Position Paper: SGIM Sex- and Gender-Based Women's Health Core Competencies.

Despite these advances and progress in our understanding of women’s health, studies demonstrate continuing deficiencies in IM residents’ knowledge and skills. 7 – 11 Reasons for the slow progress are complex and include uncertainty about what should be included in the curriculum and which disciplines are responsible for teaching. In addition, many model interdisciplinary or stand-alone, non-gynecology women’s health services that were important clinical teaching sites closed when federal funding for the National Centers of Excellence in Women’s Health ceased in 2007 and market forces favored other service models. Women’s health leaders and faculty involved in curriculum development turned to other activities when outside funding and institutional support waned. The ACP provided guidance in a 2018 Position Paper on the scope of sex- and gender-based women’s health conditions that IM training should encompass. 12 The purview includes medical and mental health conditions that are more prevalent or manifest differently in individuals who identify as women; routine office gynecological, reproductive, and peri-partum care; interpersonal and sexual violence; and health disparities in racial/ethnic minority women and LGBTQIA individuals. The ACP was also explicit in its belief that internists are responsible for the primary and comprehensive care of women across the lifespan. 12

The SGIM sex- and gender-based core competencies address a decades-old gap and changing health care landscape in the care of women and gender-diverse individuals. The competencies fulfill a societal and training need and offer practical guidelines for residency training programs to help prepare IM residents to care for women of diverse race/ethnicity, sexual orientation, and gender.

