Communicating about sexuality: an initiative across the core clerkships

Recently there has been a renewed interest in teaching communication skills in U.S. medical schools. Yet a large number of physicians and medical students may be uncomfortable discussing matters of sexuality with their patients. We have developed a comprehensive, cross-clerkship curriculum for third-year medical students that strives to fill the educational gap concerning a variety of topics in sexuality. The objectives of this project are (1) to increase awareness among medical students that communication about sexuality is central to comprehensive health care; (2) to train faculty to teach students the knowledge, skills and attitudes necessary for communicating effectively with patients about issues of sexuality; and (3) to improve the level of student comfort in discussing sexual issues.

With support from the Josiah Macy, Jr. Foundation (part of the UMass Macy Initiative in Health Communication), and in consultation with clerkship directors, specific topics in sexuality were chosen for inclusion in four clerkships: internal medicine, family medicine, pediatrics, and psychiatry. The family medicine clerkship incorporated a fictional female adolescent into their case-based "standardized family." Faculty were trained to lead their small groups in a discussion of the potentially wide range of sexual behavior in this case study. Supplemental readings were provided and a PDA application is being developed. During the internal medicine clerkship a "difficult interview" session was held. Student volunteers interviewed three standardized patients with sexual issues: a sexually active young woman desiring contraception, a homosexual young man at risk for HIV, and a heterosexual male noncompliant with blood pressure medication due to sexual dysfunction. An HIV counselor was brought in as a discussant. The pediatric clerkship utilized a multimodal format to cover topics pertaining to gay and lesbian youth. Included were a didactic presentation, a videotaped panel discussion featuring two youths and a parent, and a modeled patient interview. The psychiatry clerkship included three relevant interventions: a didactic session around the topic of medication-related sexual dysfunction; a videotaped modeled interview of a sexually traumatized woman; and a session involving a standardized patient-a lesbian whose sexual orientation was not part of her psychopathology. Adjunct activities included a cross-clerkship faculty development session, evaluation components, and a module designed for the staff of a private office. The latter was piloted in the office of a community pediatrician.

Medical students who experienced the curriculum found it valuable. Student self-evaluations, done at the end of each clerkship, indicate increased comfort in dealing with issues of sexuality. During the pediatric clerkships only, half the students received the curriculum while the other half served as a comparison group. The intervention group showed a slight decrease in homophobic attitudes; the lack of a larger effect is likely due to a high level of baseline acceptance and comfort around issues of sexual orientation in this particular medical school class. The pediatric segment will be modified to take this into account and present more advanced topics around sexual orientation and interviewing. The entire curriculum is being incorporated into ongoing clerkships using existing resources at the medical school.