Women’s health training in internal medicine residency programs has evolved significantly since the 1990s.1 Leading medical societies now identify competence in the provision of contraceptive care as an essential skill for all internal medicine (IM) physicians.1-2 Despite this recognition, IM residencies continue to have significant gaps in teaching residents contraceptive care.3 One particular deficit stands out: few IM residency programs routinely provide training in long-acting reversible contraceptive (LARC) care, which includes subdermal implants and intrauterine devices (IUDs).4 Further, when IM physicians are trained, they often face challenges getting credentialed to provide LARC care.
Two recent publications highlight these gaps and their consequences and propose solutions. Both articles emphasize the critical lack of access to contraceptive care for patients who seek primary care from IM physicians. The papers stress the urgent need to address this gap in care and help patients prevent unintended pregnancies, especially given the health risks associated with pregnancy and the unacceptably high maternal morbidity and mortality rate in the United States.1 This article discusses these papers and highlights their call for universal training of all IM physicians in comprehensive sex-and gender-based women’s health care.
The SGIM Sex- and Gender-Based Women’s Health Core Competencies
SGIM clinician educators developed and recently published the SGIM Core Competencies in the Journal of General Internal Medicine.1 The Competencies serve as a comprehensive set of recommendations for training IM residents in sex- and gender-based women’s health.1 The position paper also describes a practical approach to implementing these competencies in residency programs. The document calls for the universal training of IM residents in sex- and gender-based preventive health care, all forms of contraception, and education on abortion care and reproductive planning.1 The paper includes a summary table with a broad overview of the core competencies, organized by ACGME domains. The article’s appendix provides a more detailed and comprehensive explanation of each competency.
This document calls for universal education of IM physicians in comprehensive sex- and gender-based women’s health care, including LARC care. Until IM physicians are competent in providing basic sex- and gender-based health care, including contraceptive counseling, this professional development will remain critical. Our faculty must be competent in providing comprehensive health care, so they can train the next generation of IM physicians to effectively care for patients.
Credentialing Internal Medicine Physicians to Expand Long-Acting Reversible Contraceptive Access
This timely article, published in Annals of Internal Medicine in August 2023, highlights challenges many of our IM colleagues have faced when trying to provide LARC care at their institutions’ primary care practices.5 The perspective also suggests practical solutions to LARC credentialing and implementation. Regarding IM physicians’ provision of LARC, the authors identify considerable and unjustifiable variation in credentialing practices, an issue that merits urgent consideration.5 The paper discusses the safety of LARC procedures, especially relative to other IM core privileges, and based on this safety, argues for the universal training and credentialing of all IM physicians to provide LARC.5
The Annals article describes practical steps for implementing LARC training, credentialing, and care in IM departments, with detailed rationale for the recommendations and a useful table. The table highlights early planning considerations for IM leadership, ways to make training opportunities available to IM physicians, LARC credentialing standards, and long-term considerations for sustainability of LARC programs.5
The call for universal training and credentialing of all IM physicians in LARC care comes at a particularly critical time. In the post-Dobbs era, access to effective birth control is more important than ever. As an IM community, it is essential that we work to improve access to these forms of contraception when they are desired.
IM physicians are ideally positioned to provide comprehensive sex- and gender-based primary care. As a part of IM practice, this care includes access to all forms of contraception for those who seek care from internal medicine physicians. Given the urgency of addressing our patients’ needs for contraception, practical steps are needed to ensure all IM departments and residency training programs implement comprehensive sex- and gender-based health training for practicing physicians and residents.
- Henrich JB, Schwarz EB, McClintock AH, et al. Position paper: SGIM sex- and gender-based women’s health core competencies. J Gen Intern Med. 2023 Apr 20;1-5. doi:10.1007/s11606-023-08170-y. Online ahead of print.
- Daniel H, Erickson SM, Bornstein SS. Women’s health policy in the United States: An American College of Physicians position paper. Ann Intern Med. 2018 Jun 19;168(12):874-875. doi:10.7326/M17-3344. Epub 2018 May 29.
- Casas RS, Hallett LD, Rich CA, et al. Program directors’ perceptions of resident education in women’s health: A national survey. J Women’s Health (Larchmt). 2017 Feb;26(2):133-140. doi:10.1089/jwh.2016.5860. Epub 2016 Aug 9.
- Casas RS, Prifti CA, Bachorik AE, et al. Contraceptive procedures in internal medicine clinics and resident education: A qualitative study of implementation methods, barriers, and facilitators. J Gen Intern Med. 2021 Nov;36(11):3346-3352. doi: 10.1007/s11606-021-06832-3. Epub 2021 May 6.
- Michener JL, Hirsh DA, Batur P, et al. Credentialing of internal medicine physicians to provide long-acting reversible contraception. Ann Intern Med. E pub 2023 Aug 1. https://doi.org/10.7326/M23-1034.
Clinical Practice, Medical Education, Sex and Gender-Informed Medicine, SGIM, Women's Health
Dr. Michener (Jennifer.firstname.lastname@example.org) is assistant professor of general internal medicine at the University of Colorado School of Medicine in Aurora, CO. Dr. Hirsh (email@example.com) is professor of medicine and an associate dean for undergraduate medical education at Harvard Medical School in Boston, MA. Dr. Bimla Schwarz (Eleanor.firstname.lastname@example.org) is professor of medicine at the University of San Francisco California and chief, division of general internal medicine at San Francisco General Hospital in San Francisco, CA. Dr. Gomez Kwolek (email@example.com) is assistant professor of general internal medicine at Harvard Medical School and lead, women’s health sex-and gender-based medicine program at Massachusetts General Hospital in Boston, MA.
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