KISSIMMEE, Fla. – The "show and tell" table at this gathering of doctors featured contraceptive sponges and female condoms. Life-size rubber pelvises and female breasts covered several other tables at the back of a windowless convention center ballroom. The lectures focused on topics like how to help a rape victim feel comfortable in an exam room.
Not unusual for a doctors' meeting, but these were doctors and nurse practitioners with the Veterans Affairs Department, a cohort of medical professionals who in the past might have gone years without seeing a female patient. But avoiding topics like gynecology and breast exams is no longer possible because of an influx of thousands of female veterans of Iraq and Afghanistan into the VA's system of hospitals and clinics.
Used to treating the men who served in Vietnam or World War II, many of the VA's practitioners are rusty on skills like performing pelvic exams on women and talking about birth control. Some are downright nervous over treating women.
The result has been very limited availability at some VA clinics for gender-specific health appointments for women. Female veterans often had to drive hours to get to another facility, or the VA had to pick up the tab for them to go to a nearby private doctor — if they opted to go at all.
The VA is working toward having a trained, designated women's provider in every facility. So far, officials have achieved the goal in its approximately 150 medical centers and in at least 60 to 65 percent of its 900 community-based clinics, according to the VA.
The VA has been bringing doctors and nurse practitioners by the hundreds to mini-residency programs like this one outside Orlando, Fla., focused on women's health. A key component of the training is performing pelvic exams on live models — typically volunteer nurses — who critique them.
"What we heard time and time again from providers that have been there so long is, 'I have forgotten since medical school how to do a lot of the women's specific care,'" said Dr. Robert Dorr, chief of staff at the VA medical center in Saginaw, Mich. Providers who will be treating women in smaller VA clinics in Northern Michigan went with him to the seminar in Kissimmee.
"There was anxiety," Dorr said. "There was a lot of nervousness. There was even some fear: 'Would I be able to take care of a female appropriately?'"
In addition to exams on live models, the providers practiced breast and pelvis exams on large, lifelike rubber simulators with abnormalities that doctors need to be familiar with.
One topic was care for patients who have been sexually assaulted. An estimated 22 percent of female users experienced what the VA calls "military sexual trauma," meaning they endured unwanted sexual harassment, assault or rape in a military setting. The providers learn tips like washing their hands in front of a patient to help ease the patient's comfort level, and to always have a chaperone during a pelvic exam. They also learn about what the women might have experienced in combat.
Women have been heavily involved in the fight in Iraq and Afghanistan in roles such as medics, truck drivers, pilots and military police officers, even though military policies prohibit women from serving in many combat positions. About 15 percent of the military is comprised of women, compared with 11 percent in the 1991 Persian Gulf War and 3 percent in the Vietnam War.
After the 2001 start of the war in Afghanistan and the 2003 U.S. invasion of Iraq, female veterans began coming in large numbers to VA hospitals and clinics. Most of the women from the recent conflicts were under age 40.
They frequently found facilities without private changing areas or women's clinics, staff members who did not believe they'd been in combat, and doctors unfamiliar with their health needs. In 2009, the Government Accountability Office said the VA wasn't doing enough to ensure female patients had complete privacy, noting that it had found in some facilities gynecological exam tables facing the door.
The VA began the mini-residency program in women's health in 2008 and 1,100 providers have now completed it. The agency has also added more women's clinics with separate waiting areas within its facilities and made other improvements, such as creating private areas for women to change and bathe. Recently, VA Secretary Eric Shinseki announced that pilot childcare centers were being rolled out in Northport and Buffalo, N.Y., and Tacoma, Wash.
Joy Ilem, deputy national legislative director at Disabled American Veterans, said the VA is headed in the right direction in providing care for women but has yet to implement all the changes needed system-wide. She said having providers trained in women's health is probably the most critical of all improvements that are needed.
"They've made progress and they should keep going and finish it," Ilem said.
Once VA officials started more closely tracking women's issues, they discovered that older women were seeking VA care as well. More than half of the VA's female patient population is 45 or older, said Dr. Patty Hayes, the VA's chief consultant for women's health. As the economy has worsened and as word has spread about the improved quality of care for women, some of the older women are walking into VA facilities for the first time. The VA has responded by educating providers on menopause and heart disease as well as issues faced by younger women.
"It's not that the women aren't there. It's that we didn't invest soon enough in having women's health providers," Hayes said.
Hayes said that today about 22 percent of men eligible for VA health care use it, compared with 16 percent of eligible women, up from 10 percent before the changes were implemented.
Before leaving the mini-residency programs, which typically last a few days, the providers are asked to identify one thing they want to change at their home hospital or clinic to improve care for women. Some of the things changed from early workshops include the purchase of gynecological tables and the acquisition of a rapid test for gynecological infections, said Dr. Laure Veet, director of women's health education in the VA's Women Veterans Health Strategic Care Group.
Dr. Aimee Sanders, a physician with the VA in Columbus, Ohio, who was one of the facilitators at the recent mini-residency session, recalled going into the Ohio facility where she now works when she was a medical student about a decade ago. Back then, she found it "not a female-friendly place." Today, she is one of a few doctors who work in a separate women's clinic within the facility, providing comprehensive care for women. She treats only women, with patients ages 19 to 91.
The female vets who walk in the door say they would've come in sooner if they'd known how nice it was, Sanders said.
"Demand is much greater than the supply of physicians that we have," she said.
Online: Veterans Affairs Department: http://www.va.gov/
Disabled American Veterans: http://www.dav.org/
Kimberly Hefling can be reached at http://twitter.com/khefling