|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 1 | Page : 50-59
Implementation and sex-specific analysis of students' attitudes toward a longitudinal, gender-specific medical curriculum – a pilot study
Anja Böckers1, Claudia Grab2, Christiane Waller3, Ulrike Schulze4, Susanne Gerhardt-Szep5, Benjamin Mayer6, Tobias Maria Böckers7, Wolfgang Öchsner2
1 Institute of Anatomy and Cell Biology, Medical Faculty, University Ulm, Ulm, Germany
2 Office of the Dean of Studies, Medical Faculty, University Ulm, Ulm, Germany
3 Clinic for Psychosomatic Medicine and Psychotherapy, University Ulm, Ulm, Germany
4 Department of Child and Adolescent Psychiatry and Psychotherapy, University Ulm, Ulm, Germany
5 Department of Operative Dentistry, Dental Clinic, Goethe University of Frankfurt am Main, Frankfurt am Main, Ulm, Germany
6 Institute of Epidemiology and Medical Biometry, Medical Faculty, Ulm University, Ulm, Germany
7 Institute of Anatomy and Cell Biology, Medical Faculty; Office of the Dean of Studies, Medical Faculty, University Ulm, Ulm, Germany
|Date of Web Publication||13-Jul-2017|
Institute of Anatomy and Cell Biology, Medical Faculty, University Ulm, Albert-Einstein-Allee 11, Ulm 89081
Source of Support: None, Conflict of Interest: None
Background: Gender medicine has gained importance over the past 20 years. Nevertheless, the scientific findings concerning gender- and sex-specific patient care have not been sufficiently integrated into the education of physicians. It was therefore our aim, against initial resistance in our school, to integrate clinically relevant aspects of gender medicine into the existing medical curriculum. This paper describes the implementation process of a lecture-based interdisciplinary, longitudinal, basic gender curriculum and evaluates students' attitudes in relation to sex and semester level. Methods: The curriculum encompasses 15 lecture sessions scheduled in years 1 through 5 of the medical curriculum at Ulm University, Germany. Prospectively gathered evaluation data of two cross-sectional analyses of this basic curriculum in the first and fifth semesters are analyzed by sex. Results: More than 80% of the students have registered for this new curriculum. Evaluation data show a predominantly positive (75.5%) student response; however, only about half of those surveyed indicated that they had learned new material or judged the content on gender to be relevant to their practice of medicine. Students at a more advanced semester level (88.2% vs. 55.2%) and male participants more than female participants (36.7% vs. 62.4%) showed lower acceptance. Discussion: It was possible to integrate gender issues into the existing medical student curriculum. Despite the overall positive rating, our evaluation data identified the aspects of rejection and resistance in some students, particularly male and more advanced students. Further studies on the development of student attitudes toward gender issues are needed.
