Women's Health

The 1990s have witnessed growing interest and activism devoted to women's health issues. Although individual women have always been concerned about problems and issues they face in trying to maintain their health and obtain the care they need, it is only recently that enough women have secured political and medical leadership roles to be able to influence important health care policy decisions. Traditional medical education has focused on the "70 kilogram male" model and has excluded female subjects from clinical trials, therefore it is not surprising that the unique ways in which various conditions, diseases, and medications affect women are only recently coming to be addressed and understood. For example, because women as a group outlive men, they are much more likely to suffer from the chronic and degenerative conditions of old age. It is especially important to study how these conditions, such as dementia, affect women.2

• Do the primary care fields of general internal medicine or family practice cover the comprehensive primary care needs of women, or should women's health be designated as a separate specialty?
• Do obstetricians/gynecologists fulfill the primary care needs of women? Should ob/gyn be designated as a primary care field?
• How can physicians-in-training work to improve medical education on women's health and overall care for women in general?

In addition, there is much debate over who is most qualified to provide primary care for women. Some even support the creation of a specialty in women's health. While academia, physicians, and politicians debate, however, women are trying to get the care they need. Furthermore, because they lack insurance, many more women than men cannot access the healthcare system.2,3 A 1993 survey showed that 36% of women were uninsured during the last year as compared to 23% of men, and that 13% of the women did not get the care they needed as compared to 9% of the men.3 The effects of managed care on women's health are yet to be seen; many women hope it will increase access to the preventive services important to keeping women healthy, such as mammograms, blood pressure screening, and prenatal exams.

STUDENT ORGANIZERS GUIDE
This Project-in-a-Box is designed to be used as a tool to generate interest in the major educational, policy, and research issues surrounding primary care for women. Along with an update on the current situation in women's health and a brief history of the women's health movement, you will find ideas for activities to plan at your school, as well as suggestions for how students can learn more about the issue and work to improve medical education on women's health. There is also a current article on the debate over making women's health a specialty.

To find speakers, contact the departments of family medicine, internal medicine, and obstetrics and gynecology in your school or in other institutions or health-care facilities nearby. Also, see the Resources section at the end of the Box for a listing of many local and national organizations devoted to promoting women's health issues and research. Many of these organizations can suggest national speakers and might know of women's health experts in your area.

Activity and Speaker Suggestions

• Ask interested students to read the Box and article and come for an informal discussion or simply copy the materials and distribute them to students in your school.
• Invite a practicing generalist physician with a special interest in women's health who sees many female patients to come share personal experiences and opinions.
• Invite an obstetrician/gynecologist, internist, and/or family practitioner who has definite views about the issue of women's health to discuss the topic: who is best prepared to serve the primary care needs of women. Or sponsor a debate discussing "making women's health a specialty."
• Invite a physician who works in a women's health center to discuss the care provided in such a center and the rationale behind providing healthcare to women in this type of setting.
• Ask a physician involved in planning your school's curriculum in women's health (if there is one) to meet with students and discuss the parameters and purpose of the program.
• Invite female patients from different backgrounds to discuss challenges they have faced accessing the health care system and finding good, comprehensive care.
• Invite education or government policymakers who are particularly active and interested in women's health issues to address women's health from a policy standpoint.
• Create a panel discussion; invite several of the physicians, policymakers, and healthcare workers listed above.

Remember that for any kind of activity you plan, providing food is a great way to boost attendance. If you don't want to plan an elaborate dinner, try something as simple as pizza!

