ORIGINAL CONTRIBUTION

Foundations for a Novel Emergency Medicine

Subspecialty: Sex, Gender, and Womens
Health
Alyson J. McGregor, MD, MA, Tracy E. Madsen, MD, ScM, and Brian Clyne, MD

Abstract
Sex and gender affect all aspects of health and disease, including pathophysiology, epidemiology,
presentation, treatment, and outcomes. Sex- and gender-specic medicine (SGM) is a rapidly developing
eld rooted in womens health; however, inclusion of SGM in emergency medicine (EM) is currently
lacking. Incorporating principles of sex, gender, and womens health into emergency care and training
curricula is an important rst step toward establishing a novel subspecialty. EM is an ideal specialty to
cultivate this new eld because of its broad interdisciplinary nature, increasing numbers of patient visits,
and support from academic medical centers to promote expertise in womens health. This article
describes methods used to establish a new multidisciplinary training program in sex, gender, and
womens health based in a department of EM. Womens health and SGM program initiatives span
clinical care, patient education, clinical research, resident and fellow training, and faculty development.
ACADEMIC EMERGENCY MEDICINE 2014;21:14691477 2014 by the Society for Academic
Emergency Medicine

omens health has evolved over the

past 30 years from a strict focus on
reproductive health into the burgeoning
discipline of sex- and gender-specic medicine (SGM).
Historically, medical research has been both sex- and
gender-neutral or skewed toward male physiology. This
has resulted in missed opportunities for prevention,
diagnosis, and treatments specic for women. Despite
progress during the past 20 years, women still have not
achieved equity in biomedical and health outcomes investigations. Failing to routinely consider the effect of sex
and gender on research, medical education, and training,
womens health is being left to chance. For this reason,
womens health and SGM are inextricably linked.
During the early 1990s, womens health and SGM
became a focus for clinical research, resulting in numerous studies establishing the role of sex and gender in
health and disease.16 At the same time, there has been
increasing emphasis on womens health in graduate
medical education. Internal medicine, family medicine,
obstetrics and gynecology (OB/GYN), and psychiatry

have endorsed or developed curricula related to sex,

gender, and womens health. As early as 1997, the
American Board of Internal Medicine and the American
Academy of Family Physicians published womens
health competencies for residency training. Further curriculum recommendations have been published by the
National Academy of Womens Health in Medical
Education7and the Council on Graduate Medical
Education.8
Despite progress identifying sex and gender differences in many conditions encountered in emergency
medicine (EM), residency programs currently offer little
formal training in this area. This may relate to a historical
lack of emphasis on womens health in the EM core content and accreditation standards. In the 2011 Model of
the Clinical Practice of Emergency Medicine, the term
gender occurs only once, within the physician task of recognizing age, gender, ethnicity . . . and other factors that
may affect patient management. In the same document,
sex is only found under sexual assault examination, and
women is not mentioned at all.9 Similarly, the 2013

From the Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
Received March 8, 2014; revision received April 24, 2014; accepted May 21, 2014.
Sponsored by the Division of Sex and Gender in Emergency Medicine (SGEM), formerly Women's Health in Emergency Care
(WHEC) at the Warren Alpert Medical School of Brown University.
The authors have no relevant nancial information or potential conicts to disclose.
A related commentary appears on page 1318.
Supervising Editor: David C. Cone, MD.
Address for correspondence and reprints: Alyson J. McGregor, MD, MA; e-mail: amcgregor@lifespan.org.

2014 by the Society for Academic Emergency Medicine

doi: 10.1111/acem.12544

ISSN 1069-6563
PII ISSN 1069-6563583

1469
1469

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Accreditation Council for Graduate Medical Education