Keywords: Attitudes, curricular development, gender awareness, gender medicine, medical education, undergraduate teaching, women's health care
|How to cite this article:|
Böckers A, Grab C, Waller C, Schulze U, Gerhardt-Szep S, Mayer B, Böckers TM, Öchsner W. Implementation and sex-specific analysis of students' attitudes toward a longitudinal, gender-specific medical curriculum – a pilot study. Educ Health 2017;30:50-9
|How to cite this URL:|
Böckers A, Grab C, Waller C, Schulze U, Gerhardt-Szep S, Mayer B, Böckers TM, Öchsner W. Implementation and sex-specific analysis of students' attitudes toward a longitudinal, gender-specific medical curriculum – a pilot study. Educ Health [serial online] 2017 [cited 2023 Jun 2];30:50-9. Available from: https://educationforhealth.net//text.asp?2017/30/1/50/210508
| Background|| |
Over the past 20 years, the knowledge gained in the field of gender-specific medicine has increased exponentially and attracted interest worldwide. Numerous scientific publications and international gender textbooks that provide advice for daily medical practice are now available for physicians.,
In this paper, we would like to define “gender” as a term that encompasses not only biological but also social aspects of being female or male. Accordingly, we view gender medicine as the “study of how the normal function and the experience of disease differ between men and women. It is dedicated to the study of the unique aspects of men's biology as it is to that of women…” Evidence show that not paying attention to patient gender in medical treatment leads to substandard, suboptimal health care for both male and female patients., As an example, the authors outline the need for a gender-sensitive diagnostic approach and therapy regimen of cardiovascular diseases as women and men differ in regard to their causes and symptoms. Study evidence like this has thus far only gained hesitant acceptance in the training of physicians. Policymakers at medical schools are called upon to develop strategies to eliminate deficits in gender knowledge,,, to integrate gender issues into the education of physicians-to-be, to implement gender knowledge in the form of professional skills (e.g., communication), and to promote gender-sensitive attitudes in students and instructors. Gender awareness to be fostered in this context encompasses the recognition of gender stereotypes and gender bias and the inclusion of sex and gender as the basic determinants for health and disease.,, Unfortunately, attempts to introduce gender curricula into medical education have stalled, often from the lack of institutional support., Resistance to the implementation of gender issues in medicine is often from teachers and university leaders.,,, Male instructors in leadership positions view gender aspects as important, but of low priority. This might be explained by manifestations of resistance such as avoidance or simplification of gender issues, especially among male teachers. Therefore, this manuscript presents strategies to surmount difficulties in the processes of implementing a gender curriculum.
To incorporate a gender perspective into medical curricula, educational objectives that should be pursued should be determined. Fundamental elaboration of educational objectives in gender medicine has already been undertaken., These learning objectives constitute an excellent basis for all designers of a gender curriculum. To date, literature has described different implementation models for undergraduate ,,, and postgraduate medical education. However, Henrich and Henrich et al. (2006) were able to show that very few of the existing gender curricula were designed to be interdisciplinary, integrated, or to last for multiple academic years., Accordingly, this paper aims to present a longitudinally, integrated and interdisciplinary gender curriculum at Ulm University. The basic gender curriculum presented is only a first step in an ongoing future implementation process as it is based exclusively on a lecture teaching format and therefore teaches primarily gender knowledge, but not gender skills or attitudes. By means of integrating a basic gender curriculum, we intend to make clinically relevant sex- and gender-specific content visible to students and teachers. After attending the basic gender curriculum, students should be able to name and reflect on at least ten different entities of clinically relevant gender differences in patient care and their consequences.
It has been shown that a physician's gender has an impact on patient treatment and communication in the physician–patient relationship., In addition, female students, physicians, and faculty members assess gender issues as more important than their male colleagues., Cheng and Yang showed that, in the context of hidden curriculum, gender stereotypes and patriarchic values are even prevalent among students. This might be reflected in gender differences in students' evaluation data.
In this study, we wish to present the basic gender curriculum and its implementation process to other health professional educators and to assess students' attitudes toward integration of gender issues into the curriculum.
This study also addresses two questions: (1) Do the attitudes of female and male students toward the content on gender in the basic curriculum differ? (2) Do the attitudes of the first-semester and fifth-semester students toward the content on gender in the basic curriculum differ?
| Methods|| |
Medical education in Ulm follows a traditional 6-year curriculum. The preclinical part encompasses 2 years of studying primarily basic science subjects before students take their first state examination. After attending all clinical subjects during the following 3 years, students take their second state examination, and then begin their internship during their last year of study.
Design and implementation
As a first step, gender competence (i.e., the capacity to identify where difference on the basis of sex and gender is significant) was imparted into our graduate profile of our medical school. Under the leadership of the Office of the Dean of Studies and the countenance of the faculty council, an interdisciplinary working group was assigned with the task of designing a curriculum covering the basic scientific, gender-specific principles relevant to medical student training. To begin with, the working group analyzed the existing curriculum for any already present gender-specific content. Since there are still no official guidelines in Germany on curricula addressing gender, we used the course catalog for the postgraduate master's degree program in gender medicine in Vienna as a guide. The working group defined learning objectives and identified the course content that needed supplementation.