Key Questions on Women's Health

• The following list contains some hotly debated and still unresolved questions relating to women's health, primary care, and medical education. Choose some of them to send to your speakers ahead of time, or use them to generate discussion/debate during your planned activity.
• What are the challenges you face as a physician in trying to provide comprehensive care for women?
• What do you feel are the strengths and weaknesses of the different primary care fields in terms of being qualified to provide comprehensive care for female patients? Do you have strong feelings about physicians in one field being more qualified to provide this care?
• How does medical education need to change to ensure that one or all of these types of practitioners can address the full spectrum of women's primary care needs?
• Where should ob/gyn fit into the primary care picture?
• Are ob/gyn residencies changing to prepare these physicians to provide better primary care? Do OB-Gyns want to be primary care providers for women?
• How can internists and family practitioners be better trained to incorporate reproductive services and reproductive screening tests into their practices?
• What are the most important facets of education on women's health that should be incorporated into the first- and second-year medical school curricula? How can medical students work with schools to make sure that they are incorporated?
• Will the increasing number of women medical students, many of them interested in providing care for women, put increasing pressure on medical schools to reform women's health curricula and training opportunities?
• How will the growing number of women physicians change primary care for women?
• What are the advantages and disadvantages to care provided through women's health centers?
• How is managed care affecting health care for women?

Suggestions for Follow-up
You may want to plan time for a follow-up activity at the end of the discussion and conduct an informal poll to find out what students think about these issues. For example, find out: how many students think ob/gyn should be considered primary care; how many think women's health should be a specialty; and for those who don't think it should; which type of primary care physician should be responsible for providing comprehensive care to women. In addition to the poll, using the suggestions from this module, you can discuss how interested students can become more active in promoting medical education and policy reform related to women's health. See the section at the back of this Box on "What Can Students Do To Get More Involved?"

An Overview of the Issues
In their Fifth Report, "Women and Medicine: Physician Education in Women's Health and Women in the Physician Workforce," published in July 1995, the Council on Graduate Medical Education (COGME) found that "Women have difficulty receiving comprehensive and coordinated care as a result of deficiencies in physician training and fragmented care...Physicians as primary care providers should have a broad understanding of issues relating to women's health."2 Yet there is much debate over who is most qualified to provide primary care for women - family practitioners, internists, or obstetrician/gynecologists. Some think the best way to ensure comprehensive care for women is to create a specialty in women's health. Others suggest that all primary care physicians should be trained to accommodate the health needs of women since they make up slightly more than half of the total population. It is not likely that consensus around these issues will be reached soon, yet it is clear that medical education must be reformed to include specific training in women's health issues. Medical students should help lead the reform.

The simple fact is that women now occupy more than 50% of the slots in some freshman medical school classes. These women medical students should push for more time and attention to be devoted to teaching about gender-specific differences of disease progression and health maintenance.1 This is important because female medical students seem to be more likely to choose the primary care fields. According to an Association of American Medical Colleges survey in 1994, 30% of female medical school seniors planned to practice generalist medicine (general internal medicine, general pediatrics, or family medicine) as compared to 18% of the male seniors.5 There is already some evidence suggesting that the gender of the doctor makes a difference in the level of care provided to women, especially with regard to preventive care services such as Pap tests and mammograms.4

Because the current system is not meeting womens' needs, health professionals and the public are calling for changes in the health care system and in medical education. Practicing physicians are flocking to continuing education classes focusing on specific women's health needs. More permanent changes, however, have to come at the undergraduate and graduate medical education levels. Some medical education and training programs are building comprehensive programs in women's health, yet others still lag far behind without any plans to implement a such curriculum.

Women's Health Movement Milestones: How did we get to this point?
Within the last decade, women's health issues have worked their way from the back page to the front in terms of the amount of attention they generate. This recent women's health movement, which is still gaining momentum, has its roots in a movement which started in the 1960s. That earlier movement focused on the "paternalistic attitude of medicine" and concerns over health information not being readily available to women. Responding to the movement's pressure, the Boston Women's Health Collaborative produced Our Bodies, Ourselves in 1973, covering the functioning of the woman's body and encouraging women to take responsibility for their own healthcare.1 The 1973 decision to legalize abortion served as another catalyst to the women's health movement, again emphasizing women's responsibilities and choices about their health.