Key areas of change that make it imperative to readdress core competencies in women’s health include: Advances in our understanding of the effects of sex and gender on conditions that cause the greatest morbidity and mortality in women. Research initiated by the National Institutes of Health, and further inspired by the 2001 Institute of Medicine Report, “Does Sex Matter?,” provided pivotal new data on conditions present in both women and men but that disproportionally affect women and/or have important implications for patient care. 2 Advances were initially most notable in cardiovascular disease but now extend widely to other conditions, such as autoimmune disorders, osteoporosis, and dementia. 3 Advances in our understanding of health conditions that affect women . Research on reproductive health conditions across the lifespan, notably the menopause, changed our understanding of reproductive aging and the effects of exogenous hormones, and fundamentally changed the practice of medicine. Other areas of important progress include advances in breast cancer prevention, detection, and treatment, and in cervical cancer prevention and screening. 3 Adoption of a more inclusive concept of women . New more inclusive terminology extends the term “women” to refer to individuals assigned female sex at birth, as well as to those who self-identify as women, irrespective of sex assigned at birth, and includes transgender individuals and gender-diverse people. These individuals often avoid care due to discrimination and adverse experiences related to inadequate care from uninformed physicians. Internal Medicine physicians must be trained to provide informed care, including reproductive and preventive health care; organ-specific cancer screening; and knowledge of the medical effects of gender-affirming hormone therapy and surgery. 4 Awareness of health disparities in racial/ethnic minority women and gender-diverse individuals . The Covid-19 pandemic highlighted disparities in care to these vulnerable populations, related partly to economic/social issues, access to health care, and explicit and implicit bias. Black women as a group, for example, have the lowest life expectancy of US women due to an undue burden of chronic diseases, such as hypertension, diabetes, and CVD. They also have the highest rates of maternal mortality and pregnancy complications, such as preeclampsia. Transgender individuals have higher rates of mood disorders than cisgender women and have unique health needs that are often not addressed. Internal Medicine physicians play a key role in reducing barriers to care and must be deliberate in incorporating knowledge of disparities into residency education and patient care. 5 Evolution of reproductive health . Unacceptably high rates of maternal morbidity and mortality in the USA highlight the need for training on effective preconception counseling. Given the health risks posed by pregnancy, and particularly undesired pregnancy, internists must be well versed in the full range of contraception options, including emergency contraception. As the prevalence of vascular risk factors is elevated in many patients cared for by internists, it is imperative that internists are able to effectively counsel patients about estrogen-free contraceptives, including intrauterine contraceptives (IUDs) and subdermal contraceptive implants (e.g., Nexplanon). To decrease barriers to long-acting, effective contraception use, all residents should receive training in the placement and removal of subdermal contraceptive implants and in the removal of IUDs. Training in IUD placement should be made available to interested residents. In addition, IM physicians must be familiar with medication regimens that can be used to manage early pregnancy loss and abortion. In regions with limited access to legal abortion services, awareness of complications that may follow attempts at pregnancy termination is warranted. 6 Advances in our understanding of the effects of sex and gender on conditions that cause the greatest morbidity and mortality in women. Research initiated by the National Institutes of Health, and further inspired by the 2001 Institute of Medicine Report, “Does Sex Matter?,” provided pivotal new data on conditions present in both women and men but that disproportionally affect women and/or have important implications for patient care. 2 Advances were initially most notable in cardiovascular disease but now extend widely to other conditions, such as autoimmune disorders, osteoporosis, and dementia. 3 Advances in our understanding of health conditions that affect women . Research on reproductive health conditions across the lifespan, notably the menopause, changed our understanding of reproductive aging and the effects of exogenous hormones, and fundamentally changed the practice of medicine. Other areas of important progress include advances in breast cancer prevention, detection, and treatment, and in cervical cancer prevention and screening. 3 Adoption of a more inclusive concept of women . New more inclusive terminology extends the term “women” to refer to individuals assigned female sex at birth, as well as to those who self-identify as women, irrespective of sex assigned at birth, and includes transgender individuals and gender-diverse people. These individuals often avoid care due to discrimination and adverse experiences related to inadequate care from uninformed physicians. Internal Medicine physicians must be trained to provide informed care, including reproductive and preventive health care; organ-specific cancer screening; and knowledge of the medical effects of gender-affirming hormone therapy and surgery. 4 Awareness of health disparities in racial/ethnic minority women and gender-diverse individuals . The Covid-19 pandemic highlighted disparities in care to these vulnerable populations, related partly to economic/social issues, access to health care, and explicit and implicit bias. Black women as a group, for example, have the lowest life expectancy of US women due to an undue burden of chronic diseases, such as hypertension, diabetes, and CVD. They also have the highest rates of maternal mortality and pregnancy complications, such as preeclampsia. Transgender individuals have higher rates of mood disorders than cisgender women and have unique health needs that are often not addressed. Internal Medicine physicians play a key role in reducing barriers to care and must be deliberate in incorporating knowledge of disparities into residency education and patient care. 5 Evolution of reproductive health . Unacceptably high rates of maternal morbidity and mortality in the USA highlight the need for training on effective preconception counseling. Given the health risks posed by pregnancy, and particularly undesired pregnancy, internists must be well versed in the full range of contraception options, including emergency contraception. As the prevalence of vascular risk factors is elevated in many patients cared for by internists, it is imperative that internists are able to effectively counsel patients about estrogen-free contraceptives, including intrauterine contraceptives (IUDs) and subdermal contraceptive implants (e.g., Nexplanon). To decrease barriers to long-acting, effective contraception use, all residents should receive training in the placement and removal of subdermal contraceptive implants and in the removal of IUDs. Training in IUD placement should be made available to interested residents. In addition, IM physicians must be familiar with medication regimens that can be used to manage early pregnancy loss and abortion. In regions with limited access to legal abortion services, awareness of complications that may follow attempts at pregnancy termination is warranted. 6

The textbook, “Sex- and Gender-Based Women’s Health: A Practical Guide for Primary Care,” published in 2021 and edited and authored by SGIM members, is an important complementary resource to the recommended competencies: Sex- and Gender-Based Women’s Health: A Practical Guide for Primary Care. Tilstra, S., Kwolek, D., Mitchell, J.L., Dolan, B.M., Carson, M.P. (Eds.) Springer Nature. Springer, 1st ed. 2020 edition (January 20, 2021) 10.1007/978-3-030-50695-7_29. 15 This textbook is an evidence-based guide with current clinical guidelines for general internists and learners at all levels of training. For clinician-educators, each chapter provides a curriculum for recommended ACGME-based core competency topics outlined in Table 1 and the  Appendix , with measurable learning objectives and multiple-choice questions that can aid in teaching. Additional resources are provided in References. 14 – 23