There were two initial major hurdles: The implementation of the basic gender curriculum could not lead to any increase in teaching hours (study load) and representatives of most departments resisted changing their present teaching concepts or topics. As the most common thread to start with, the working group agreed on the implementation of primarily cognitive gender-specific knowledge into the main lectures of gender-relevant subjects. Unfortunately, the working group was not able to recruit colleagues from the departments of internal medicine as gender lecturers, due to their concerns for issues such as lack of time, low priority, and lack of expertise. To not increase students' study load, individual lecture sessions with a gender-specific emphasis in already established curricular lecture series were joined together into the basic gender curriculum. For example, a lecture session about neurophysiology in the mandatory physiology lecture series in the 1st year of study was revised to emphasize and integrate neurophysiological gender aspects. By doing this, it was possible to offer all students an interdisciplinary longitudinal (from 1st to 5th year) curriculum on gender medicine integrated (not add-on) in the mandatory curriculum [Table 1].
|Table 1: Chronological order of gender-/sex-specific topics in the basic gender curriculum at Ulm University in winter term 2013/2014|
Click here to view
By regular conferences and by using an online communication platform, a uniform presentation format with a high recognition value was developed for all lectures within the basic gender curriculum and the organization of the project accomplished.
Lecturers were recruited by their expertise in the respective disciplines, most of them without certified gender medicine expertise or training. Responsibility for scheduling and conducting each of the gender-specific lectures within the gender medicine curriculum remained with the lecturers in the particular specialties.
The basic gender medicine curriculum was offered to all medical students from years 1 to 5 of their academic studies [Table 1] at a time starting with the specific lectures for each given semester. Therefore, students in their 1st semester in winter term 2013-2014 were able to attend the entire gender curriculum right from the beginning during their following study time. Students at a more advanced semester level, for example those in their 5th semester, were only able to attend parts of the gender curriculum starting with lectures assigned to their semester level in winter term 2013–2014. Nevertheless, these more advanced students had the chance to acquire a certificate of gender competence as an additional key qualification by attending the gender-/sex-specific lectures of lower semesters on a voluntary basis (“retrograde participants”). After having completed a minimum of 80% of the lectures offered, students get an official academic certificate for their additional key qualification in gender competence.
Mode of evaluation
The faculty's standard evaluation questionnaire was modified and supplemented with gender-specific questions. The modified questionnaire includes a total of 22 questions [Table 2] addressing the outcome, organizational aspects, a general evaluation which included an assessment of students' attitudes toward the relevance of gender-related content to their future professional practice, and questions about the teaching methods (hidden curriculum) of the gender-/sex-specific content. The items were rated using a 6-point Likert scale ranging from (1) “strongly disagree” to (6) “strongly agree.” In addition, students were asked to indicate their sex (item 21).
|Table 2: List of the survey items rated on Likert scale (item 21=indication of sex; items 5 and 6, respectively, indicate the proportion and labeled designation of the gender-/sex-specific content as a percentage) plus study results presenting mean values and standard deviation of each questionnaire item|
Click here to view
This questionnaire was used by students in their first semester to evaluate the 2013–2014 winter semester gender lecture entitled, “Anatomy: Phenotypical sex differentiation” (L-1). This lecture was held by a male instructor. The same questionnaire was also filled in by 5th semester students, who had not visited any gender-/sex-specific lectures beforehand. Fifth-semester students evaluated the gender lecture entitled, “The good doctor: Gender medicine and gender in medicine” (L-5), a lecture given by a female instructor. The evaluation took place on a completely voluntary and anonymous basis immediately after each lecture and was performed in a paper and pencil format. Since no personal data were collected and all data were gathered within the scope of the regular teaching evaluations conducted by the Office of the Dean of Studies, approval by Ethics Commission was not required by the medical school.