In 1977 women's health took a giant step when, with less than 20 female members in Congress, the Congressional Caucus for Women's Issues was established. Women in powerful leadership positions were ready to make women's health a priority. During that same year, however, the Food and Drug Administration decided on a policy that would not allow pharmaceutical companies to include pregnant women, or women who were potential childbearers, to take part in drug trials. This policy set the precedent for women to be excluded from health research both physically and theoretically.1 Instead of studying men and remaining mindful that women might be affected or react in different ways, the woman's body was disregarded, as if either it did not exist or had changed to resemble the man's.

Women researchers began to point out that although women were dying of cancer and heart disease at the same rates as men, they were not being studied. The Congressional Caucus for Women's Issues urged the federal government to take action. In 1983, the U.S. Public Health Service formed a task force to investigate the status of women's health. The report from the Public Health Service Task Force on Women's Health, released in a 1985, proved that the current, inadequate system of healthcare for women was caused by inattention given to women's health in the past in both research and practice. Based on the findings of this report, the National Institutes of Health (NIH) announced a policy encouraging the inclusion of women in clinical research. However, it took five years, an investigative study by the Government Accounting Office, and more urging from the Congressional Caucus on Women's Issues, until the NIH put their self-proposed policy into practice.2 The 1985 report also emphasized the importance of preventive health services for women and defined women's health issues as "diseases or conditions that are unique to or more prevalent or serious in women, have distinct causes or manifest themselves differently in women, or have different outcomes or interventions."6

Finally, in 1990, the NIH established the Office of Research on Women's Health (ORWH) to take responsibility for establishing policy and promoting research on women's health. The ORWH is also works to increase the number of women in biomedical career.2 At about the same time that the ORWH was established, Dr. Bernadine Healy became the first woman director of the NIH and launched the Women's Health Initiative, a fifteen-year, $628 million study, that focuses on 163,000 postmenopausal women. It studies the prevention and causes of heart disease, breast and colon cancer, and osteoporosis.1 Some of the early leaders of the women's health movement are working on this study, a prevention document unprecedented in the U.S. both in size and in scope. They hope that the results will shepherd lasting changes into medical education. In 1993, Congress passed the NIH Revitalization Act, a law mandating ORWH and requiring NIH studies to include subpopulations, including women and minorities. Other important advances include Dr. Joycelyn Elders, the "controversial and outspoken" first woman surgeon general hired and fired by President Clinton, who made her mark as a strong female leader in healthcare policy.7

In 1992, COGME identified 42 essential training components to prepare physicians to provide comprehensive care to women.1 In 1993, Congress asked the Department of Health and Human Services to study women's health and how it was addressed in undergraduate medical education. HHS studied medical school curricula and recommended changes. Most medical schools do not have comprehensive programs in women's health, but many are changing as the women's health movement gains more momentum.2

What is Women's Health?
The fact that women's health needs have been, and in most places still are, categorized as "reproductive" and "all other" illustrates the problem.2 "Reproductive" needs are perceived as the only needs unique to women. "All other" needs fit into the "regular" system of medicine, which is based on the male body. With this division of women's health, it is not surprising that a fragmented system of care developed. Women's health must be seen as a holistic concept that includes all biopsychosocial aspects of the woman's being.

Beyond gynecologic and obstetric needs, many conditions and diseases affect the woman differently the man. Although some health issues are the same, men and women often face them at different points in the life cycle and experience different physical and psychological responses. This chart shows when these basic health issues that affect women:

A Lifespan Approach to Women's Health Issues 2

Birth to Adolescence

• Developmental issues: physical, sexual, psychosocial
• Injuries
• Suicide
• Chronic disease or disability
• Sexual abuse

Ages 15-44 Years

• Breast and reproductive tract cancers
• HIV infection
• Risk-taking and health behaviors
• Substance abuse
• Eating disorders
• Reproductive health
• Autoimmune disorders
• Mental disorders
• Injuries
• Interpersonal violence

