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Special | September 01, 2006

Formal Training in Women’s Issues in Psychiatry: A Survey of Psychiatry Residency Training Directors

Liza H. Gold; Steven A. Epstein

Academic Psychiatry 2006;30:403-409.

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Received September 9, 2005; revised March 2, 2006; accepted March 23, 2006. Dr. Gold is Clinical Professor of Psychiatry, Department of Psychiatry, Georgetown University Medical Center, Washington, D.C. Dr. Epstein is Professor and Chair, Department of Psychiatry, Georgetown University Medical Center, Washington, D.C. Address correspondence to Dr. Gold, 2501 Glebe Rd., Suite 204, Arlington, VA 20007; lhgoldmd@yahoo.com (E-mail). Copyright © 2006 Academic Psychiatry.

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Abstract

Objective: The authors describe the availability of formal residency training opportunities in women’s issues in psychiatry and explore the potential relationships between the availability of training and characteristics of residency programs. Method: The authors surveyed psychiatry residency training directors to identify program characteristics and training opportunities. Results: Certain didactic subjects were available in greater than 80% of residencies. Clinical training opportunities were less available and often not required. Conclusions: Selected didactic training in gender issues is commonly available in a majority of residencies. Nevertheless, general clinical instruction and didactic instruction in several important topics are less available.

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Since the early 1980s, there have been calls for increased instruction in gender and women’s issues in psychiatric residency programs, based on the principle that training in women’s issues is essential to providing competent psychiatric treatment (¹). Demonstration of knowledge of gender-related aspects of psychiatry has been formally acknowledged as a core competency in psychiatry. In its review of core competencies, the American Board of Psychiatry and Neurology (ABPN) states that physicians should be able to demonstrate "knowledge of major disorders, including considerations relating to age, gender, race, and ethnicity, based on the literature and standards of practice" (²). The Accreditation Council of Graduate Medical Education (ACGME) states in its program requirements for residency training in psychiatry that didactic curricula of all training programs should include the "presentation of the biological, psychological, sociocultural, economic, ethnic, gender, religious/spiritual, sexual orientation, and family factors that significantly influence physical and psychological development through the life cycle." Clinical training "should provide sufficient experiences in the elements of clinical diagnoses with all age groups of both sexes …" (³).

During the 1970s, a "knowledge explosion in women’s studies" (⁴) took place across all disciplines, including psychiatry. An extensive body of literature addresses the need for differential assessments of women’s psychological development; the effects of women’s social experiences, such as domestic violence; reproductive psychiatry, such as the use of medication during pregnancy; psychiatric issues associated with the reproductive life cycle; and the effects of gender on the course, treatment, and outcome of psychiatric disorders (⁵—¹⁴).

Despite the increasing wealth of scientific literature over the past decades relating to women’s biological, psychological, developmental, and social issues in psychiatry, little is known about the availability of formal training in gender issues in residency training programs. A literature search revealed only four studies exploring the extent to which formal training in women’s issues was available in residency training programs (¹, ¹⁵—¹⁷).

The only systematic review of the availability of instruction in gender issues in psychiatric training, published in 1999 (¹⁷), assessed training directors’ perceptions of the training needs of psychiatric residents regarding ethnic and gender issues through a survey questionnaire. The study's authors also examined training program characteristics associated with appraisals of greater adequacy of training in these areas. Only 21.3% to 36.4% of training directors reported that their programs had adequate training in any of five gender-specific subjects identified. Two variables were associated with the residency training directors’ appraisals: the availability of coursework on gender issues, and the residency director’s age, with the younger residency training directors found to be more likely to appraise their residents as having lower adequacy of training. The study did not directly assess the presence or absence of formal clinical or didactic training in these areas. Nevertheless, the availability of coursework was strongly related to the assessment of adequacy of training (p<0.0001).

Our survey study was prompted by our experience with informal attempts to find a gender-based didactic course upon which to model a new didactic lecture series in the Georgetown University Hospital Psychiatry Residency Training Program. Only one of numerous programs contacted reported any formal course or curriculum. The literature on developing and implementing gender courses in residency programs was also limited. Only one curriculum on gender and women’s issues has been published (¹⁶), and only one program contacted prior to this survey appeared to be aware of it, despite its adoption by the APA’s Committee on Women.