(ACGME) program requirements for EM do not mention
the terms women or sex. The term gender is found in
relation to treating a comprehensive patient population
and in the context of demonstrating sensitivity to different patient populations.10
The move toward competency-based education and
acceptance of the milestones has highlighted the need for
curricula in womens health and SGM. Without referencing women directly, the new EM milestones11 demand
resident competency caring for patients with specic
needs. Milestone 20 (Professional Values 1) calls for competency interacting with a diverse population of patients
and families. Milestone 3 (Patient Care 3) includes
appropriate diagnostic testing based on the probability
of disease, and Milestone 5 (Patient Care 5) calls for
selecting appropriate pharmacotherapy based on mechanism of action, intended effect, possible adverse effects,
. . . and other modifying factors. One of the goals of the
Clinical Learning Environment Reviews initiative is for
institutions to demonstrate a reduction in health care
disparities; this is further rationale to include education
about womens health and SGM in residency training.12
In 2013, The Journal of Womens Health published a
Directory of Residency and Fellowship Programs in
Womens Health, listing 23 fellowship programs in the
United States dedicated to providing subspecialty training in womens health.13 None were sponsored by
departments of EM. To address this educational gap,
the authors developed a curriculum for EM residents on
sex, gender, and womens health. They also identied
areas where emergency care, gender-specic medicine,
and clinical research overlap to contribute to the growing body of scholarship on womens health beyond
reproductive issues. The curriculum subsequently
evolved into a novel postgraduate training program
designed to meet the need for focused and intensive
training in womens health and SGM in the context of
EM. The program draws on local resourcesin medical
education, research, and clinical careto provide a
unique specialty training experience.
While the nature and extent of training in womens
health and SGM within EM is not well described, many
departments have the ability to sponsor similar fellowship experiences. The purposes of this article are to: 1)
describe one programs experience developing a postgraduate training curriculum in womens health and
SGM; 2) encourage the formation of other similar programs that improve patient care and create academic
opportunities for residents, fellows, and faculty; and 3)
construct the foundation for womens health and SGM
to become a recognized subspecialty area within EM.
THE RATIONALE: WHY EM? WHY NOW?
Emergency medicine is important to the growth of
womens health and SGM and arguably an ideal home for
this new eld. Emergency department (ED) visits are
steadily increasing, with the number of women seeking
emergency care rising faster than men. Recent studies
indicate that women make up 54.3% of all ED visits, with
a steep trend toward increased ED occupancy.14 EM sits
at the cross-section of many disciplines, allowing natural

McGregor et al. FOUNDATIONS FOR A NOVEL EM SUBSPECIALTY

collaborations with specialties that have experience in

womens health but lack access to a large patient population with acute, undifferentiated illness. Despite the range
of conditions seen in the ED, most patients are readily
identied by their gender, making it an excellent setting
for comparative effectiveness research or gender-based
clinical interventions.
As medicine grows more complex, subspecialization
has become increasingly common. For instance, internal
medicine has over 20 approved subspecialties in which
the American Board of Medical Specialties can offer certication; areas including geriatric medicine and adolescent medicine are subspecialties directed toward
subpopulations of society as a whole. In contrast, EM
currently includes eight subspecialties where certication
is offered by the American Board of Emergency Medicine with only pediatric EM offered as a subpopulation.
Womens health currently is not offered as a subspecialty
within any of the medical or surgical specialties, as it has
often been dened as reproductive health and assumed
by the medical specialty of OB/GYN.
National EM specialty societies have increasingly
devoted educational and research resources to womens
health, creating favorable conditions for a new eld of
study to ourish. Organizations like the American College
of Emergency Physicians and the Society for Academic
Emergency Medicine (SAEM) include subcommittees,
interest groups, leadership opportunities, and grant programs dedicated to supporting womens health and faculty development. Core EM journals are publishing
research studies, educational articles, and commentaries
related to sex, gender, and womens health with increasing frequency.2,15,16 In 2013, the U.S. Department of
Health and Human Services Ofce of Womens Health
published ndings of a national expert panel summarizing the
womens health literature and highlighting opportunities to
improve education. The report includes recommendations for
curriculum development and calls for the establishment of
additional womens health clerkships and fellowships.17
Academic Emergency Medicine has declared 2014 the year to
emphasize the inclusion of sex and gender into the research
and clinical practice of EM. The focus of its annual consensus
conference was Gender-specic Research in Emergency
Care: Investigate, Understand, and Translate How Gender
Affects Patient Outcomes. Collectively, these efforts provide a
forum within EM to study, teach, and improve outcomes in
womens health and SGM.
CURRICULUM DEVELOPMENT, PART I:
ESTABLISHING A WOMENS HEALTH/SGM
ELECTIVE FOR EM RESIDENTS
Overview/Objectives
The authors used established educational methods to
develop the elective curriculum for EM residents.18 An
initial needs assessment and literature search were conducted followed by a review of guidelines and womens
health curricula from other specialties and health professions.1922 Core faculty held informational interviews
with content experts and developed educational objectives. For example, faculty met with experts in womens
cardiovascular disease to identify how gender can affect
the presentation, diagnosis, or treatment of cardiac