Ages 45-64 Years

• Chronic disorders
• Menopause
• Life cycle transitions
• Cancer

Ages 65 Years and Older

• Chronic and degenerative conditions
• Social isolation

Although the "basic diseases of man are the diseases of women," the gender-specific responses and issues related to those general conditions are only recently starting to be studied and understood.8 For example, because estrogen seems to provide some type of protection in the woman's body before menopause, the onset of heart disease occurs ten years sooner in men than in women.2 Although there is often a tendency to look at it in a vacuum, the woman's menstrual cycle affects, or is affected by, many different health conditions and has a great influence on the total health of a woman. The menstrual cycle affects how drugs react in the woman's body, and certain conditions, such as asthma, are known to intensify or ameliorate at specific times during the menstrual cycle.8 Women live longer than men overall, but during most of their lifespan they make more visits to physicians and "experience more acute and chronic conditions".2 See the attached article, "Women's Health: Should It Be a Specialty?" for a more in-depth discussion of the biological and physiological differences between men and women.

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Women's Health is devoted to facilitating the preservation of wellness and the prevention of illness in women and includes screening, diagnosis, and management of conditions which are unique to women; are more common in women; are more serious in women; and have manifestations, risk factors or interventions which are different in women. It also recognizes the importance of the study of gender differences; recognizes multidisciplinary team approaches; includes the values and knowledge of women and their experience in health and illness; recognizes the diversity of women's health needs over the life cycle, and how these needs reflect differences in race, class, ethnicity, culture, sexual preference and levels of education and access to care; and includes the empowerment of women, as for all patients, to be informed participants in their own health care.

(Definition of Women's Health, as accepted by the National Academy on Women's Health Medical Education, September 26, 1994.)

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Factors Affecting Women's Health
Besides the traditional conceptual framework upon which our medical system is based, there are many other factors, i.e. socioeconomic status, demographic shifts, changing family structure and lack of insurance, contributing to the problem of women not receiving comprehensive healthcare.2 Women outnumber men in the older segment of the population and are therefore disproportionately affected by the diseases and conditions of old age. In 1996, there were 13 million men enrolled in Medicare, as compared to 19 million women (Washington Post. January 16, 1996:H6). By 2030, the U.S. Bureau of the Census predicts that Caucasians will comprise only 60% of the U.S. population. Ethnic minority women have a lower life expectancy than Caucasian women and suffer disproportionately from some medical problems.2 COGME also found that, "Because of their socioeconomic status and position in the workforce, women are twice as likely as men to be underinsured for their health care needs."2

Women's Health As a Specialty
Should women's health be a specialty? Proponents of the idea believe it is the best way for women's health to gain the attention it deserves in a system traditionally biased toward males. They want a separate specialty to give women's health a strong foundation to provide training on the specific health concerns of women and advance the women's health research agenda. Opponents are afraid that making women's health a specialty will lead to further fragmentation of the system and perpetuate the philosophy of women as "other". They want to improve care for women by expanding and improving training in the other primary care fields.2

The issue gets further complicated by the debate over which primary care providers are most qualified to provide comprehensive care to women. Some think family practice and internal medicine physicians are best suited to provide that care, while others believe that obstetrician/gynecologists are just as qualified. This leads into the question whether ob/gyn should even be considered primary care. Increased attention to the issue should lead to better training of physicians and improved comprehensive care for women; it will be an empirical change for the better, regardless of one's position in the debate. See the article included with this Box, "Women's Health: Should It Be A Specialty," for a more in depth look at the arguments.

