Barriers to the Care of Menopausal Women

Barriers to care fall into two general categories, knowledge gaps and implementation gaps (1). The art of medicine rests upon the practitioner understanding what is and is not known, recognizing the limitations of our evidence and interventions, and then developing an informed and affordable therapeutic approach that a specific patient is able and willing to follow. Given that physicians are treating patients and not conditions per se and that the patient’s condition occurs in the context of multiple other medical and sociocultural modifiers, it takes experience to become an artful physician who can walk from generalization (fund of knowledge) to individualization (application of the fund of knowledge). We begin the journey in medical school but the steepest ascent is in residency and fellowship when immersion in a chosen specialty during formative years aims to yield a prepared and motivated practitioner. Residency training is guided by established learning objectives that delineate core areas of knowledge acquisition. Learning objectives are a critical beginning. Yet most physicians would likely agree that exposure to a variety of patients with relevant medical conditions under the watchful and avuncular eye of supervising physicians is critical for the physician who emerges from training to be able to apply the knowledge and experience gleaned during residency wisely. Thus, resident education and exposure frame the career of that physician; it is critical for all stakeholders, including residents, patients, and populations, that we are inclusive and anticipatory.

The manuscript by Kling et al (2) seeks to understand if we are adequately preparing residents in obstetrics and gynecology, family medicine, and internal medicine to care for menopausal women. The survey included 20 US residency programs, and it demonstrated that residents recognize the importance of training in menopause management. Most women will not only become menopausal but will also spend significant years in reproductive transition prior to becoming menopausal. Their health care before and after menopause will be primarily provided by family physicians, internists, and gynecologists, and the appropriateness and precision of that care have significant health implications for an individual’s quality of life as well as population health. The survey results showed that residents display important knowledge gaps and that there is room for improvement. Most notably, approximately one-third of the surveyed residents opted not to offer hormone therapy (HT) to a symptomatic, newly menopausal woman without contraindications or to a prematurely menopausal woman until the natural age of menopause, despite the overwhelming evidence that HT is efficacious and safe for these 2 categories of women (3). As virtually every health condition is impacted to a greater or lesser extent by reproductive hormones, it is critical that the physicians of tomorrow understand the endocrinology of reproductive ontogeny and the intersection of menopause and aging. In addition, understanding reproductive endocrinology from “womb to tomb” is a portal for understanding sex differences in disease presentation, progression, and therapeutic intervention. We are failing the doctors and patients of tomorrow if we do not adequately prepare them for the inevitable.

What can and should be done to foster better resident education in the care of menopausal women?

The first step is to address knowledge gaps. Knowledge acquisition begins by delineating core concepts and content. However, it also requires the development of perspective and an awareness of and an ability to articulate the limitations of that body of evidence. What is and is not known that is critical to the care of patients in general or to a patient in particular? What are the reproductive modifiers of disease presentation? Which hormonal formulations work best and in which situations? What is gray and what is black and white? Some physicians will be inspired to learn more and to develop the skills that will allow them to become physician-investigators capable of addressing gaps and controversies. The best training provides exposure to highly knowledgeable and experienced physician-educators and physician-investigators, as well as basic and translational investigators. The process of learning to apply and contextually adapt knowledge requires not only learner, but also institutional commitment, motivation and resources. The good news is that the survey results presented by Kling et al suggest that our residents recognize the importance of the topic of menopause and the gaps in their knowledge and state that they want to learn more. The bad news is that there is so much to learn and competition for resident time and energy. Residents often lack access to “elective” training venues and access to subspecialty populations such as symptomatic perimenopausal and menopausal women. There are also economic barriers driven by administrative demands for high throughput that constrain both learners and educators. Optimally, we would have the resources and support to establish cross-disciplinary training opportunities. Knowledge acquisition is a pursuit that never ends, so we need to modify the mindset that once doctors are trained that they then become “producers”. This mindset, often couched as cost-effectiveness or population health, impedes knowledge transfer and life-long learning in part by constraining recognition of physiological complexity.

The second step is to correct implementation gaps. Ideally, residents have learning venues that foster progressive independence and supervisors who are compassionate and sensitive educators. Time is a great enemy and economic incentives to see patients rapidly often interfere with resident education. Teaching and supervising require knowledge of the medical condition and available therapeutic options. In the case of hormone therapy (HT), one wonders if prescribing patterns of residents reflect the ambivalence and uncertainty of their teachers, some of whom witnessed the changes in HT prescribing practices after the Women’s Health Initiative (WHI) trial results were released (4). The results of this trial raised concerns regarding the risks of cardiovascular disease and breast cancer in women utilizing combined hormone therapy, and had a long-lasting negative impact on HT prescribing practices, particularly those of family and internal medicine physicians. Indeed, menopausal women feel that their doctors do not recognize the importance of menopause, with one-third feeling resistance to being offered HT (5). Therefore, “teaching the teachers” is the linchpin in ensuring that residents acquire a state-of-the-art approach to HT. Finally, the healthcare team must respect and accommodate the needs and pace of learners, the learner’s stage of knowledge and learning style. It is easy to see why we fall short of our goal of providing residents with the knowledge and opportunities for experiential learning.

What can we do? Attitude and advocacy are critical. We need the various stakeholders to adjust their understanding of the word “productivity”. When medical care is conceptualized mostly or exclusively as a transaction rather than as a relationship between a patient and a sensitive and knowledgeable health professional and his or her team, then “care” may miss the mark. When menopause is viewed simplistically as a physiological change in hormones that needs minimal or short-term “mitigation”, we may miss the opportunity to provide comprehensive and compassionate care targeted to individual circumstances.

Attitude matters. Seeing and embracing complexity may be inconvenient, but nonetheless important. Residents want to learn more about menopause. Let’s embrace that opportunity!