It is clear that sex- and gender differences exist and influence patient outcomes, and, thus, must be taught in medical school. Incorporating SGSH as a crucial part of personalized medicine will improve patient outcomes in a variety of disease states including cardiovascular disease, malignancy, and neurodegenerative diseases [24]. Even a single training session can improve understanding and application of SGSH topics as verified by pre-and post-assessments [16]. Indeed, one of the written comments to the survey indicated that the respondent didn’t have knowledge of sex and gender differences until taking the survey.
SGSH topics have not been routinely incorporated into medical curricula. In comparing student reported SGSH content from 2012 to 2020 in the curriculum and in spite of efforts to increase course content of the related topics, the coverage of SGSH topics showed variability with the majority of subject areas (6/9) reported to have less coverage than in 2012 while only coverage of Neurology, Nephrology, and Immunology were reported to have increased. However, when comparing the number of correct responses to medical knowledge and practice guideline questions, 17/33 questions showed more correct responses in 2020 (Fig. 1). Therefore, there appears to be an increase in students understanding of SGSH concepts, and students are learning about SGSH concepts even when it is not directly acknowledged. Important medical knowledge questions such as the risks pre-eclampsia poses to mothers later in life or the sex-specificity of irritable bowel syndrome (IBS) were well answered by the students. The discrepancy between student reporting and correct answers to knowledge-based questions emphasizes the importance of being intentional with inclusion of SGSH educational materials. The fact that students correctly respond to some questions despite indicating that these topics were not well taught could indicate that interested students are reading material on their own or gaining the information from sources other than structured curriculum. Although the improvements in the results of the survey over the 8 years are encouraging, they provide the impetus for improvement in clarity of instruction and perhaps the need to address alternative educational approaches to the subject matter.
In 2020 as well as 2012, students had high rates of correct responses to questions relating to practice specific guidelines. The questions related to practice guidelines had a greater than 60% correct response rate, and all showed increased correct responses in 2020 compared to 2012. As further research demonstrates clear sex and gender differences in disease, it would be expected that students’ exposure to these topics in their curriculum would rise, as well as their ability to correctly answer questions regarding this content.
The questions that most students answered incorrectly provide insight into areas where SGSH content could be improved. For example, given that 70.3% of students attested that SGSH topics were not included in Nephrology, it is not surprising that less than half of students correctly identified that progressive loss of kidney function occurs faster in men. Likewise, students struggled with the true/false questions asking whether gastric secretion is higher in men than women (44% answered incorrectly), which is further supported by the fact that only 33.7% of students said that Gastroenterology addressed SGSH concepts.
There are many resources available to streamline the integration of SGSH concepts into medical student curriculum and several examples of successful integration carried out both in medical school and later levels of training. Medical textbooks such as How Sex and Gender Impact Clinical Practice, Sex- and Gender-Based Women’s Health, and Principles of Gender-Specific Medicine provide accessible and relevant information for a variety of clinical topics [25,26,27]. Modules are available online from many sites including the NIH Office of Research on Women's Health (ORWH), the Laura Bush Institute’s Sex and Gender-specific Health Curriculum, and U.S. Food and Drug Administration (FDA) webinars [13, 22]. Tools such as these will allow for easy supplementation of existing curricula with SGSH concepts. One example of successful integration of SGSH curricular integration is the elective-course “Sex- and Gender-Based Medicine: an Overview,” offered by Alpert Medical School [13]. The popular course consisted of a hybrid learning model in which students attended lectures given by experts in SGSH, and supplemented their learning with the tools discussed above [13]. Ideally, SGSH topics will be incorporated throughout the curricula; however, these tools can be useful to begin the process of integration.
Importantly, the degree of student interest in improving coverage of SGSH should be noted. In fact, over sixty percent of the students chose to write in an additional response asking for more coverage of these topics. This information is incredibly important as student-driven change has the potential to transform curricula. For example, the University of Illinois College of Medicine-Chicago (UICOM-Chicago) has recently instituted a new Student Curricular Board that has been very successful and well-received in improving and diversifying the curriculum [28]. Involving all stakeholders, students and educators alike, in curricular change will lead to more effective and well-received change [22].
Improving the integration of SGSH concepts into medical student education and subsequently clinical practice is essential to provide evidence based and personalized patient care. Educators must first be educated about the importance of SGSH and informed about the status of integration of these concepts into current curriculum before progress can be made. The results of this survey should by no means reflect badly on the medical education curriculum at MCASOM or its students. MCASOM is ranked as a top medical schools and is one of the most selective medical schools in the US. Efforts have been made through the introduction of the Science of Healthcare Delivery curriculum to expand student’s knowledge of socioeconomic, racial, and gender-expression based disparities in care [29]. Therefore, we mean this current study to reflect the current trends in sex- and gender-based medicine in medical student education more broadly.
Strengths and limitations
This study longitudinally evaluated curriculum in the area of SGSH using the same survey over a period of eight years. Furthermore, it included representation from three geographically diverse student populations under the umbrella of a single medical school. Because the study compared the results of the same survey applied in both 2012 and 2020, it was not possible to correct any ambiguity in the survey questions. The inclusion of Gynecology is important as this specialty was traditionally considered the only one of sex-based interest. With the emphasis on gender and issues related to LBGTQ + sexuality care, the specialty takes on a gender-based components such as education, culture, ad socioecomomic status. Although the survey contained more emphasis on sex differences than gender differences such that the intersectionality of biological factors with those of gender including concepts of LGBTQ + status, ethnicity, and socio-economic status will provide a more holistic, patient-centered approach to SGSH. Likewise, including patient sex and gender into studies assessing the effects of race, age, socio-economic status, etc. helps to obtain more nuanced results [1]. A recent work by Jaehn et al. argues for the importance of considering intersectionality when determining study representativeness and identifies how crucial it will be for future research to use an intersectional approach to draw accurate conclusions about study cohorts to improve future practice guidelines [30].
A limitation of the study is the response rate. The original survey was delivered in person to 1st and 2nd year students at the end of the school year term. However, the current survey was delivered electronically which perhaps contributed to the lower response rate. While, the current survey consisted of more responses (101) than the 2012 survey, it was given to all years of medical school and some topics may have yet to have been covered for individual student programs (77). As this study only surveyed students at a single medical school program, it is difficult to generalize results to other programs. It is also limited to medical student perception and recall and findings are not corroborated by curriculum review.
Most of the respondents were female and women and female medical learners are more likely to consider gender and sex in providing care [31]. A large nationwide survey found that male medical students were more likely to state that they had received more SGSH education than female medical students who had received the same education [32]. This discrepancy may indicate that female students would be more likely to request more training than their male counterparts which could influence the results of our study, particularly the student interest in increasing SGSH coverage.
Because this study is limited by the small sample size given remote delivery of the study at a single medical school, the p-values comparing the two surveys are variable making statistically significant conclusions difficult. However, the study does provide a snapshot view of the current state of SGSH at this medical school upon which informed recommendations can be made to improve the curriculum.