Women's Health Centers
The term "women's health center" started to be used when the women's health movement began in the 1960's and referred to freestanding centers designed by women as alternatives to mainstream healthcare.9 The first of the women's health centers focused mainly on gynecological and reproductive services. The 1993 National Survey of Women's Health Centers estimated that there were 3600 women's health centers in operation with service designations as follows: 71% were reproductive health centers, 12% were primary care centers, 6% breast centers, 4% birth centers, and 6% were "other" various types.9 At this time they found that 7% of U.S. women, 7.8 million women, used women's health centers as their "usual source of care".9 In general, there has not been much research assessing these centers and it remains to be seen whether they can or will become significant sources of comprehensive care for women. What is clear is that women are the prominent leaders and administrators in these centers.9

The U.S. Department of Health and Human Services is currently making an effort to support the "one-stop shopping" type centers for comprehensive women's health care. In the fall of 1996, they selected six academic institutions to serve as National Centers of Excellence in Women's Health including, Allegheny University of the Health Sciences in State University Medical Center, University of California at San Francisco, University of Pennsylvania and Yale University.10 As they strive to provide comprehensive care to women, the sites will conduct projects on education in gender differences in the causes, treatment and prevention of disease; develop a multidisciplinary research agenda; and distribute educational materials to health care providers and the public.10

Six more academic institutions are to be selected as National Centers of Excellence in Women's Health and funding for the initiative is expected to increase. For more information on this program, contact the U.S. Public Health Service Office on Women's Health at (202) 690-7650.

Prevention and Managed Care
Dr. Vivian Pinn, director, Office on Women's Health, National Institutes of Health, outlines women's chief health concerns, "Wellness and how to preserve wellness. Prevention from the standpoint of personal responsibility, as 'Do I eat right? Do I take care of my body? Do I deal with stress right?' Prevention is the key."(New York Times.June 22, 1997)

Everyone seems to agree that preventive care and preventive services are crucial to women's health. And the number of women in all age, racial and ethnic groups receiving these services is increasing, however, large numbers of women are still not getting recommended preventive care.2 According to a study conducted for the Commonwealth Fund in 1993, these percentages of women had not received the following basic preventive care services in the past year:

• Breast exam 33%
• Pap smear 35%
• Pelvic exam 36%
• Complete physical 39%
• Mammogram (women over 50) 33%3

The reasons for women not receiving these services are varied, including inadequate insurance coverage, lack of recommendations from physicians and lack of uniform standards for preventive services.2 It is clear that there is great room for improvement in this area, and it is believed that improving preventive care for women will significantly improve women's health overall. Whether the shift to managed care will help to improve preventive care is yet to be seen; the potential seems to be there. Some believe that the structure of the managed care system has the potential to amend some of the fragmentation of services and lead better comprehensive, coordinated care that includes preventive services. Research so far has brought mostly inconclusive evidence and a great deal more research is needed to determine how the shift to managed care will impact the health of women.11

Developing Better Curricula and Training in Women's Health
In 1993, the American Medical Women's Association (AMWA) and, specifically, Dr. Lila Wallis, who is referred to as "grandmother of the women's health movement", created the Advanced Curriculum on Women's Health.1 The two-part, continuing medical education course, which has been used to re-train many physicians, focuses on conditions and diseases affecting women at all life stages. It addresses both psychosocial and biological effects. Contact AMWA (see the Resources section) for more information.

Women's Health in the Curriculum: A Resource Guide for Faculty was recently published by the National Academy on Women's Health Medical Education (NAWHME), a joint project of the American Medical Women's Association and the Allegheny University of Health Sciences in Philadelphia. This 193-page book details how women's health can be incorporated into any level medical education curriculum. For information contact Glenda Donoghue, MD, at (215) 762-4260 or email to donoghue@auhs.edu

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There is a "current inadequacy of women's health training in medical school education. Because of a lag in research on women's health, and because almost all medical schools use the 70-kilogram male as their model, medical practitioners have gaps in their knowledge about the special health needs of women. Physicians, therefore, are not adequately trained to address the needs of half of our population, which results in poorer quality of care for women and increased costs as some of women's health care needs are misdiagnosed or mistreated."12

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The ORWH published Women's Health in the Medical School Curriculum: Report of a Survey and Recommendations which identifies content areas that should form the core of a women's health curriculum. It recommends that women's health needs start being addressed the first year of medical school. The report also emphasizes that medical students need to understand the patterns that women follow in seeking health care and demonstrate sensitivity to gender-specific differences in making clinical decisions.12