The primary purpose of this study was to explore the extent to which formal instruction in women’s issues in psychiatry has been implemented in psychiatry residency training programs and to describe what formal clinical and didactic training opportunities were available at the time of this study. In addition, we collected descriptive information about selected characteristics of program directors and programs to explore whether relationships existed between these characteristics and training opportunities offered.

Method

We surveyed the extent and specific content of formal instruction in gender issues in psychiatric residency programs with a questionnaire we sent to the psychiatric residency training directors of the 181 accredited residency training programs in the United States in the academic year 2003—2004. Training directors were identified through the ACGME website. The survey was also made available on the Internet, where it could be completed electronically. Survey responses, whether hard copy or electronic, were anonymous. The Georgetown University Institutional Review Board for the Social and Behavioral Sciences approved the study design.

Program directors were asked to identify selected characteristics related to themselves and their programs: the director’s age and gender, years in his or her position, how many residents were in the program per academic year, and the number and types of fellowships available. The questionnaire then listed specific subjects in didactic and clinical training and asked program directors to identify whether these were formally offered, and if so, whether as core curricula or electives. We generated the list of specific subjects (Tables 1 and 2) after a review of available literature. Residency training directors’ written comments regarding the survey and instruction in women’s issues were solicited at the end of the survey. This provided the residency training program directors an opportunity to mention or discuss other types of instruction not specifically queried, such as grand rounds and supervision.

Results

The survey response rate was 54.7% (99 survey responses: 40 hard copy and 59 electronic). Approximately 95% of responding training program directors provided all data. The few who did not excluded selected personal characteristics as noted below.

1. Characteristics of Responding Residency Training Directors and Programs

Characteristics of Residency Training Directors

Of the training directors who responded and provided specific demographic data, 67.8% were male. Five percent of respondents did not provide gender data. The mean age of residency training directors was 51.3 years (SD=7.2) (8% of respondents did not provide their age). The mean number of years in the position of training director was 6.7 (SD=5.3) (14% of respondents did not provide this information).

Characteristics of Residency Training Programs

Residency training directors were asked to provide information regarding the total number of residents in their programs and the number of fellowships available in subspecialties, including addiction psychiatry, consult and liaison psychiatry, forensic psychiatry, child and adolescent psychiatry, emergency psychiatry and forensic psychiatry. These findings are summarized in Table 1.

2. Availability of Didactic Instruction

We surveyed a total of 18 subjects (Table 2). The mean number of didactic subjects taught was 10.5 (SD=4.4); the median number of subjects offered as didactics was 10 to 12 when frequencies were considered as ranges (Table 3).

3. Availability of Clinical Training Opportunities

Seven specific clinical training opportunities were queried. Specific types and results are summarized in Table 4. The mean number of clinical training opportunities was 1.6 (SD=1.5). When calculated in terms of range, 28.9% of responding directors indicated their programs offered no specific clinical training opportunities, and 45.6% indicated they offered only one to two clinical training opportunities. Ranges are listed in Table 5.

4. Associations Between Program Characteristics and Availability of Clinical and Didactic Training

We performed correlations among the measured variables. There was a significant association between the number of clinical courses and the number of didactic courses offered (r =0.37, p<0.001). There were no significant associations between characteristics of program directors and availability of training in women’s issues. The number of residents and the number of types of fellowships were positively correlated (r=0.47, p<0.001). The number of types of fellowships was associated with the number of didactic courses offered (r=0.25, p=0.017); the number of residents was associated with the number of clinical courses offered (r=0.24, p=0.025).

Qualitative Results

Interest in providing and expanding formal instruction in women’s issues was evident in many of the comments included by the training directors. One respondent stated that greater awareness of the nature of available instruction in this area was "very important." Three others indicated that the survey had spurred them to efforts to increase integration of formal instruction in women’s issues. "Filling out these questions helps make us realize how much more we need to do." "We touch on many of these issues, but definitely could give it more of an operational focus." Three respondents expressed a wish for a model or standardized curriculum including a reading list and references. One suggested that a formal workshop on providing instruction in gender issues at the American Association of Directors of Psychiatric Residency Training (AADPRT) meeting would be helpful.