Data entry was performed automatically using Evasys software (Evasys by Electronic Paper Comp., Dublin, Ireland). The statistical analysis of the raw data was carried out with a licensed version of the IBM software SPSS 19.0 (SPSS Inc., Chicago, IL, USA). Agreement to questionnaire items was determined by adding the two most positive rating levels of the 6-point Likert scale. Data presentation was supplemented by calculation of the median value with range as measure of dispersion and mean values and standard deviation [Table 2]. The comparative analysis of the unpaired evaluation data between the two lectures was done using Mann–Whitney U-test, giving the mean rank sum value. The comparison of the evaluation results of male and female students was also performed using Mann–Whitney U-test, with a level of significance of P < 0.05.
| Results|| |
The majority of enrolled students (n = 320; female: 64.3%; male: 35.7%) participated in the basic curriculum (winter 2012–2013: n = 297 [92.8%]; winter 2013–2014: n = 278 [86.9%]; and winter 2014–2015: n = 230 [71.9%]). So far, there have been 1335 participants in the basic gender curriculum and 39 students who gained their certificate for the additional key qualification in gender competence.
Cumulative evaluation results for both lectures on gender
The two lectures on gender (L-1: Anatomy – phenotypic sex differentiation and L-5: The good doctor – gender medicine and gender in medicine) were evaluated by a total of 321 students, of which 71.7% (n = 231) were female and 28% (n = 90) were male, giving a response rate of 50.2%.
Three-quarters (75.5%, n = 237) of participants agreed that there was a good overall structure to the lecture. Likewise, a large majority indicated that the slides shown during the lecture were clearly marked with the gender logo or made apparent through the master slide, and that more than 60% of the slides shown dealt with gender-/sex-specific issues (88.4%; n = 275). However, only 66.9% of the participants claimed that the acquisition of gender competence was clearly recognizable as a learning objective.
The lecturers appeared to have been well prepared according to the participants (83.5%; n = 300) and gave the lecture a lively structure with practical references and examples (85.5%; n = 271). However, only 59.7% (n = 192) of the students felt motivated to grapple with gender-/sex-specific learning material. Even lower were the percentages of those who stated that they learned a lot of new materials on gender-specific issues (51.7%; n = 166) or believed that the curricular content was relevant to their future professional activities (55.7%; n = 179).
Only 53% (n = 169) of the participants had the impression that discussions on gender-specific material were encouraged during the lecture. According to the opinions of those surveyed, the lecturers were less explicit in pointing out the necessity of using gender neutrality in German - a language with grammatical gender (40.4%; n = 125), but the instructors themselves did mainly use language in a way that included both genders equally (65.4%; n = 207). Student assessment indicated that the scientific references in the teaching materials used by the lecturers were made mostly without mention of a scientist's sex (39.7%; n = 129), images of men and women were equally frequent and meaningfully presented (73.9%; n = 233), and presentations of stereotypical role models were avoided for most of the part (59.7%; n = 190).
The majority of students indicated that they had learned to recognize gender stereotypes in the medical profession (67.4%; n = 217), to even critically question them (68.3%; n = 219), and to take the sociocultural factor of gender and sex in their profession into account (70.4%; n = 221).
Comparison of the evaluation results of the gender lectures in the 1st and 5th semesters
The gender lecture for the 1st semester students (L-1) was evaluated by a total of 205 students (64.1%; female (f): 71.2%; male (m): 28.3%). In contrast, L-5 was evaluated on a voluntary basis by only 126 students (36.6%; f: 72.6%; m: 25.4%). A comparison in the evaluations of the students at the first and fifth semester levels is shown in [Figure 1].
