BACKGROUND

Almost half of US pregnancies are unintended.1 Women with chronic diseases are at higher risk for complications in the event of unintended pregnancy and seek primary care predominantly with Internal Medicine (IM) or Family Medicine (FM) clinicians compared to obstetricians and gynecologists (OB/GYNs).2 Additionally, a subset of women may prefer having reproductive health services in IM or FM settings compared to specialty settings.3 Thus, prevention of unintended pregnancy is an essential element of comprehensive primary care provided by general internists.

Long-acting reversible contraceptives (LARCs), including intrauterine devices (IUDs) and implants, are readily reversible, highly effective, and increasingly popular among women not desiring pregnancy. These methods are considered safe in the setting of many chronic medical conditions and are recommended as first-line contraception in appropriate patients.4,5 However, placement and removal of the device into the uterus (IUD) or arm (implant) requires an in-office procedure with a trained clinician.

Despite the importance of contraception in primary care, most IM clinicians are not prepared to provide LARC counseling, placement, or removal. While contraceptive training is standard for FM and OB/GYN physicians, prior studies show that IM physicians have inadequate training in contraceptive counseling and procedures.6,7,8,9 LARC training has been associated with the intention to provide or provision of these services by FM, OB/GYN, and general practice clinicians, and with reductions in unplanned pregnancy rates.10,11,12,13,14,15 To ensure that women who seek primary care in IM settings are offered all contraceptive options when desired, general internists must be prepared to counsel and refer patients for these services, and in some cases, provide LARCs themselves.16,17

In response to these needs to increase comprehensive contraceptive access, IM programs nationally have integrated LARCs into their clinics and residency curricula. To date, Brigham and Women’s Hospital has published a model of a specialized family planning clinic within an IM clinic setting.16 Similar programs have been introduced nationally, but there is no existing literature outlining approaches, barriers, and facilitators. This national, qualitative study examines the factors contributing to successful and unsuccessful integration of LARCs into IM clinics and resident education.

METHODS

Overview

This qualitative study used inductive thematic coding to analyze the experiences of IM faculty who have integrated or attempted to integrate LARCs into their clinics and residency education. This study was approved by the Institutional Review Boards at the Pennsylvania State University and Boston University Medical Center.

Goal/Objectives

This study describes existing programs that have successfully or unsuccessfully incorporated LARCs into IM clinics and residency education. We report the (1) approaches to integrating LARCs into IM clinics and resident education, (2) advantages and disadvantages of different approaches, and (3) barriers and facilitators to implementation.

Participants, Eligibility Criteria, and Recruitment

Eligible participants were a convenience sample of clinicians (physician or advanced practice clinician) working in IM clinics at US academic institutions who independently performed LARCs following residency/fellowship training. Participants could be prior or current LARC providers and/or teachers at the time of the study who had implemented or attempted to implement LARC training for residents in their IM clinic. We included faculty who were unsuccessful in attempts to incorporate LARCs to capture their encountered barriers.

We identified eligible participants through (1) personal communication with known LARC providers, (2) a list of LARC providers compiled by a study author (MS) from the Society of General Internal Medicine (SGIM), (3) online messaging to the SGIM Women’s Health Education Interest Group, (4) a published women’s health residency directory, and (5) snowball sampling from interviewed faculty.18 Through these sources, we identified potential key informants from 31 institutions who were emailed to confirm if they met eligibility criteria. Faculty from 7 institutions were excluded (2 because all eligible faculty were involved in this study and 5 due to lack of attempted LARC training for residents in their IM clinics). Faculty at an additional 3 institutions were non-responders (eligibility undetermined). The remaining 21 eligible faculty, each at a separate institution, were invited for an interview. Fifteen faculty completed interviews and 6 did not.

Instrument Development

The research team developed a semi-structured interview guide prior to study initiation focused on participants’ approaches and perceived facilitators and barriers to implementing LARCs into clinics and/or residency education (Appendix 1). We developed this guide based upon available literature, the personal experience of study authors (AB, MS, RC, and CP) at six institutions (Brigham and Women’s Hospital, Rhode Island Hospital, Penn State Health Milton S. Hershey Medical Center, Massachusetts General Hospital, Oregon Health & Sciences University, and Boston Medical Center), and informal conversations with additional faculty.16 We asked participants for demographic information about their careers and programs.

Data Collection

Eligible participants were invited to participate in a one-on-one, 45-min, audio-recorded phone interview with one of three study authors (RC, AB, or CP). Non-responders were sent two additional, weekly emails. Consent was emailed and reviewed at the start of each interview. Interview participants were eligible for a $20 gift card.

