The GCC states that the goals of training for gastroenterology fellows in women’s health issues can be divided into three categories, all of which must be included in training. They are as follows: general women’s health issues, specific digestive diseases and women’s health issues, and pregnancy and childbearing issues. This study is the first to evaluate training in women’s digestive disorders since the GLC incorporated this area into the GCC nearly a decade ago. Our survey assessed whether gastroenterology fellowship programs in the United States are meeting GCC guidelines in four pre-specified domains of training.
We found that both GI fellows and program directors perceive the quantity of didactic teaching in this area to be low and clinical experiences in specific areas of women’s GI health to be infrequent (mean score <3 in both domains). However, there were significant differences between fellows and program directors responses in these domains. Program directors’ perceived didactic teaching and clinical experiences to be greater than did fellows, indicating a potential disconnect between what program directors believe they provide and what fellows believe they receive.
With regards to perceived competence in women’s GI health issues, we found that fellows rate themselves as being less than “somewhat prepared” to evaluate and manage these issues in contrast to program directors who perceive fellows’ preparedness to be significantly greater. Notably, these differences remained significant for all 3 years of training, suggesting that even fellows nearing the end of their training in gastroenterology rate their preparedness in women’s health issues and the quality and quantity of clinical and didactic teaching to be low.
We found attitudes towards women’s GI health training to be favorable in both groups. Fellows, however, responded with significantly more positive responses. This suggests willingness among fellows towards training in this area. It also suggests that a lower perceived need to train in GI women’s health among program directors may account for the low mean scores in the other domains of training we assessed.
Our findings are similar to results from prior studies in other fields of medical training. In a survey of internal medicine residents at a single institution, Spagnoletti et al. found that senior residents received little didactic teaching or clinical experiences in several women’s health topics that are covered on the ABIM Certificate Examination in Internal Medicine and that have been included in competency guidelines since 1997 [9
]. The majority of their respondents felt unprepared to deliver care to patients who have such issues. Using a national sample of trainees in gastroenterology, we showed women’s health training to be similarly poor. Together, these studies suggest that women’s health issues, although recognized as a critical area for training by academic leaders, are inadequately addressed by many US training programs.
With regards to GI fellowship program compliance in other core clinical areas, a recent study by Guardino et al. found adherence to GCC guidelines in hepatology training to be adequate overall [10
]. The authors reported that most prescribed hepatology core topics were covered and that fellow and program director assessments of compliance were highly concordant. While it is reassuring that GI fellowship programs are meeting national guidelines in hepatology, our study suggests that compliance may not be uniform across the 17 core clinical areas and that compliance in some areas may significantly lag.
In addition to assessing compliance in women’s GI health training, we identified institutional and personal barriers and facilitators to meeting training guidelines. We found that the number of teaching sessions dedicated to women’s GI health was positively associated with greater self-competence as well as with greater clinical experience in this area. The latter association may be because programs which offer more didactic teaching in women’s health also provide more opportunities for clinical exposure to these issues. If so, then increasing the number of teaching sessions in women’s GI health, in itself, may not lead to better training.
We also found that the number of pregnant patients treated and the number of referrals from Ob/Gyn serve as positive predictors for didactic teaching, clinical experience, and self-competence in women’s GI health. We hypothesize that this may be because close collaboration between Ob/Gyn and gastroenterology in the form of shared patients leads to better training in women’s GI health issues for fellows. If so, then efforts to improve collaboration between these services at both the institutional and national level may be very important if training is to improve in this area.
As predicted, having a VA hospital as the site for fellows’ GI ambulatory care clinic was significantly associated with lower scores in clinical experience and self-competence in women’s GI health. To overcome this barrier to training, programs could consider adding a second clinic site at a non-VA hospital where fellows would be more likely to treat female outpatients.
Somewhat surprisingly, the number of female GI faculty was not associated with any of the domains of training we studied. The number of faculty with an interest in women’s GI health, however, was associated with the amount of didactic teaching fellows receive in this area. Thus, focused recruiting and hiring of faculty, male or female, with focused interest in women’s GI health appears to be more important for fellow training in this area than simply increasing the number of female faculty.
Lastly, we found male gender of the fellow to be significantly associated with higher self-reported scores in perceived quantity of didactic teaching and self-competence in women’s GI health but found no difference by fellow gender in relation to perceived clinical experiences. This suggests that male fellows, as compared to female fellows, are more likely to perceive that they received an adequate amount of teaching in this area despite receiving the same amount of clinical experiences. As a result, male fellows are more likely to feel competent to manage women’s GI health issues. We hypothesize that this difference in self-reported competence may reflect over-estimation of competence on the part of male fellows, or alternatively, under-estimation of competence on the part of female fellows.
Our study has several limitations. First, while our response rate was relatively high for program directors our response rate was low for fellows, introducing the possibility for non-response bias. Nevertheless, our fellow response rate was comparable to response rates reported in other mail survey studies of physicians [11
] and represents a national sample of fellows. Second, nearly one-third of our fellow respondents were in their first year of training. Given that our survey was distributed early in the academic year many fellows responded after having had only limited exposure to their program’s offerings and before they could realistically achieve self-competence in the topics addressed in the survey. We accounted for this by adjusting for year of training when computing the mean scores in the four training domains and found that even senior fellows perceived compliance with the GI women’s health training guidelines to be low compared with program directors. Third, we did not verify didactic and clinical offerings by fellowship programs and therefore cannot assess whether respondents accurately represented their programs. Future studies which objectively assess curricular offerings in women’s GI health training as well as in other core clinical areas of the GCC should be considered. Lastly, we investigated a limited number of potential barriers and facilitators to training. Potential barriers we did not study such as the costs of training and lack of time to acquire training should be addressed in future studies.
In conclusion, using a national sample of GI fellows and program directors, we found that both fellows and program directors perceive didactic teaching and clinical experiences in women’s GI health during GI fellowship to be low with fellows perceiving this training to be significantly lower than program directors. In addition, we found program directors rate competence in women’s GI health issues of their fellows to be higher than do fellows themselves and report less positive attitudes towards the need to train in this area. Lastly, we identified multiple barriers to women’s GI health training. Future work targeted towards these barriers is needed to improve compliance with GCC guidelines in women’s digestive disorders and improve fellows’ training overall.