|Figure 1: Comparison of the evaluation data between the 1st and 5th semester students. Illustrated are each item's average Likert scale score and its standard deviation for L-5 and L-1. Data are listed in the same order as in Table 2|
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In summary, 88.2% of the students were able to discern a good overall structure in L-1, while this was only seen by 55.2% of those who attended L-5. While 73.5% of the 1st semester attendees still felt motivated to deal with gender-specific issues, this significantly fell to only 35.9% of those in the later semester. Likewise, 70.3% of the beginning students responded that they had even learned a lot of new materials, while among the students beginning their fifth semester, only 18.8% shared this opinion. This trend continued to be visible in the evaluation of the relevance of gender-/sex-specific curricular content to later practice of medicine: this statement was positively rated by 60.5% of the 1st semester students and by only 47.4% of the 5th semester students.
Only 28.5% of the 5th semester students evaluated the sequencing of the longitudinal gender curriculum as positive and thus significantly differently as the beginning students (65.4%). The students from L-1 rated that the instructors presented the lecture's material as significantly more lively than those who attended L-5, but in both lectures, the subject matter was presented quite often with less encouragement to hold discussions (L-1: 56.1% vs. L-5: 45.6%).
According to students' opinion, the curricular material was imparted in both lectures using German in a way that treated both genders equally (L-1: 64.4%, vs. L-5: 67%). Nevertheless, the 5th semester student assessment indicated that the necessity of using gender-inclusive language was pointed out significantly more clearly than that of the 1st semester students (L-1: 32.7% vs. L-5: 46.1%).
Open-emded responses by the students on L-1 expressed a wish for better introduction to the topic of gender since many purported that they still did not fully grasp what gender competence was. Comments on L-5 evaluated the material presented as self-evident, not particularly exciting, already known or marked by feminism. The students voiced a desire for more practical examples and advice.
Comparison of the evaluation results of male and female students
It was clear that female listeners in both lectures rated all items equally or more positively than male participants [Figure 2]. The greatest difference between both subgroups was in the perceived relevance of gender-/sex-specific content to medical profession (P< 0.001). In both lectures, women found that the gender-specific content of each lecture was significantly more relevant to their future occupation than the men did (f: 62.4%, m: 36.7%). Female students in both lectures rated the item asking whether the instructors organized the lecture in a lively manner noticeably more positively than male students (f: 86.5%, m: 76.6%). In addition, in both subgroups, a significant difference was noted concerning learning outcome shown by evaluation results of items 17 and 18. Female students agreed more often that they learned to scrutinize gender stereotypes and to consider gender as a sociocultural factor in their medical profession than males (P = 0.03 and P = 0.001). The results for the items above became also obvious when viewing lectures and student cohorts separately [compare [Table 3].
|Figure 2: Comparison of the evaluation data between male and female students in both gender lectures. Illustrated are each item's average Likert scale score and its standard deviation of female and male students. Data are listed in the same order as in Table 2|
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| Discussion|| |
Gender issues were integrated into our medical school's curriculum in an interdisciplinary and longitudinal manner without an increase in class hours. The findings of this pilot study detected that most students agreed that lectures were well organized although less than half of the students surveyed stated that they had learned new material or found the gender-related content to be relevant to their medical work. Noticeably, the overall level of acceptance was lower among students in their 5th semester and among male participants.
It is a weakness of our curriculum that it only imparts primarily gender knowledge mediated in a lecture format, wherein students do not have the chance to interact or extensively discuss their views. Firmly, changing the attitudes should be a goal for the future development of our gender curriculum. However, overall at our university, this was the best strategy to begin integrating gender issues.
This study involves only a cross-sectional investigation at one university. Only evaluation data on two specific lectures, not yet the whole gender curriculum, were analyzed. Our data mirror the students' attitudes toward these lectures specifically and not their actual gender competence. In addition, it must be taken into account that we looked at evaluation data of two nonstandardized lectures held by different lecturers. Lecturers were comparable in their teaching expertise but of different sexes, which by itself can cause a gender bias affecting student attitudes.