Although the survey was limited to formal, dedicated didactics and clinical training, some training directors indicated that they responded positively to specific questions because they believed informal training was being provided, even though formal courses were not available in their program. Ten respondents, representing 10% of total respondents, indicated that didactic training in their programs in the areas queried is integrated in general lecture series, and thus they responded positively to questions regarding availability of didactics in these areas. Eight (8%) respondents indicated that although no specific clinical training experiences in these areas were available, clinical training in these areas did occur over the course of general training. One of these training directors stated, "We do not have many programs or clinics as indicated above but residents do see a good number of cases from different categories outlined above." Another commented, "All rotations cover these types of issues so all residents get adequate training in gender issues."

Five responding training directors (5%) reported that they did not have specific clinical training or didactic courses for women’s issues because they did not have the resources. One director stated frankly that he or she would like to include more instruction in these subjects but does not "have the personnel or time to develop them." Another director wrote, "It would be nice if we could cover all of the topics listed above in a formal manner. We used to up until a few years ago, but the demands on faculty time are so great and we are stretched so thin." Another wrote, "We already have so much stuff that we are mandated to teach that little room is left for things that would be highly desirable." One program director concluded, "We try to cover these issues informally, but I would suspect that unless we had a faculty member who really wanted to teach this stuff, it will never be focused on in this program."

Discussion

A large percentage of residency training directors who responded to the survey reported that their programs offer required didactic courses in many women’s issues in psychiatry. Approximately 25% of respondents reported their training programs offer seven to nine didactic topics, and another 25% offer between 10 and 12 didactic topics. Approximately 30% reported that they offered between 13 and 18 didactic training topics.

Certain topics related to women’s issues were widely available. These included psychiatric disorders related to pregnancy and lactation, including postpartum disorders (90%); psychiatric medication during pregnancy and breastfeeding (88.9%); sexual function and dysfunction (88.9%); childhood abuse and its psychological effects (83.3%); menstrual cycle and mood disorders (74.4%); and women and violence (74.4%).

Topics notably less available included those related to women and aging. In this area, the most available didactic training was in psychiatric aspects of menopause (56.7%). Mental health issues for older women and psychological aspects of cancers of the female reproductive system, which are associated with aging, were available in only 27.8% and 26.7% of programs, respectively. The subject of women’s psychology was formally taught in only 37.8% of programs; the subject of women in the workforce was in only 34.4% of programs; and infertility and mental health was offered by only 18.9% of programs. These findings argue for a greater emphasis in these didactic areas.

Formal clinical training opportunities related to women’s issues were less available than didactic training. Almost 30% of residency training director respondents reported that their programs offered no formal clinical training. Approximately 45% of responding directors reported that their programs offered only one to two formal clinical training opportunities. The most widely available clinical training was in the area of eating disorders (34.4%), but only 28.6% reported that this type of clinical training was required. Clinical training in a domestic violence program was available in 32.2% of programs and 42.9% of those require this training. Fewer than 25% of respondents reported offering a women’s mental health inpatient or outpatient training setting (24.4%), a reproductive psychiatry clinic (24.4%), or a trauma, abuse, or dissociative disorders training setting (22.2%). Of these, only approximately 20% in each category required such training. Only 8.9% of programs offered clinical training in sexual function or dysfunction and 11.1% in infertility clinics.

There is a strong association between the extent of clinical and the extent of didactic training (r=0.37, p<0.001). This association may reflect the fact that certain programs have faculty available who are interested in teaching gender-related subjects both clinically and didactically. The size of the program, as measured by the number of types of fellowships offered and the average number of residents, appeared to be associated with the availability of didactic and clinical training. The more types of fellowship a program offered, the more didactic courses it offered. Similarly, the more residents in the program, the more clinical training opportunities were offered. The association between larger programs and more availability of training is not surprising, since larger programs are more likely to have greater resources, in terms of both faculty and clinical sites.