Data Analysis

We followed the Framework Method for thematic analysis.19 Audiotapes of interviews were transcribed verbatim with all identifiers removed. We then read the transcripts line-by-line to identify relevant codes representing voiced concepts. Three investigators (RC, AB, and CP) independently coded three transcripts and developed the initial list of coding categories by consensus. Additional transcripts were independently coded by the three investigators with modifications to the codebook until an interrater reliability reached a kappa score of 0.7 for three interviews. All interviews were subsequently analyzed using the finalized codebook (Appendix 2) using NVivo 12 (QSR). We then collaboratively developed representative themes using inductive thematic coding. Demographics were reported using descriptive statistics.

RESULTS

Participant and Residency Characteristics

Fifteen IM clinicians were interviewed (14 physicians and 1 nurse practitioner). All participants were female and were on faculty for an average of 5.5 years (range 1 to 10 years). Fourteen performed LARCs in their current clinical practice and 12 taught LARCs to IM residents (9 implants and IUDs; 3 implants only). Participants most commonly received LARC training during residency or fellowship by FM and/or OB/GYN clinicians in longitudinal continuity clinics and/or women’s health electives.

The represented programs were in urban (N=14) and suburban (N=1) settings. Of these programs, 11 had a primary care track and 4 had both primary care and women’s health tracks. The number of IM faculty trained in LARCs per institution ranged from 1 to 5.

Models for LARC Integration into IM Clinical Practice

The main reported approaches to integrate LARCs into IM clinical practice were through (1) a dedicated procedure or women’s health clinic (procedures are scheduled during particular session(s)), (2) integrating procedures into existing clinical time (procedures are scheduled during any available slot with LARC provider), or (3) an interdisciplinary IM and OBGYN/FM clinic (clinicians from multiple departments work in the same space). Each model has different advantages and disadvantages from a clinical and educational standpoint (Table 1), and efforts to balance the needs of both patients and residents were a common theme.

Table 1 Advantages and Disadvantages of LARC Integration Models into IM Clinical Practice
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Models for LARC Integration into IM Residency Curricula

Most of the 12 programs that were teaching LARCS to IM residents used a curriculum model that incorporated a mix of educational modalities, with opportunities based upon resident interest and the desired goals and outcomes for the program (Table 2). Educational modalities included manufacturer implant training, simulation workshops, didactics, electives, and second site/longitudinal clinics. All represented programs trained residents in IM clinics, with half providing additional experiences in external clinics (OBGYN/FM/family planning). Programs that aimed for trainee exposure to comprehensive contraception counseling had all residents rotate through a clinic with LARCs at least once (N=2). Programs aiming for proficiency in LARCs by graduation offered experiences with a higher volume of procedures for few residents (N=5). Multiple outcomes were possible with a tiered model that offered a baseline experience for all residents and elective experiences for residents with more interest (N=5).

Table 2 Curricular Models Including LARCs Based upon Desired Outcomes
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Most programs did not assess procedural proficiency in LARCs (N=8). The remaining programs used direct observation (some using a rubric) and/or resident self-assessment of skill. The goal number of insertions and removals ranged from 3 to 30 for implants and 7 to 40 for IUDs. No programs used measures for program evaluation or clinical outcomes.

Three programs had at least one resident who provided LARCs independently following graduation. These programs had been training residents in LARCs for 4 to 10 years. All three of these programs focused on training a small number of residents with a high volume of LARCs through longitudinal clinics and/or electives and offered opportunities inside and outside of IM. Two of the three programs had an integrated IM/GYN clinic with at least four IM faculty available for precepting. All three of these programs had primary care tracks and two had women’s health tracks.

Barriers and Facilitators to LARC Integration into IM Clinical Practices and Residency Curricula

Barriers and facilitators to integrating contraceptive procedures into IM clinics and residency curricula involved process considerations (Table 3) and stakeholder perceptions (Table 4).

Table 3 Barriers and Facilitators to Integrating LARCs into IM Clinical and Educational Settings
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Table 4 Participant Identified Stakeholder Perceptions about LARCs in IM Clinical and Educational Settings
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Process considerations were clinical, educational, or both (Table 3). The most commonly cited clinical facilitators were ease of access to equipment and efficient workflows. Main educational facilitators included having a curricular or assessment model to reference. Procedural volume and credentialing considerations were important to maintain the skills of existing preceptors and to train new clinicians. Participants recognized having connections from an outside department as a facilitator across multiple process categories.

LARC integration in IM required support from multiple stakeholders including patients, residents, clinicians, and leadership (Table 4). Some participants had the benefit of an advocate, while others felt alone in the process of navigating competing professional, clinical, and educational obligations. Participants varied in their approach for support, some seeking buy-in from their wider institution, while others focused efforts on their direct leadership. Participants reported that multiple stakeholders showed disinterest in LARCs or perceived that these procedures were not within the realm of IM. Importantly, patient preference for the location of LARCs was cited as both a facilitator and barrier.