ACADEMIC EMERGENCY MEDICINE December 2014, Vol. 21, No. 12 www.aemj.org

disease in the ED. Focus groups with local educational

stakeholders were conducted to rene the learning objectives
and identify available resources. The process resulted in a distinct educational goal: To teach residents how to improve
emergency medical care of women through discovery of the
biological, physiological, pathological, and therapeutic differences between men and women and how that inuences
emergency care for all. Learning objectives were then developed that broadly reect the important topics for EM residents to learn on a womens health/SGM elective.
Learning Objectives for a Womens Health/SGM
Resident Elective
1. Recognize sex and gender differences in the acute
presentation and management of common EM conditions.
2. Explain the scientic evidence behind current controversies in the diagnosis and management of sexspecic conditions, such as emergency urological,
gynecological, and obstetric conditions.
3. Identify risk factors and effective screening tools for
intimate partner violence (IPV) and sexual assault, as
well as best practices for treating victims of IPV and
sexual assault.
4. Understand the unique medical and mental health
needs of transgender or gender variant patients,
including barriers to health care access.
Core Competencies
Individual competencies were developed using the
ACGME framework of patient care, medical knowledge,
practice-based learning and improvement, interpersonal
and communication skills, professionalism, and systemsbased practice. Competencies specic to womens health
and SGM were integrated with existing EM core competencies.10 Table 1 represents the results of this process: the
essential knowledge, skills, and attributes for EM residents
to achieve basic competence in womens health and SGM.
Elective Activities/Recommendations for Program
Development
In addition to dening the educational content, curriculum leaders considered the delivery methods, teaching
strategies, and methods of learner assessment. The elective was modeled on existing rotations in the core EM
residency program, using similar didactic approaches
and evaluation tools. The principal components of the
curriculum include assigned readings and questions;
didactic conferences (case discussions, simulations, or
small group learning); a capstone presentation whereby
participants teach peers about a topic related to sex and
gender in emergency care; and clinical experiences.
For other EM departments developing a sex, gender,
and womens health curriculum, the mix of clinical
experience will be program-dependent; many EM programs, however, will have access to high-volume academic or community EDs, a womens specialty or
primary care clinic, and a specialized womens hospital
that routinely treats pregnant patients. A sample resident elective schedule listing our programs clinical
training sites can be found in Table 2.
Depending on the site, clinical supervision may be provided by faculty from other disciplines (i.e., internal medi-

