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New research has found notable inconsistencies in how different medical schools approach the teaching of women’s cardiac health, prompting calls for more comprehensive education on this topic.
Ischaemic heart disease ranks as the second leading cause of death among Australian women (here), just after dementia, causing 7340 fatalities in 2021. Despite established links between pregnancy-related complications (such as placental abruption and pre-term birth), sex-specific risk factors (such as early menarche, use of combined oral contraceptives, and early menopause), and increased risk of cardiovascular disease (CVD) later in life, awareness among patients and physicians remains alarmingly low.
A study in the United States revealed that only 22% of primary care physicians and 42% of cardiologists feel extremely well prepared to assess women-specific CVD risk. Furthermore, 71% of women reportedly never discuss heart health with their doctors. This situation highlights an urgent need to boost physician awareness regarding CVD in women.
Despite substantial efforts over recent decades to raise awareness of CVD in women (here), the 2011 Lancet Women and Cardiovascular Disease Commission highlights the troubling reality that women’s heart health “remains understudied … underdiagnosed, and undertreated.” To address these disparities, the Commission recommends several broad strategies for all countries. These strategies focus on educating health care providers and patients about early detection and prevention of heart disease in women. They also emphasise the need to expand heart health programs, particularly in densely populated and underdeveloped areas, and to boost sex-specific research and international collaboration.
Our project emerged in response to an inquiry from the New South Wales Hearts and Heels cardiology roundtable. They questioned the extent and depth of women’s cardiovascular health education in medical curricula across Australia and New Zealand. Our goal is to ensure that future medical professionals are well equipped to recognise and understand the sex-specific differences in CVD.
Exploring the depth of teaching in our medical schools
In our research, we reached out to 22 medical schools across Australia and New Zealand for a survey on the integration of women’s cardiovascular health into their curricula. We identified relevant academics at these schools and reached out to them via email. Each email included a participant information sheet and a link to the Qualtrics survey. This survey, drawing inspiration from the study on dermatology teaching by Gupta and colleagues, was modified to better suit our focus and tested to ensure its relevance and validity.
The data we collected spanned from January to May 2022. We then analysed the responses using Excel, employing descriptive statistics to interpret the findings.
In our study, seven out of the 22 medical schools we contacted participated. Within this sample, three schools included women’s cardiovascular health in their core curriculum and learning outcomes. Additionally, two schools reported its inclusion in their examination blueprint. The subject was taught across a range of disciplines in six schools, including pre-clinical sciences, obstetrics and gynaecology, cardiology, renal medicine, endocrinology, and primary care. These findings align with the Lancet Commission’s emphasis on the importance of multidisciplinary care in managing women’s cardiovascular health.
The participating schools used various assessment methods for women’s cardiovascular health. Two schools incorporated related questions in their examination blueprint. Four others employed alternative assessments such as clinical evaluation exercises (CEXs), direct observation of procedural skills (DOPS), logbook reviews, and oral presentations.
Our study used these assessment modalities as a proxy to gauge the emphasis on teaching women’s cardiovascular health. This approach is based on the well established principle that assessment drives learning. However, it is crucial to note that medical education is a complex field. Examination blueprints often change annually, and our survey may not fully capture these nuances. In addition, there is a challenging balance in medical education between covering a wide range of topics and the limitations imposed by time constraints and the vast scope of necessary medical knowledge.
Implications of our research
Therefore, the primary aim of our study is not to advocate for a separate curriculum for women’s cardiovascular health. Instead, we seek to assess the thoroughness of its inclusion and advocate for its thoughtful integration within the existing framework. Our hope is that this study will establish a quantifiable baseline for future research and heighten awareness about the importance of incorporating this topic into medical education.
However, our study is subject to several significant limitations that must be considered. First, the primary limitation is the small sample size. With only seven out of 22 contacted medical schools participating, our ability to draw broad, generalisable conclusions about the state of women’s cardiovascular health education in Australia and New Zealand is limited.
Second, response and self-selection biases could have influenced our results. There is a possibility that medical schools with poor or extensive coverage of this topic might have been less inclined to respond. Conversely, those schools actively engaged in teaching women’s cardiovascular health might have been more likely to participate. Despite this potential bias, the variability in responses regarding core medical curricula across the surveyed schools might suggest that these biases did not significantly skew our findings.
Another notable limitation is the lack of a clear, standardised definition of women’s cardiovascular health within the survey itself, although a brief description was provided in the participant information sheet. This absence means that each respondent’s understanding of the topic could vary, adding a layer of complexity to the interpretation of our results.
Conclusion
We recognise the inherent challenges in creating a diverse and balanced medical curriculum. Achieving an ideal curriculum that encompasses all necessary subjects is a complex and ambitious goal. Thus, our goal is not to fully revolutionise medical curricula, but rather to raise awareness of this issue and to provide a baseline for further research to be built upon.
Our findings highlight notable inconsistencies in how different medical schools approach this subject. Given the existing gaps in awareness and knowledge about women’s cardiovascular health, these inconsistencies point to a need for more rigorous and comprehensive education on this topic.
By enhancing the teaching of women’s cardiovascular health, we hope to better equip future medical professionals, ensuring graduates are well positioned to address these inequalities in their future clinical practice.
Aphakorn Hasdarngkul is a medical graduate from Western Sydney University.
Shivany Vignarajan is a doctor at Westmead Hospital in Sydney.
Distinguished Professor Annemarie Hennessy is the leader of the Vascular Immunology Group at the Heart Research Institute.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Unfortunately, our models of care for ischaemic heart disease are moving further and further from the general nature of the disease in our population – especially the growing sector of elderly women.
The physician-cardiologist is now less common (especially in urban areas), being increasingly replaced by the proceduralist-cardiologist. Much of the “the time-is-muscle” and “opening-the-artery” approach is based on the older model of the “widow-maker” infarct – an obstructing clot in a large coronary vessel.
In contrast, older women are more likely to have small vessels and multi-vessel disease – these conditions are less well served by artery-opening procedures.
This is just another example of the tendency to shoe-horn the patient into the medical model rather than designing (and rewarding) models of care that match patient needs.
Hopefully these principles can also be taught to our young medical students.
While not diminishing the importance of awareness and education of women’s CVD health risks raised in this article, this is just another symptom (albeit a major one) of the significant variation in quality and coverage of medical education between medical schools in Australia.
Anyone who is involved in teaching and working along side with medical students and junior medical officers for the last 2 decades will realise the vast difference in the length and breadth of their knowledge. While there is admittedly already a wide range of medical graduates from one medical school, from their mastery of facts and their application to their approach and outlook in healthcare provision (due to the variegated background of students in contemporary medical programs), there is also no doubt that each medical school have their own teaching syllabus, with strengths and weaknesses in their content, delivery and retention.
Despite reassurances from the AMC (and Medical Deans) that the accredited programs can “produce graduates competent to practice safely and effectively under supervision as interns in Australia and Aotearoa New Zealand, and with an appropriate foundation for lifelong learning and for further training in any branch of medicine”, I personally do not share that confidence since the rapid expansion of medical training in the early 2000s.
I strongly advocate the need to extend the AMC exams (currently taken only by international medical graduates entering Australian healthcare system) to all ANZ graduates; this will both demonstrate that the standards of the AMC exams like the USMLE apply equally to all doctors wanting to work in Australia as well as ensuring the ANZ medical graduates attain the same minimum standards across the board.
Only then when these threshold are set, then the medical schools and potential graduates have no choice but to well aware of the well-established issues of health inequities by gender and ethnicities