The ORWH report suggests some specific strategies for incorporating women's health into medical school curricula. First, gender-specific information should be incorporated into both the basic science and clinical years of medical school. Second, clinical information should be introduced into the basic science curricula in the preclinical years using newer, problem-based teaching and learning methods. Third, it is important to look at the health issues facing women at different stages in their life span. Fourth, special modules can be developed to address gender-specific issues, such as domestic violence or child abuse. Finally, clinical clerkships can be restructured to provide rotations that cover comprehensive care for women.12 Some medical schools have already developed women's health centers that provide comprehensive care for female patients of all ages (see previous section on Women's Health Centers).

How can students get more involved?

1. Contact your congressional representatives to show support for bills that reform women's health and vote for candidates that support these bills/issues.
2. Contact AMSA's Advocacy Standing Committee on Women in Medicine to find out how you can get involved at the local and/or national level. Call (703) 620-6600, ext. 458, to leave a voicemail message for the coordinators.
3. Get involved in women's health programs already established in the community or start a new program.
4. Contact any of the organizations listed in the resources section and ask them for suggestions. Just recently the Jacobs Institute of Women's Health offered a $1000 manuscript prize for the best submission on developing new models of primary women's health care. It's a timely topic, and there are increasing funds available for research and programs.
5. Join the National Women's Health Network or the American Medical Women's Association and get involved on a national level. The Resources section at the end of the Box contains the contact information.
6. Use this Project-in-a-Box to plan a women's health-focused activity at your school!
7. Review your school's women's health curriculum (if there is one) and make suggestions for changes or lobby to get a women's health program instituted. See "Developing Better Curricula and Training in Women's Health" for resources.

Developing a women's health curriculum in a medical school requires joint efforts of the curriculum committees, representatives from various disciplines, and the student body. To improve healthcare for women, it is imperative that students study women's health issues from day one in medical school, not in just a single OB/GYN clerkship.12

"There is a concerted effort by professional societies, women's health advocates, and others to influence licensing exam committees and those responsible for the accreditation of health professional schools and graduate medical education programs to give more attention to gender issues in curricula and training. . . these issues are especially relevant to the education of the generalist physician and the movement away from specialty medicine towards primary care."13

-Dr. Vivian W. Pinn, director of the Office on Women's Health, National Institutes of Health

Resources

American Academy of Family Physicians

(800) 274-2237

 

American College of Physicians

(800) 523-1546

 

Council on Graduate Medical Education

(301) 443-6190

 

American Medical Women's Association, Inc. (AMWA)

801 North Fairfax St, Ste 400, Alexandria, VA 22314

(703) 838-0500

http://www.amwa-doc.org/

 

Journal of the American Medical Women's Association

AMSA Advocacy Standing Committee on Women in Medicine

(703) 620-6600, ext. 456

 

The Commonwealth Fund Commission on Women's Health

Columbia University

630 West 168th Street, P&S 2-463, New York, NY 10032

(212) 305-8118

 

Jacobs Institute of Women's Health

409 12th Street, SW, Washington, DC 20024-2188

(202) 863-4990

email: jacobsinst@aol.com

http://members.aol.com/jacobsinst/welcome.html

 

The Women's Research and Education Institute

1700 18th Street, NW, Suite 400, Washington, DC 20009

(202) 328-7070

 

World Foundation for Medical Studies in Female Health

405 Main Street, Port Washington, NY 11050

(516) 944-3192/8655

 

National Institutes of Health

Office of Research on Women's Health

Bldg 1, Rm 201, Bethesda, MD 20892

(301) 402-1770

*For more info. on women in biomedical careers, contact Joyce Rudick at the above address

 

National Women's Health Network

514 10th Street, NW, Suite 400, Washington, DC 20004

Clearinghouse (202) 628-7814

journal: Women's Health: Research on Gender, Behavior and Policy

Some publications produced include: Taking Hormones and Women's Health: Choices, Risks, and Benefits, Women and the Crisis of Sex Hormones, and Turning Things Around: A Women's Occupational and Environmental Health Resource Guide, and packets on many other issues.