1471

cine, OB/GYN, and family medicine) or other

professional backgrounds (i.e., nurses, midwives, and
advanced care providers). Supervising faculty should be
informed about the competencies and trained to assess
learners. Methods for assessment are competencyspecic, but may include multiple-choice examinations,
standardized direct observation, objective structured
clinical examination, standardized patients, oral examinations, global rating scales, or reective essays. The resident elective is designed to run over 4 weeks to allow for
in-depth exploration of topics and exposure to multiple
clinical settings, although womens health/SGM resident
electives can also be offered as a 2-week experience.
CURRICULUM DEVELOPMENT, PART II:
ESTABLISHING A WOMENS HEALTH/SGM
FELLOWSHIP
Overview/Objectives
The decision to establish a womens health/SGM fellowship evolved from positive experiences with the EM
elective, favorable institutional conditions, and the need
to develop leaders in the eld of womens health and
SGM. Developing the curriculum followed a rigorous
process, similar to that of creating the resident elective,
but with emphasis on advanced clinical prociency,
research skills, teaching abilities, and leadership. The
goal of a womens health/SGM fellowship is to develop
physician-leaders with the specialized knowledge and
skills for clinical care, education, research, and advocacy
in womens health and SGM.
The selection process seeks to identify EM residents
with demonstrated interest and aptitude for academic
medicine. Non-EM graduates may also be considered,
with options to complete their clinical experience in
primary care or urgent care settings. This exibility
allows a program to accommodate candidates with various training backgrounds and support career interests
that include acute care, but perhaps not EM. A 2-year
program provides sufcient breadth and allows fellows
to customize some aspects of the experience. The fellowship will likely be less structured than the resident
elective to allow for exploration of specic interests.
Depending on their specic goals, fellows may choose
to spend more time focusing on either teaching or
research activities, especially during their second year.
The womens health/SGM fellowship was designed as a
2-year experience with adequate time to achieve the
following objectives:
Learning Objectives for a Womens Health/SGM
Fellowship
1. Gain the skills necessary to practice comprehensive
SGM emergency care.
2. Develop research skills to address evidence gaps in
SGM emergency care.
3. Complete a masters degree in public health or other
related advanced degree coursework.
4. Identify teaching, leadership, research, and advocacy
opportunities in womens health/SGM.
5. Recognize the unique challenges associated with the
care of gay, lesbian, and transgender patients in the
ED.

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McGregor et al. FOUNDATIONS FOR A NOVEL EM SUBSPECIALTY

Table 1
Competencies for a Womens Health/SGM Elective
Competency Area

Activity

Patient care and procedural

skills

Medical knowledge

Practice-based learning and

improvement

Interpersonal and
communication skills

Perform an appropriate sex- and gender-specific physical examination.

Describe sex- and gender-related differences in the evaluation and management of sexually
transmitted diseases.
Describe guiding principles for the management of victims of violence and abuse.
Demonstrate appropriate emergency management and follow-up planning for sexual assault
victims.
Demonstrate appropriate prioritization in initial management of the pregnant trauma patient.
Perform successful airway management in pregnant patients.
Perform routine EM procedures on pregnant patients with attention to anatomical and
physiological differences.
Demonstrate appropriate skill managing obstetric emergencies including first-trimester
bleeding, preterm labor, ectopic pregnancy, second- and third-trimester bleeding,
complications of labor, and postpartum care.
Demonstrate proficiency in the use of transvaginal ultrasound in the identification of ectopic
pregnancy.
Describe the biological and physiological mechanisms for gender-related differences in
acute clinical conditions.
List sex and gender differences in risk factors for myocardial infarction, stroke, and
subarachnoid hemorrhage.
Identify and explain sex differences in drug metabolism and toxicity.
Summarize the indications for and forms of emergency contraception.
Discuss the differential diagnosis of first-, second-, and third-trimester bleeding.
Discuss the pathophysiology and treatment of preeclampsia and eclampsia.
Explain the risk factors and emergency management of preterm labor.
Identify factors for ectopic pregnancy.
Critically evaluate studies for sex and gender differences and the application to the acute
care of women.
Summarize the incidence and prevalence of violence against and abuse of women using
available data sources and published literature.
Prepare a didactic lecture, workshop, or simulation for health care professionals on a
topic that showcases how sex and gender affect emergency care.
Identify opportunities for quality improvement related to the care of women in the ED.
Demonstrate empathy, respect, and cultural sensitivity when communicating with women
and other unique patient populations (i.e., gay, lesbian, and transgender) in the ED.
Perform appropriate screening for substance abuse, high-risk sexual activity, and
interpersonal violence.
Demonstrate the ability to take a complete sexual history.
Describe how sex, sexuality, gender, and sociocultural factors influence patient
communication.
Demonstrate the ability to perform a safety assessment for patients who disclose violence
or abuse.

Professionalism

Demonstrate respect, compassion, and integrity when treating sensitive topics surrounding
interpersonal violence, sexual assault, and reproductive health.

System-based practice

Identify disparities in clinical research, access, and delivery and their effect on womens
health.
Integrate state and local requirements for reporting violence and abuse.
Summarize and discuss one major womens health policy issue in depth.

SGM = sex- and gender-specific medicine.

Table 2
Sample Weekly Schedule for a Resident Womens Health/SGM Elective
Day
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday

8 a.m.12 p.m.