Twenty-five years ago, the American Board of Internal Medicine (ABIM) published the first core competencies in women’s health. 1 They were developed in response to accumulating data demonstrating gaps in the knowledge and skills of internal medicine (IM) residents in women’s health. The competencies addressed a broad spectrum of domains, including medical knowledge; interviewing and counseling skills; clinical skills and procedures; and professionalism. Included under clinical skills and procedures was the requirement, for the first time, that residents demonstrate competency in conducting a breast and pelvic exam, and a Pap test. To emphasize the importance of these recommendations, the ABIM identified women’s health as a separate content area in the ABIM certification examination blueprint, as well as in the Board certifying examination. Coincident with the ABIM publication, other national policy-making organizations were documenting deficiencies in the education and training of physicians in women’s health and advocating for change. In 1996, the American College of Physicians (ACP) stated explicitly that “all physicians who provide primary care to women should be competent to diagnose and manage the most common conditions women present in the ambulatory setting.” 1 They acknowledged the interdisciplinary nature of women’s health and the need to collaborate with other disciplines, especially gynecology, in physician education and training. 1 These landmark publications occurred during concerted efforts by professional organizations, and by the federal government, to increase research on women’s health, and to create new models of physician education and clinical care. The signature national program was the federally funded National Academic Centers of Excellence in Women’s Health.

Table 1 provides a broad overview of core competencies that IM residents should demonstrate to provide comprehensive care to women and gender-diverse individuals in a general medicine clinical setting; the Appendix provides a more detailed scope of content. These documents were developed using the approach detailed below: Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Internal Medicine and the 2023 ABIM Certification Examination Blueprint. 13 , 14 Competencies are directed to IM residents; however, they are applicable to general medicine and primary care physicians in practice. Content is organized around the six domain competencies recommended by ACGME and is intended to supplement or reinforce existing ACGME-guided residency program curricular guidelines in the areas of women’s and gender health. It does not include more global competencies residents need to attain to graduate. Women’s health is defined in the document as “the unique manifestations of conditions in individuals assigned female sex at birth, or who self-identify as women or non-binary, irrespective of sex at birth.” Content acknowledges health disparities in racial/ethnic and gender-diverse minority populations served by many IM training programs and the imperative to create education and training experiences for residents that address the needs of women and gender-diverse individuals in the community. Other SGIM groups are working on specific competency recommendations for these special populations. This work is complementary to theirs during the development process. The competencies affirm and promote the importance of using a sex and gender lens when conducting research and in the application of research to all aspects of medical education and clinical care. Table 1 Overview of Core Competencies in Sex- and Gender-Based Women’s Health I. Professionalism : Residents must:   1. demonstrate attitudes and behaviors that acknowledge the societal context in which women and gender-diverse individuals of diverse cultural, racial, and ethnic backgrounds lead their lives   2. establish and maintain a compassionate and trusting therapeutic relationship with patients that respects patients’ personal values and preferences in shared decision-making II. Patient care A. Interviewing: Residents must be able to:   1. apply patient-chosen identity and relationship terminology, including use of chosen names, pronouns, sex and identity, and terms for sexual organs   2. elicit and report essential components of the female sex and gender-specific history using patient-centered interviewing B. Physical examination: Residents must be able to:   1. perform a clinical breast exam using standardized techniques   2. perform an atraumatic pelvic+/−rectal examination and a modified examination, when indicated, for patients with impaired mobility, atrophic vaginitis, history of sexual trauma, gender-affirming surgery, female genital cutting, vaginal