 

National Women's Health Resource Center

2425 L Street, NW, Washington, DC 20037

(202) 293-604

 

National Women's Resource Center for the Prevention and Treatment of Alcohol, Tobacco and Other Drug Abuse, and Mental Illness

1515 King Street, Alexandria, VA 22314

(800) 354-8824

 

Society for Advancement of Women's Health Research

1920 L Street, NW, Suite 510, Washington, DC 20036

(202) 223-8224

 

National Organization of Women (NOW)

Web site: http//www.now.org/

 

Women Organizing for Change

Web site: http://wlo.org

Additional Women's Health Resources

1. In Her Own Right by Beryl Lieff Benderly. Recently released by the Institute of Medicine. A good guide to women's health issues, this book uses a comfortable, conversational approach to address the above issues plus many more. Call (800) 624-6242 to order it.
2. The New Our Bodies, Ourselves was published in 1992 by the Boston Women's Health Book Collaborative; New York, Simon and Schuster, Inc.
3. The New Physician (AMSA's magazine) published a special issue in March 1995, "Women Add a New Dimension to Medicine," that focuses entirely on issues in women's health and women in medicine. Call (703) 620-6600, ext. 217, to purchase a copy for $5.
4. The Women's Health Information Source Book, produced by the National Association of County Health Officials (NACHO) in June 1994, is made up of a series of information and fact sheets on such topics as adolescent health, addictive disorders, chronic disease, and reproductive health, and focuses on interdisciplinary issues related to women's health. Call NACHO at (202) 783-5550 to request a copy.

REFERENCES

1. Tschida M. Beyond the 70-kilogram male. The New Physician. March 1995:13-22.
2. Fifth Report: Women and Medicine. Rockville, M.D.: Council on Graduate Medical Education; July 1995. U.S. Dept. of Health and Human Services publication HRSA-P-DM-95-1.
3. The Commonwealth Fund. Survey of Women's Health (survey conducted by Louis Harris& Associates, Inc.). July 1993.
4. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women: does the sex of the physician matter? N Engl J Med. 1993;329:478-482.
5. Association of American Medical Colleges' Study (using data from the 1993 Matriculating Student Questionnaire and the 1994 Medical School Graduation Questionnaire). Cited by: Women M.D.s continuing to choose generalist careers in greater percentages than men, AAMC study shows. Health Professions Report. July 3,1995;24:1.
6. Women's Health: Report of the Public Health Service Task Force on Women's Issues (two volumes). Washington, D.C.; May 1985. U.S. Dept. of Health and Human Services publication PHS-85-50206.
7. Tschida M, Durso C. Monitor. The New Physician. March 1995:5-6.
8. Harrison M. Woman as other: the premise of medicine in women's health­should it be a specialty? AMSA Task Force Quarterly. Fall 1995.
9. Weisman CS, Curbow B, Khoury AJ. The national survey of women's health centers: current models of women-centered care. Women's Health Issues. Fall 1995;5:103-117.
10. "Project promotes 'one-stop shopping" for women's health care". Primary Care Weekly. July 21, 1997;3:5.
11. Collins KS, Simon LJ. Women's health and managed care: promises and challenges. Women's Health Issues. Jan./Feb. 1996;6:39-44.
12. Women's Health in the Medical School Curriculum: Report of a Survey and Recommendations. Bethesda, MD: Public Health Service Office on Women's Health; 1996. U.S. Dept. of Health and Human Services Health Resources and Services Administration , and National Institutes of Health publication HRSA-A-OEA-96-1.
13. Butler RN, Collins KS, Meier DE, Muller CF, Pinn VW.Older women's health:'taking the pulse' reveals gender gap in medical care.Geriatrics. May 1995;50:39-49.