12 p.m.5 p.m.

Clinicalwomens care hospital

Research project or clinical case study
Clinicaloutpatient OB medicine clinic
Resident didactic conference
Journal review evaluating research design
Clinicaladolescent health care clinic

Clinicalwomens care hospital

Research project or clinical case study
Research project or clinical case study
Focused reading
Clinicaloutpatient womens cardiology clinic

SGM = sex- and gender-specific medicine.

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Core Competencies
Table 3 illustrates an expanded list of competencies for
fellows with an emphasis on research, teaching, and the
routine incorporation of sex and gender into clinical
practice. The fellowship extends beyond EM, promoting
a broader understanding of sex, gender, and womens
health through experiences in public health and population research.
Fellowship Activities/Recommendations for Program
Development
Key fellowship elements include clinical work, formal
research training through coursework, hands-on

1473

research experience, teaching opportunities, leadership

development, and ongoing self-directed learning.
Table 4 shows a sample block schedule for a 2-year fellowship incorporating these elements.
Clinical Experience. Clinical experiences are used to
reinforce consistent use of the gender lens at the bedside. Over the course of the fellowship, fellows have the
opportunity to develop this skill in a variety of clinical
settings including the ED. The combination of experiences will vary based on the available institutional
resources; recommended supplementary experiences
include an OB acute care site and outpatient clinics spe-

Table 3
Womens Health/SGM Fellowship-specific Competencies
Competency Area
Patient care and procedural
skills

Medical knowledge

Activity

Practice-based learning and

improvement

Interpersonal and
communication skills

Professionalism

System-based practice

Interpret the patient history and diagnostic tests in a gender-specific context.

Recognize subtle signs and symptoms of interpersonal violence and abuse.
Prepare management protocols and care plans that optimize sex- and gender-specific care.
Apply evidenced-based clinical practice in gender-specific medicine and womens health care.
Demonstrate competence caring for pregnant patients with common emergency conditions.
Interpret and restate evidence on sex-related differences in the management of
cardiovascular, neurological, endocrine, autoimmune, metabolic, psychiatric, and traumatic
clinical conditions.
Apply knowledge base of the emerging literature on sex and gender differences in common
ED conditions, and use this knowledge in patient care decisions.
Explain the biological and physiological basis for gender-related differences in
commonacute clinical conditions.
Describe the diagnostic evaluation and management approach to pregnant patients with
common non-obstetric emergencies.
Describe the effects of gender and related sociocultural stressors on disease outcomes.
Describe how sex and gender differences in acute disease change across the lifespan.
Identify key publications stating the significance of sex- and gender-based research,
education, and practice.
Identify current diagnostic and treatment controversies in womens health.
Discuss the historical barriers to including women in clinical trials and research studies.
Identify research questions related to sex and gender that will improve patient care.
Develop research skills to initiate, execute, and disseminate projects in the area womens
health, including study design, data collection and management, basic statistical analysis,
interpretation of results, and manuscript preparation.
Design, conduct, and submit an original, gender-focused research project suitable for
peer review.
Prepare and submit a research proposal for grant funding on a topic related to womens
health- or gender-specific medicine.
Develop educational sessions to teach other providers about sex, gender, and womens health
to promote health care.
Describe how sex and gender differences inform the doctorpatient relationship.
Teach other providers about sex- and gender-related differences in communication skills.
Evaluate the communication skills of other providers with respect to sex and gender.
Educate patients on how sex and gender differences are pertinent to their disease processes.
Identify opportunities to participate and lead within professional organizations that promote
sex- and gender-specific care.
Describe the ethical issues related to gender bias and health care disparities.
Develop strategies to educate providers about the ethics of gender differences in
clinical outcomes.
Identify major public health programs and initiatives promoting gender-specific health care.
Describe the gender-specific barriers to health care access and its consequences and
outcomes.
Discuss the historical trends and significance of the changing role of women in health care.
Recommend strategies to improve access to care for women.
Demonstrate ability to mobilize system resources to optimize gender-specific health care.

SGM = sex- and gender-specific medicine.