Some survey responses reflected a tendency toward reporting formal training based on the belief that women’s issues were subsumed but nevertheless taught in nondedicated didactics, such as grand rounds and supervision. In some programs, women’s issues may be mentioned in rotations or lectures other than those formally designated as women’s topics.

However, the assumption that these constitute adequate instruction in women’s issues might actually present an obstacle to comprehensive training. Assumptions that subjects in any area of training are adequately or well taught because they are subsumed into the general curriculum generally lead to less rather than more adequate training and education (¹⁶, ¹⁷). In addition, when leadership assumes that faculty and graduating residents are already sensitive to and expert in gender and women’s issues, additional allocation of time and resources to a formal women’s curriculum is likely to be considered unnecessary (¹⁶). Reliance on less formal opportunities, such as grand rounds and supervision, may also result in less exposure than optimally desired to train residents effectively. King et al. (¹⁷) found that training directors’ ratings of their residents’ adequacy of training about gender issues in psychiatric practice were significantly related to having coursework that addressed gender issues included in the residency program.

Limitations of the Study

Despite a robust response rate of 54.7%, almost half of residency training directors did not participate in this study. Examination of these programs might change the results. For example, directors with larger women’s health programs might have been more likely to respond, resulting in overrepresentation of the availability of training. Limitations of this study are also those generally associated with the use of survey studies: bias due to self-report, anticipation of desired responses of the researcher, and the desirability of endorsing training opportunities in women’s issues. A number of responding directors made comments indicating that they responded positively to questions regarding availability of formal instruction opportunities because they did not know how to quantify their informal training experiences and felt the need to report these as formal training.

This study also intentionally did not set out to study the integration of courses in issues related to men, but only to women. In addition, the study examined only select characteristics of programs and program directors. Future studies may choose to explore other characteristics in relation to the availability of training, such as the number of female faculty members. This study also did not attempt to assess the quality of the available instruction opportunities.

Conclusions

Many programs reported that they offered formal instruction in women’s issues. Nonetheless, of responding residency training directors, 29% indicated their programs offered no clinical training opportunities and 46% indicated their programs offered only one to two clinical training opportunities. When offered, less than 25% on average of responding training directors indicated their programs required training in these clinical rotations.

In contrast, responding directors indicated didactic training was more widely available and more frequently required when available. Some didactic topics were generally available in a large majority of programs, such as menstrual cycle and mood disorders, use of psychiatric medication during pregnancy, psychiatric disorders during pregnancy and postpartum, childhood sexual abuse and its psychological effects, and women and violence. However, less than half of responding training program directors indicated their programs offered didactics in other subjects, including women’s psychology, mental health issues for older women, and psychological aspects of female reproductive cancers.

Residency training in many programs would likely benefit from expanding clinical and didactic training opportunities in the less widely available subjects in women’s issues. Smaller programs and programs where clinical training opportunities may be more difficult to arrange may benefit from adopting strategies to expand training opportunities. For example, some programs may want to consider collaboration with primary care and obstetrics and gynecology departments as a means to obtain clinical training. Smaller or more isolated programs might benefit from sharing a didactic curriculum with larger programs.

In addition, all programs may benefit from examining the extent to which the training opportunities reported are actually separate and specific rather than integrated into their general training. Further studies on both the availability and adequacy of training in women’s issues could provide information regarding the utility of developing a standard didactic curriculum, including a reading list that could be shared among all residency training programs.

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TABLE 1. Characteristics of Residency Training Programs

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TABLE 2. Didactic Subjects Offered

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TABLE 3. Didactic Subjects Offered

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TABLE 4. Clinical Training Opportunities Offered

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TABLE 5. Clinical Training Opportunities Offered

Acknowledgments

The authors thank the program directors for their participation. The authors also gratefully acknowledge the assistance of Peter Schmidt, M.D., Renee Binder, M.D., Thomas Gutheil, M.D., Melissa Glennie, and Ana Rincon, and the support of the Georgetown University Hospital Department of Psychiatry.

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