life experiences and the influences of family, peers, and media on gender roles. Factors of gender-related attitudes and themes with regard to doctor-patient encounters are discussed to help facilitate a heightened level of gender awareness.
Tutorial two,gender and communication, focuses on eliciting the influence of gender on doctor and patient communication and how stereotyped expectations of men and women can affect doctor-patient relationships. Gender differences are addressed that can cause misunderstanding and that can hamper communication between dyads of men and women. An overview of potential gender-related pitfalls in doctor-patient communication is given.
Tutorial three consists of two parts of one and a half hour each: (a) gender in depression and anxiety disorders, and (b) abuse of alcohol or benzodiazepines. In this tutorial we address one's own beliefs, norms and values with regard to gender that can influence the provision of care to others. Also we focus and clarify the differences of social expectations for appropriate behaviours of men as compared to women as is the case for alcohol consumption.
Tutorial four deals with gender differences in cardiovascular disease (CVD) and urinary incontinence (UI). Here, we explain the persistent gender differences in cardiovascular disease and the potential biases in the care for patients with CVD such as the stereotypical conceptualisation of CVD as a male disease. GP registrars are taught the importance to reflect on their own and others interpretations, reactions, and conduct in patient care with regard to coronary risk factors in men and women. We address gender differences in patients' beliefs with urinary incontinence for example despite incontinence in men being less severe they experience more distress than women.
Tutorial five, recognizing and responding to sexual abuse, addresses sexual violence, a serious and widespread problem for women with a number of social and gender-related barriers that make it hard for GPs to identify such abuse. For example doctor's availability for abused women differs by gender as female doctors tend to restrict their availability due to distress it brought about and male doctors because of time constraints.
After each tutorial, GP registrars were asked to indicate their level of agreement with initially 5 and later 7 statements to evaluate the course. Each statement was designed to assess the quality of and their opinion on the learning and teaching methods, the perceived relevance for practice, and the usefulness of the applied knowledge. GP registrars' participation was voluntary. We did not assess demographic features with the exception of their sex. We used Likert scales where 1 = totally disagree, and 5 = totally agree. Data were analysed in the SSPS 16.0. Answers were dichotomized so that a response of 1, 2 or 3 suggested a rejection of the program and a response of 4 or 5 implied acceptance of the programme. Significance (p < 0.05) was assessed with the use of Chi square test. Similarly, the learning points were evaluated after each tutorial. They were coded and analysed according to the three objectives of the course by the first author (PD).
This study fell within the domain of programme evaluation. Consequently ethical approval was not required according to the current regulations at our university.