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McGregor et al. FOUNDATIONS FOR A NOVEL EM SUBSPECIALTY

Table 4
Sample Womens Health/SGM Fellowship Block Rotation Schedule

Timing
Year 1
July
December

January
June

Year 2
July
December

January
June

Clinical Activities

ED attending
shifts
Womens care
hospital
elective
ED attending
shifts
Womens care
hospital
elective

Research

ED attending
shifts
OB-medicine/
womens care
outpatient
elective

ED attending
shifts
OB-medicine/
womens care
outpatient
elective

Coursework

Leadership
Development

Teaching/Education

Literature
review
Choose
research focus
Study design

Epidemiology/
biostatistics
(two courses)

Journal review/
focused reading

Join national
organizations/
committees
relevant to SGM

Study design
Data collection

Study design/
biostatistics
(two courses)

Presentation
at resident
conference
Medical student
education

Active participation
local/national
committees
relevant to SGM

Study design/
meta-analysis
(two courses)

Grand rounds
preparation
Medical student
education

Obtain leadership
roles in local/
national SGM
committees

Grant writing/
thesis preparation
(2 courses)

Grand rounds
presentation
Patient education
initiative

Advance SGM
agenda through
leadership roles
in local/national
committees

Data collection
Data analysis
Abstract
preparation
Research
presentation

Manuscript
presentation
Manuscript
submission

OB = obstetrics; SGM = sex and gender-based medicine.

cializing in the care of nonpregnant women with a variety of medical issues. In each of these settings, as well
as the ED, fellows are taught to incorporate patient sex
and gender into the diagnostic and therapeutic decisions. To solidify this core competency, fellowship
directors should evaluate fellows ability to integrate
gender into bedside decisions through case reports,
presentations, and regularly scheduled follow-up meetings. In the current womens health/SGM fellowship,
longitudinal core clinical rotations are based at a
womens specialty hospital and include experience in an
OB emergency care setting and a dedicated OB/GYN
hospital with an emergency triage unit. The fellow can
benet from clinical elective time each month by rotating at this facility and others committed to practicing
specialty care for women such as inpatient OB-medicine
consulting service, a womens cardiac center, an adolescent clinic with providers trained to evaluate transgender patients, and a womens outpatient health center
with gastrointestinal, pulmonary, oncological, and
behavioral medicine services.
Advanced Coursework. Whether to include an
advanced degree is an important decision when establishing a womens health/SGM fellowship. In these early
stages of the eld, it is important to equip fellows with
the skills to contribute meaningfully to the body of
research in sex, gender, and womens health. As such,
including a master of public health (MPH) or a master
of clinical and translational research (MCTR) is
advantageous. A 2-year program allows fellows to
receive additional training in research methodology and

the analytic capabilities required to advance the eld.

This added instruction will serve the fellow in many
ways, including increasing prociency in conducting
sex- and gender-specic research in EM, gaining the
skills necessary to assume leadership roles locally and
nationally and using the knowledge to translate
research ndings into clinical practice in EDs.
If institutional resources are limited, a robust 1-year
fellowship program without an advanced degree is still
highly valuable. As the eld gains momentum, it is more
important to generate well-trained scholars than to
restrict the training to institutions that can offer
advanced degrees.
Research Experience. It is important for the fellow to
understand the application of research skills in an interdisciplinary arena. Having prior experience in research
methodology and design is favorable; however, instruction on designing and conducting sex, gender, and
womens health research will be a critical aspect of the
fellowship training. Given that much historical research
focused disproportionately on males, this area is ripe
for study questions and offers many opportunities for
collaborative analysis of existing data sets. Fellows
should also learn the importance of sex-specic data
analysis and reporting in research studies not primarily
focused on womens health. In particular, opportunities
exist that allow the fellow to leverage the core strengths
of any institution by evaluating sex and gender differences in many areas germane to EM such as injury
prevention, cardiovascular, neurological, and other
health care systems science.