Response rates of evaluation data for L-1 and L-5 differed markedly. This might be explained by the fact that students participated completely voluntarily in our questionnaire, but in the end, study results gained from only a third of the 5th semester students cannot be extrapolated unconditionally to the complete cohort of students.
The overall more negative evaluation by the students in their 5th semester might be explained in part by their generally more critical attitude; they implicitly considered the relevance of specific course content to their impeding examinations and were, after just completing the preclinical phase of the study, particularly interested in receiving relevant clinical input with many practical tips. This might be also reflected in the lower evaluation response rates of 5th semester students.
Scarcely, half of the participants felt that gender issues are clinically relevant to their future occupation, which agrees with an earlier study  that describes the sense of gender issues in medical education as being “important and interesting” but also as “relevant with doubts.” It should be debated whether the decrease in acceptance seen here–in case it could be confirmed as a longitudinal effect–is subject to similar influences as they have been described already for other social competencies and attitudes of physicians.,,
Acceptance of gender in medical education was higher among female than male students. Accordingly, addressing gender issues is more likely to meet the needs of women, while men more often show irritation  or very possibly perceive the content as being colored by politics or feminism. This attitude could be a possible explanation for lower response rates of 5th semester male students as well. Our evaluation results are consistent with the results of Lee and Coulehan who point out that women have a more positive perception of the relevance of sociocultural factors such as gender and race than men.
Difficulties in implementing gender curricula
Integrating gender issues into undergraduate medical education was complicated at our university as policymakers showed low or hardly any inherent interest in doing so. Therefore, a strong project leader who takes a strong hand in initiating the process is indispensable for a successful implementation of a gender curriculum. Like prior studies, we found that mostly male instructors and policymakers viewed gender issues as important but of low priority.,,, Thus, an important prerequisite for the implementation process was the outright support of medical school policymakers and the stringently top-down management exercised by the Office of the Dean of Studies, particularly for mastering the challenges of interdisciplinary course organization. Obviously, hurdles of our after-the-fact implementation process could be avoided when ongoing curriculum reform processes consider the inclusion of gender issues up front.
Unfortunately, this project was primarily initiated by committed female teachers as has happened elsewhere. For this reason, Westerståhl et al. demand that male faculty members should participate more actively in the implementation process. They would act as role models for male students to emphasize the relevance of gender issues and to diminish a possible evaluation bias.
Unfortunately, during this project, we were not yet successful in including all the clinical departments (e.g., internal medicine, rheumatology) in the design of the gender curriculum, particularly disciplines with a historically low percentage of women. For future developments, it might be advantageous that instructors get easy access to gender knowledge and gender science platforms to be enabled to teach gender content appropriately. In addition, an attractive incentive system could encourage them to participate more actively in gender curricula. For successful implementation of gender curricula, it is necessary to clearly define educational objectives, to regularly monitor the curricula for their effectiveness (for instance through testing), to promote interdisciplinary discussion about gender knowledge among faculty members, and to offer sufficient educational programs.
We experienced a new aspect demonstrating that students–in particular male students–do not as a matter of course accept the integration of gender issues, and we feel that educators elsewhere should also expect resistance. Therefore, it is more important to include gender issues in the main curriculum and to cover them on subject-specific examinations because students primarily measure the relevance of course content in terms of its relevance for tests.
| Conclusion|| |
Despite some resistance, we were able to familiarize students with gender issues. In the future, the longitudinal organizational structure of the curriculum should be expanded and crucial disciplines such as internal medicine should be recruited to participate. As a next step, students' gender knowledge should be included in their examinations before actually evaluating the gender curriculum in a longitudinal manner. In the second step, we hope to transfer gender knowledge into actual gender competence which will have to take place during the students' medical practice outside of the lecture hall. Our school currently lacks a curricular structure to do so. Our evaluation has also uncovered aspects of the hidden curriculum that should be addressed by educational programs and trainings for teachers. More detailed investigations of the longitudinal development of students' attitudes toward gender issues over the course of their studies are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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