bleeding, pelvic pain or dyspareunia, and/or other special conditions C. Skills: Residents must be able to interpret basic test results to determine a plan based on:   1. vaginal pH, saline wet mount, KOH prep   2. vaginal and urine PCR-based testing   3. bone densitometry   4. mammography and other breast imaging (ultrasound, MRI)   5. breast biopsy results   6. cervical cytology and HPV testing   7. pregnancy tests (serum, urine, quantitative and qualitative) D. Procedures: Residents must be able to perform:   1. vaginal and cervical cytology collection   2. STIs specimen collection   3. placement or removal of subdermal contraceptive implants   4. removal of intrauterine contraceptive devices (IUDs) III. Medical knowledge A. Medical knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care for:   1. conditions that affect both women and men but are more common in women or have clinically important sex- and/or gender-based manifestations or treatments/management   2. medical conditions unique to the female reproductive system (e.g., vaginitis; endometriosis; mastitis; medical conditions in pregnancy and the peripartum period; pregnancy complications that increase future vascular risk; the safe use of contraceptives, including emergency contraception; and medications to manage early pregnancy loss and undesired pregnancy)   3. the application of the sex and gender lens in all aspects of medical research, education, and clinical care B. Preventive services: Residents must be able to provide preventive services based on a patient’s age, risk factors, sexual activity, and organs present C. Initial management of emergency/urgent medical problems: Residents must be able to recognize and initially manage gynecologic emergencies (examples: sexual assault, ovarian/fallopian tube torsion, acute uterine bleeding, and ectopic pregnancy) IV. Interpersonal and communication skills. Residents must demonstrate competence in counseling patients in the following, including sex- and gender-based aspects of care:   1. breast cancer screening guidelines and risk reduction   2. cardiovascular disease prevention/risk reduction   3. cervical cancer screening and screening options   4. endometrial and ovarian cancer risk reduction   5. contraception counseling, including emergency contraception   6. preconception care   7. pregnancy options   8. intimate partner and family violence, history of trauma   9. menopausal symptoms and hormonal/non-hormonal management options   10. osteoporosis screening and treatment recommendations   11. urinary incontinence screening and treatment options   12. gender-affirming treatment options V. Practice-based learning and improvement. Residents must demonstrate the ability to: systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement (examples: periodic review of patient panel metrics for mammography, cervical cytology/HPV testing, bone densitometry) VI. Systems-based practice. Residents must be able to:   1. understand the domain/boundaries of medical practice in a primary care setting   2. appropriately refer patients to other disciplines and medical subspecialists (e.g., gynecology, urogynecology, reproductive endocrinology, breast surgery, sexual health, mental health) Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Internal Medicine and the 2023 ABIM Certification Examination Blueprint. 13 , 14 Competencies are directed to IM residents; however, they are applicable to general medicine and primary care physicians in practice. Content is organized around the six domain competencies recommended by ACGME and is intended to supplement or reinforce existing ACGME-guided residency program curricular guidelines in the areas of women’s and gender health. It does not include more global competencies residents need to attain to graduate. Women’s health is defined in the document as “the unique manifestations of conditions in individuals assigned female sex at birth, or who self-identify as women or non-binary, irrespective of sex at birth.” Content acknowledges health disparities in racial/ethnic and gender-diverse minority populations served by many IM training programs and the imperative to create education and training experiences for residents that address the needs of women and gender-diverse individuals in the community. Other SGIM groups are working on specific competency recommendations for these special populations. This work is complementary to theirs during the development process. The competencies affirm and promote the importance of using a sex and gender lens when conducting research and in the application of research to all aspects of medical education and clinical care. Overview of Core Competencies in Sex- and Gender-Based Women’s Health