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Teaching Opportunities. Fellows should have opportunities to teach in a variety of settings including
departmental grand rounds, residency conference lectures, small group learning, bedside rounds, and oneon-one mentoring with a variety of learners (medical
students, residents, and staff) interested in advancing
SGM. Medical students may have a high degree of
interest in this area, which leads to many mentormentee experiences that are mutually benecial and often
identies and engages future scholars. Collaborative
teaching efforts in other departments or institutions are
encouraged.
Ongoing Self-directed Learning. Much of the current scientic knowledge about SGM and womens
health has emerged only recently and from many different disciplines, making accessibility and coordination
into an organized curriculum challenging. Currently,
there is no centralized resource for this diffuse body of
knowledge; therefore, a reading list should take into
account the varied resources available, including journal articles, textbooks, and Web-based continuing
medical education courses. One example of a useful
online resource includes Sex and Gender Womens
Health Collaborative (http://www.sgwhc.org), a professional organization whose aim is to provide a universally accessible digital library of evidence-based sex
and gender educational resources that include curriculum and training, teaching tools, presentations, reports,
guidelines, and professional education modules that
focus on using the gender lens in research and clinical
practice. Additional online resources include Stanford
Universitys Gendered Innovations (http://genderedinnovations.stanford.edu) and the Canadian Institute of
Gender Health: What a Difference Sex and Gender
Make (http://www.cihr-irsc.gc.ca/e/44082.html). Opportunities exist for a medical student and resident educational project to compile relevant reading resources for
each institution.
BARRIERS AND SOLUTIONS FOR IMPLEMENTING
A WOMENS HEALTH/SGM TRAINING PROGRAM
Despite the fact that the attention on sex and gender
has prompted institutions to create focused womens
health fellowship tracks, training remains inadequate.
Furthermore, condence in knowledge and self-efcacy
in womens health among trainees remains low.16
Establishing a womens health/SGM curriculum is likely
to face the same challenges as other new educational
initiatives. We present commonly cited challenges to
new educational initiatives and propose strategies to
address them.
BARRIER 1: There is limited time and space in the
existing curriculum. The current curriculum must prepare residents to demonstrate aptitude in the core competencies endorsed by ACGME. This allows little
opportunity for the inclusion of new material.
STRATEGY 1: Integrate sex and gender using the
current curriculum. From grand rounds to resident
lectures, presenters should be asked to address whether
sex or gender affects the presentation, diagnosis, treatment, or prognosis of the specic entity. When simula-

1475

tion cases are under peer review, discuss how a change

in gender would affect outcome. Journal club should
include discussion of whether gender composition was
reported, included in the study design, included as an
independent variable, or considered in the primary
hypothesis.
BARRIER 2: Competition with other specic interests
(geriatrics, ultrasound, toxicology, international, etc.) for
resources. The American Board of Medical Specialties
currently recognizes eight subspecialty areas within EM
that are competing for department-level resources and
support as well as resident interest and commitment.
STRATEGY 2: Start with small wins: create a resident
elective. Residents can choose to spend their clinical
elective time completing a 2- to 4-week elective. A wellrounded elective can include the resident creating sex
and gender case studies, becoming involved in ongoing
research projects, and constructing educational modules
that can supplement the clinical time. Make the elective
available to residents from outside programs nationally
to assist in fellowship recruitment and networking. In
addition, emphasize the relevant overlap between gender-specic medicine and other subspecialties.
BARRIER 3: An absence of faculty and role models
knowledgeable in this subspecialty area. Novel subspecialties require the support of many stakeholders,
including the department chair, faculty members, program directors, residents, and students.
STRATEGY 3.1: Make it interdisciplinary by nding
qualied faculty from other specialties. Since sex, gender, and emergency care cross many specialties and
health professions, these relationships are critical to the
success of similar fellowship program initiatives. This
will also help gain approval from local Graduate Medical Education (GME) committees. At this time, the
womens health /SGM fellowship is a non-ACGME program, established with the approval of the institutions
GME committee.
STRATEGY 3.2: Faculty development for womens
health/SGM mentors is critical for establishing and
growing a new program. An important initial step is to
educate existing EM faculty about the effect of sex and
gender on patient outcomes. One example of an educational program to raise awareness among faculty is a
series of brief online videos available through Academic
Emergency Medicine: Peer-reviewed Lectures (PeRLs)
that highlight gender differences in a number of acute
conditions, including cardiovascular, neurology, pain,
toxicology, injury, violence, substance abuse, pulmonary, and sports medicine and a historical perspective
of the evolution of SGM.23,24 An additional PeRLs
reviews the effect that sex- and gender-specic research
has on the eld of EM, provides concrete examples of
current EM literature that successfully investigates sex
and gender differences, and presents analytical strategies to perform gender-based research in existing
research data.25
BARRIER 4: Personal demands on the program and
curriculum champions. Identifying faculty who are committed to establishing a novel program and implementing a new curriculum has many challenges that include
competing demands of professional development and
academic promotions, along with personal investments.