Participants Not Teaching Contraceptive Procedures to Residents

Three participants were not teaching LARCs to IM residents, with two still providing LARCs in their clinical practice. One participant worked in an adolescent medicine clinic which focused on training fellows only to preserve training volume. In another program, residents did not perform IUDs due to concerns about exam skills. The remaining participant cited a lack of administrative support and easy patient access to OB/GYN.

DISCUSSION

This study examined the experiences of 15 IM faculty in integrating or attempting to integrate LARCs into their clinics and residency education. The model for this integration at each institution depended upon clinical resources, patient needs, stakeholder support, and educational goals. While programs took different approaches reflecting these factors, successful LARC integration filled a patient care need and benefitted from individual champions and institutional support. Programs that successfully trained residents for independent LARC practice focused on high-volume training for a small number of residents. Even in successful programs, defining and achieving LARC proficiency remained challenging.

We recommend that IM faculty who are building LARC training opportunities consider the following questions regarding clinical needs, stakeholder support, and educational goals in considering which models are the best fit for their program:

  • Assess clinical needs and resources:

  • Are patients satisfied with current access to LARCs in your healthcare system?

  • Do you have access to the resources necessary to provide high-quality LARCs in your clinic?

LARC integration into IM clinics may not be appropriate or feasible in all contexts. When patients have easy access to LARCs outside of IM, there may not be a care gap to fill. Patient preference is also an important consideration, as some patients may prefer coming to their IM clinician’s office for these procedures. IM clinicians offering LARC must provide high-quality care comparable to clinicians in FM and OBGYN; this care depends not only on clinician expertise, but also appropriate equipment and workflows (Table 3).

  • Recruit support from stakeholders:

  • Who are the “champions” of LARCs at your institution?

  • How could you build support to provide LARC training?

Successful implementation of LARC into IM practice and education requires a “champion” who deliberately seeks stakeholder support. In this study, “champions” were either faculty or trainees and required support from multiple levels of stakeholders (Table 4). While some study participants were fortunate that their priorities were shared by leadership, this was not universal. Reported approaches in building support included seeking funding for education innovations, building a reputation as a women’s health expert, and developing reciprocal relationships with other departments. We highlight that there may be a gender gap in these “champions”; this is an opportunity to promote awareness of reproductive health and engage diverse supporters.

  • Describe goals for resident education in LARCs:

  • What should your residents know about LARCs by graduation?

  • How will you determine the success of your program?

The design of a curriculum in LARCs should realistically reflect desired learner outcomes, available educational resources, and a locally appropriate balance of patient and learner needs. While educational models that focus on a high volume of procedures for a few residents can lead to proficiency in LARCs by graduation, this model may not allow for LARC exposure to all residents (Table 2). A tiered educational model with limited, required experiences for all residents and additional elective opportunities provides the most flexibility, but is logistically challenging and requires a high volume of available LARC opportunities. The programs that provided the highest volume of LARCs combined experiences in IM and outside clinics, allowing for dedicated opportunities for residents in IM clinic without competition from other trainees, along with more clinical exposure than is possible in IM alone (Table 1).

Assessment of procedural proficiency was recognized as a challenge in this study with participants reporting varied assessment measures, procedure tracking, and credentialing requirements. Multiple participants desired more shared and standardized assessment resources.

Limitations

This study may not fully capture the barriers encountered by clinicians who were unsuccessful in integrating LARCs. While each of the three unsuccessful participants in this study encountered distinct barriers, these barriers overlapped with those reported by other participants. Experiences in integrating LARCs may differ in non-academic or suburban/rural settings not captured by our sampling. Because data was de-identified, we had limited ability to draw associations between program type and/or setting and optimal training models.

Conclusion

Integration of LARC into IM practice and education has been successfully achieved in a limited number of programs. What are the next steps and resources needed for more widespread LARC integration in IM? One participant called upon national societies to make published guidelines for LARC integration specific to IM. While recommendations are available from OB/GYN and FM, these do not address the barriers to incorporating LARCs into a system where these procedures are not currently offered. Standardized recommendations are likely not realistic given the complexity of culture, inter-departmental relationships, and resources at each institution. There are areas, however, where we can work together. We can create or join existing networks of LARC providers to facilitate practice and troubleshoot barriers, such as the Reproductive Health Access Network.20 Assessment rubrics can be shared across institutions and adapted from national programs, such as the Reproductive Health Education in Family Medicine (RHEDI) program.21 By understanding the potential approaches, barriers, and facilitators, IM clinicians can determine if the introduction of LARCs is needed and feasible in their program. While not one approach will fit all, LARC provision is important to meet patient and trainee needs in certain IM clinical and educational settings.