Practical steps to facilitate the integration of sex- and gender-based women’s health competencies into resident education and training are provided below. Identify current program-specific strengths and deficiencies in residents’ knowledge and skills to inform curriculum development (i.e., a needs assessment). Identify existing programs and potential partners within the department, medical school, or wider institution that offer similar content. Developing collaborations is key for curriculum development, teaching, and clinical skill-building, and for modeling the central role of IM in managing women’s and gender health issues with the appropriate use of consultants. Identify protected resident educational time for dedicated sex- and gender-specific educational activities, as well as other teaching venues for integrating this content (e.g., conferences, resident report, Grand Rounds). Protected educational sessions during residents’ ambulatory rotations are a particular opportune time to teach sex- and gender-based women’s health and help ensure a unified educational experience for all residents. Identify, mentor, and support core faculty/teachers. Some may come from other disciplines. Partner with community members to ensure that community needs are reflected in curriculum development and teaching. The inclusion of community members as teachers highlights the value of learned experience and is a powerful way to increase residents’ awareness of disparities in care and engage them in advocacy. Build capacity at clinical teaching sites to expedite and model comprehensive care to women and gender-diverse individuals. Provide enhanced sex- and gender-based women’s health educational, clinical, teaching, leadership, and scholarship opportunities for selected interested residents. Provide sex- and gender-based women’s health education and development to all faculty (“teach the teachers”) through continuing medical education courses, retreats, and other venues. Develop sex- and gender-specific Entrustable Professional Activities (EPAs) to measure residents’ learning progress that can be mapped to required ACGME competency domains. Provide training and credentialing of IM faculty to perform and teach the placement and removal of subdermal contraceptive implants and IUDs. Unnecessary barriers to the delivery of comprehensive contraceptive care in primary care outpatient settings must be removed. Recommended initial credentialing of faculty includes: Subdermal contraceptive implant (e.g., Nexplanon) placement and removal: complete FDA-mandated training; demonstrate competence with the supervised placement of one implant and the supervised removal of one implant; attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics, or Gynecology. IUD placement and removal: complete training and demonstrate competence with the supervised removal of one IUD and the placement of five IUDs with attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics or Gynecology. Identify current program-specific strengths and deficiencies in residents’ knowledge and skills to inform curriculum development (i.e., a needs assessment). Identify existing programs and potential partners within the department, medical school, or wider institution that offer similar content. Developing collaborations is key for curriculum development, teaching, and clinical skill-building, and for modeling the central role of IM in managing women’s and gender health issues with the appropriate use of consultants. Identify protected resident educational time for dedicated sex- and gender-specific educational activities, as well as other teaching venues for integrating this content (e.g., conferences, resident report, Grand Rounds). Protected educational sessions during residents’ ambulatory rotations are a particular opportune time to teach sex- and gender-based women’s health and help ensure a unified educational experience for all residents. Identify, mentor, and support core faculty/teachers. Some may come from other disciplines. Partner with community members to ensure that community needs are reflected in curriculum development and teaching. The inclusion of community members as teachers highlights the value of learned experience and is a powerful way to increase residents’ awareness of disparities in care and engage them in advocacy. Build capacity at clinical teaching sites to expedite and model comprehensive care to women and gender-diverse individuals. Provide enhanced sex- and gender-based women’s health educational, clinical, teaching, leadership, and scholarship opportunities for selected interested residents. Provide sex- and gender-based women’s health education and development to all faculty (“teach the teachers”) through continuing medical education courses, retreats, and other venues. Develop sex- and gender-specific Entrustable Professional Activities (EPAs) to measure residents’ learning progress that can be mapped to required ACGME competency domains. Provide training and credentialing of IM faculty to perform and teach the placement and removal of subdermal contraceptive implants and IUDs. Unnecessary barriers to the delivery of comprehensive contraceptive care in primary care outpatient settings must be removed. Recommended initial credentialing of faculty includes: Subdermal contraceptive implant (e.g., Nexplanon) placement and removal: complete FDA-mandated training; demonstrate competence with the supervised placement of one implant and the supervised removal of one implant; attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics, or Gynecology. IUD placement and removal: complete training and demonstrate competence with the supervised removal of one IUD and the placement of five IUDs with attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics or Gynecology. Subdermal contraceptive implant (e.g., Nexplanon) placement and removal: complete FDA-mandated training; demonstrate competence with the supervised placement of one implant and the supervised removal of one implant; attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics, or Gynecology. IUD placement and removal: complete training and demonstrate competence with the supervised removal of one IUD and the placement of five IUDs with attestation of competency by staff (MD, NP, PA, or CNM) credentialed in Internal Medicine, Family Medicine, Pediatrics or Gynecology.

The Women and Medicine Commission and the Sex- and Gender-Based Women’s Health Education Interest Group appreciate that in 2022–2023, the SGIM Council has committed to: reaffirm the role, and the responsibility, of general internal medicine physicians in providing comprehensive sex- and gender-based care across the lifespan to all patients who identify as women, including reproductive care, breast care, and care of pregnant and menopausal patients, and endorse core competencies in sex- and gender-based women’s health that align with advances in medical knowledge and an understanding of the full context in which women of diverse race/ethnicity, socioeconomic status, sexual orientation, and gender lead their lives. reaffirm the role, and the responsibility, of general internal medicine physicians in providing comprehensive sex- and gender-based care across the lifespan to all patients who identify as women, including reproductive care, breast care, and care of pregnant and menopausal patients, and endorse core competencies in sex- and gender-based women’s health that align with advances in medical knowledge and an understanding of the full context in which women of diverse race/ethnicity, socioeconomic status, sexual orientation, and gender lead their lives.

Below is the link to the electronic supplementary material. Supplementary file1 (DOCX 45.9 KB) Supplementary file1 (DOCX 45.9 KB)