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STRATEGY 4.1: Enlist outside help. Build on successful working relationships with local and national EM
faculty, as well as local faculty representing a wide variety of disciplines.
STRATEGY 4.2: Give fellows the opportunity to
advance the subspecialty. Having a fellow trained in
SGM will allow inltration of sex and gender principles
into the residency education. For example, a fellow
receiving adequate training will then be able to teach at
residency conferences, intern orientations, and resident
and faculty retreats.
BARRIER 5: Funding. There may be a lack of nancial
resources for such wide-ranging needs. The economic
needs include administrative, research, facilities, and
faculty nancial support to establish an adequate program that can fulll the broad goals of womens health.
STRATEGY 5.1: Identify funding sources. A critical
goal of a fellowship program is nancial independence.
Initially, institutional support is necessary; however, any
expansion of effort will require additional funds.
National Institutes of Health, American Heart Association, SAEM Education Fellowship Grants, and Foundation for Gender-Specic Medicine Scholar Program as
well as unrestricted educational grants from industry
sponsors should be considered.
STRATEGY 5.2: Incentivize faculty and residents. Due
to the demands of managing clinical, educational,
research, and administrative requirements, there is an
opportunity to encourage individual faculty members
and residents to take advantage of educational
resources by offering incentives. Consider small nancial rewards for completing modules, viewing videos,
and responding to CME-style questions about the topic.
Consider regular awards and recognition for the resident or faculty member who demonstrates advanced
understanding of sex and gender concepts.
BARRIER 6: Resistance to change. All medical disciplines are recognizing the need to rethink what constitutes appropriate health care for women and how to
incorporate sex and gender into research agendas and
bedside patient care. This is a fundamental shift in medicine with many challenges.
STRATEGY 6.1: Establish a broad steering committee
of supporters from all levels. To create a team of mentors, a womens health/SGM membership program
should be created to engage active support for the fellowship mission. This membership program can comprise the founding members including EM faculty,
residents, midlevel providers, nursing staff, regional
and national research collaborators, national senior
advisors, and a community advisory board. These members should attend quarterly meetings, provide educational opportunities, and assist in creating research
initiatives and establishing collaborative projects. Community outreach programs are also a vital component.
STRATEGY 6.2: Patients and staff engagement. Disseminating knowledge of gender-specic care to
patients is vital in empowering them and their families
when seeking emergency care. A series of educational
posters can be created and displayed in the emergency
waiting area and treatment rooms to inform patients
about gender-specic symptoms, injury patterns, and

McGregor et al. FOUNDATIONS FOR A NOVEL EM SUBSPECIALTY

research that may affect their care in the ED. To ensure

all providers responsible for the care of ED patients are
knowledgeable and informed about how sex and gender
affect patient care, the nursing staff should also be
encouraged to review the PeRLs videos. In addition,
small-group educational sessions are critical to engaging and educating nursing staff.
CONCLUSIONS
Emergency medicine residency programs have a
responsibility to teach residents about gender differences in common and life-threatening diseases; residents must also understand how disease management
differs based on sex and gender. Despite the fact that
formal training is lacking in EM residencies, many programs have the resources to provide high-quality training and meet an identied educational need. We
present suggestions for establishing elective and fellowship experiences that could serve as a framework for
similar programs. Incorporating curricula in womens
health, and sex- and gender-based medicine more formally within emergency medicine, is a rst step toward
recognition as a subspecialty. Additionally, these programs can be a strategic asset, serving as a resource
for education, clinical care, and research. Establishing
additional programs will benet departments seeking to
develop experts in womens health and sex- and gender-based medicine who can lead the next generation.
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