Knowledge and Training of Intrauterine Devices Among Primary Care Residents: Implications for Graduate Medical Education

Nearly half of pregnancies in the United States are unintended, a rate that has increased recently, contrasted with a worldwide decline.1,2 This lack of progress may be due to low adoption of long-acting reversible contraceptives (LARCs). The United States has the lowest rate of intrauterine device (IUD) use of any industrialized country.3,4 Because IUDs have high user satisfaction and effectiveness, increased adoption could lead to reductions in unplanned pregnancies (and fewer adverse outcomes) and prevent abortions.4,5Both in public and private sectors, primary care providers have an important role in preventing unintended pregnancies. Although many women receive contraceptive counseling and services from obstetrics and gynecology (ob-gyn) specialists, a significant proportion see family practitioners, internists, and pediatricians (caring for adolescents) for one or both.6 The National Ambulatory Medical Care Survey is designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States. According to the latest data available from this survey, 11.5 million visits occurred in 2010 for contraception and family planning counseling.7 It is important, therefore, that all provider types be well informed regarding IUDs.A significant proportion of physicians trained in primary care specialties add further training in subspecialties: subspecialist physicians take care of women with complex medical problems that pose a significant risk for pregnancy. Therefore, contraception knowledge is important to medical and pediatrics subspecialists as well. Although the Accreditation Council for Graduate Medical Education requires training in family planning and contraception as part of the core curriculum for internal medicine, pediatrics, family medicine, and ob-gyn residents, structured teaching in the area of contraception is not necessarily a systematic part of this curriculum (box).8Clinician and patient misconceptions are major contributors to the underuse of IUDs in the United States. Some concerns are based on poor evidence; some may be based on truth and simply require additional counseling or information. There is clear evidence suggesting the low knowledge and misconceptions about IUDs among women of reproductive age. Russo et al9 outlined a list of patient-related myths and misconceptions among women regarding IUD usage. These include concerns of pelvic inflammatory disease, future fertility, ectopic pregnancy, weight gain, and others.9 Health care providers play a major role in counseling patients to bust the myths regarding IUDs, but health care providers themselves are not aware of the uses and benefits of IUDs. In addition to misconceptions, additional barriers, such as concern about expulsions, perforation, and delayed return to fertility, prevent primary care physicians from counseling patients about IUDs.10–17With the implementation of the Affordable Care Act (ACA), approximately 20 million women who previously lacked insurance are in the process of obtaining coverage. Most of these women will interface with a primary care clinician who can address contraceptive needs within the context of ongoing medical conditions, highlighting the critical role of the primary care provider in the prevention of unintended pregnancy. The barriers of cost and access to highly effective contraception such as IUD will decrease for many women because the ACA18 requires that most new and nongrandfathered private insurance plans cover a full range of contraceptive services, including IUDs, without cost sharing for women.A Pennsylvania study19 measuring general contraceptive knowledge among primary care residents suggested that, although most view contraception as an important part of primary care, their knowledge bases are inconsistent across specialties. That study did not survey IUD knowledge in particular among primary care residents.19 Even ob-gyn residents seemed to lack knowledge of IUD benefits, as demonstrated in a nationwide web-based survey of ob-gyn chief residents by Tang et al.20 The results of available surveys indicate the need for continued evaluation of primary care residents' knowledge of IUDs as they are the future providers of women's health. This can help residencies determine the need to design appropriate contraception education curricula, which will, in turn, empower future graduates to appropriately advise women regarding contraception options.To understand the knowledge and provision of IUDs among primary care residents, we conducted a cross-sectional survey of residents in primary care residency programs—ob-gyn, family medicine, internal medicine, and combined medicine-pediatrics and pediatrics—at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). We distributed an IUD knowledge survey to 220 residents in 5 primary care specialties. The questions aimed to identify the common myths and misconceptions surrounding IUD use among health care providers. Sixty-six residents participated in the survey for a response rate of 30%. There were significantly more female respondents than male respondents (73% versus 27%). Only about 9% of these residents considered going into private practice, and most wanted to pursue subspecialty fellowships (42%) or academic faculty positions (30%) in the future.Not surprisingly, ob-gyn residents had the highest mean scores compared with other residency program types. All resident responders in ob-gyn and family practice felt comfortable counseling patients about IUDs. This statistic was lower, however, for the other primary care specialties, and only one-half of internal medicine residents felt comfortable counseling patients about IUDs. All ob-gyn responders and 61% of family practice residents felt they could place IUDs in patients. None of the combined medicine-pediatrics residents or internal medicine residents felt comfortable inserting IUDs, whereas only 10% of responding pediatrics residents felt comfortable inserting IUDs in patients. The table shows the comparison of ob-gyn residents and other primary care residents with respect to common myths about IUDs.Although we lack a complete understanding of primary care residents' awareness of IUD myths and counseling practices, available surveys, including our own, demonstrate a knowledge and skills gap, and the need for structured contraception education for primary care residents. Knowledge about contraception methods, especially long-acting, reversible methods, is essential for primary care providers and specialists. Residency programs can survey IUD knowledge of their faculty and residents, and identify existing gaps in knowledge. This, in turn, can help to identify the need to change the curricula for training. Resident training is an important tool with which this provider population can be informed of IUD benefits. Cross-specialty training sessions, grand rounds, and IUD workshops can be organized in training centers to achieve this goal. As leaders in women's reproductive health care, ob-gyn providers need to lead the way to start these collaborative efforts. At UCLA, we have initiated cross-training efforts to improve knowledge of primary care residents in different specialties about contraceptive methods in general, and LARCs in particular. These efforts have been structured as workshops—morning reports centered on contraception in which experts in family planning provide training to primary care residents. The IUD workshops are held for primary care residents in internal medicine and combined medicine-pediatrics. Residents receive didactic teaching about the importance of LARCs, followed by a hands-on IUD workshop. Spreading awareness of the United States Medical Eligibility Criteria for Contraceptive Use, a tool that provides contraception for a medically challenging population published by the Centers for Disease Control and Prevention, is also part of such didactic sessions.Knowledge about IUDs and their provision is key for primary care residents. Graduate medical education should promote structured didactics and training of primary care residents to decrease the unintended pregnancy rates in the United States.