Transgender Health: A Standardized Patient Case for Advanced Clerkship Students

Abstract

Introduction

Transgender patients experience poor health outcomes and often avoid seeking medical care because of negative encounters with providers. Despite growing awareness of the health disparities transgender patients face, there is very little curricular time in medical schools to improve medical students’ knowledge and skills for caring for transgender patients. This standardized patient (SP) case was developed for use in a communication challenges workshop for advanced clerkship students in order to address working with transgender patients.

Methods

This formative SP encounter takes place in a classroom as part of a half-day workshop on communication challenges with patients. We developed the case to focus specifically on skills related to obtaining patients’ preferred names and pronouns, as well as taking an appropriate patient history. Materials for SP recruitment, SP training, and case implementation are included within this publication.

Results

In preliminary uses of the case, 80% of students (N = 64) agreed or strongly agreed that it had increased their skills for working with transgender patients. Observational data from the debrief discussions also revealed that medical students perceived gaps in their medical training regarding LGBT health and expressed interest in their program incorporating more information on transgender health.

Discussion

This case adds to a growing number of curricular interventions to address medical students’ knowledge and skills with regard to lesbian, gay, bisexual, and transgender (LGBT) patients and, as a result, aims to address health disparities in LGBT patient populations.

Educational Objectives

By the end of this standardized patient case, learners will be able to:

• 1.Establish the patient's preferred name and pronouns with good rapport and sensitivity.
• 2.Obtain a complete history from the patient, including all medications the patient is taking.
• 3.Incorporate/use the patient's preferred name and history in developing an appropriate treatment plan.

Introduction

Transgender patients experience poor health outcomes and avoid seeking medical care because of negative encounters with providers.^1,2 Transgender patients often report experiencing hurtful or insulting language, being denied care, and being belittled or ridiculed for being transgender when seeking health care.² These negative encounters dissuade transgender patients from seeking health care, which negatively affects their health. Despite growing awareness of the health disparities transgender patients face, there is very little curricular time in medical schools to improve medical students’ knowledge and skills for caring for transgender patients.^3–6 A recent study found that, on average, medical schools devote only 5 hours in the curriculum to lesbian, gay, bisexual, and transgender (LGBT) topics.³ To address this curricular deficit, some medical schools have integrated lecture presentations, patient panels, and workshops on LGBT patient care.^7–11 In addition, several standardized patient (SP) cases have been implemented to improve providers’ communication and clinical skills with LGBT patients, although the cases often focus primarily on sexual history taking.^12–14

This SP encounter builds on the existing resources by focusing specifically on transgender patient care. This case was developed for a communication challenges workshop for fourth-year advanced clerkship students in order to address the knowledge and skills needed for working with transgender patients. This case was part of a half-day workshop in the Essentials of Clinical Practice and Professionalism course that advanced clerkship students take at our institution. It was a low-stakes teaching activity and one of eight cases that students encountered during the half-day session. Following the SP encounters, students attended a debriefing session with clinical faculty.

Three of the authors, Kelly Underman, Danielle Giffort, and Laura E. Hirshfield, have a background in the sociology of gender and sexuality, and the fourth, Abbas Hyderi, has worked extensively with LGBT patients in his clinical practice and teaches this content in the medical school curriculum. This combined background, along with consulting members of the transgender patient population, was used to help develop this case, which covers patient care, professionalism, and interpersonal and communication skills competency domains.

Methods

The SP encounter takes place in a classroom as part of a half-day workshop on communication challenges with patients (e.g., dealing with patients who are angry, who have experienced domestic violence, or who have not vaccinated their children). This workshop (and thus, this case) is intended for formative evaluation. Each student completes one of the eight communication challenge cases, meaning that one student completed this particular case while the other students and, in some rooms, faculty observed.

Given the importance of small-group interaction for this type of workshop, particularly for this case, course directors designed the workshop to be run with one-third (n = 64) of the total number of fourth-year medical students (N = 179) at a time. Breaking the class up into three groups allowed a relatively large medical school to accommodate all students.

SP Recruitment Criteria and Training

It was important to recruit and train a transgender person to portray the role for this case. Given the historical marginalization of actors in these roles and of members of this community, we felt it was key to find an SP with lived experience. This lived experience also provided a more authentic encounter for medical students. However, casting a transgender person in this role may not always be a feasible option. We located an actor with experience portraying various simulated scenarios in medical and nonmedical contexts. The cost of recruiting, training, and hiring this actor was approximately $345 ($230 for the half-day workshop and $115 for additional training).

At our institution, SP training involved the associate director of the simulation center and one of the case-development team members, Kelly Underman, explaining the purpose of the case and reviewing the encounter (Appendix A or B). A peer ally with relevant training was also available the day of the workshop to provide emotional support for the SP, should any triggering comments or experiences occur.

If and when the medical student brought up medications, the SP was coached to provide a red-flag question such as “Do hormones count?” in order to clue the student to the nonprescribed hormones. The SP was also coached to become more reluctant and irritated as medical students continued to use the incorrect name or pronouns and to act as they would act normally if the questions became invasive or uncomfortable, such as “Have you had the surgery?” or “What were you born as?” For the debriefing, the SP was instructed to provide feedback about their experience of the encounter with the medical student and offer limited suggestions for improvement.

SP Case

This case was developed to be portrayed by either a transgender woman or a transgender man (Appendix A or B, respectively). The patient, Cynthia or Michael, presents to the clinic because they have recently gotten married and their spouse wants to obtain a life insurance policy. The patient has not been to the doctor in at least 5 years because of previous transphobic or discriminatory encounters. The patient does not want to be at the doctor today either but is doing so to please their spouse. The patient has been self-injecting with hormones purchased online, using clean needles.

The simulated setting is an outpatient clinic visit for establishing care. The case begins with a file folder labeled Patient Chart being provided to the medical students waiting in the classroom, along with instructions to call the patient in when ready. The file folder contains learner instructions (Appendix C) that detail the patient's age, reason for visit, and name. The name of the patient depends on the SP. For example, with a transgender male SP, the file would have the name Cynthia Glenshaw on it (Appendix B). Providing students with the patient's incorrect name is the first challenge of the case. Once students are ready, they call the SP to the front of the classroom, as if calling them into an exam room, to complete the interview. The interview with the SP takes 10 minutes, and then the SP provides feedback and answers questions for an additional 5 minutes, for a total of 15 minutes per case.

Each SP completes eight encounters with eight different medical students (one in each group) during the 2-hour workshop. No additional staff are required. After all encounters are complete, students join together in a larger classroom for a 1-hour overall debriefing. For the debriefing (Appendix D), students should sit in groups based on the SP case they had (e.g., all eight students who practiced with the transgender SP). Each student should receive a copy of the terminology handout (Appendix F). Led by a clinical faculty member, the students should discuss their reactions to, and best practices for, each of the communication challenges experienced. Following the debriefing, students complete an evaluation of the case they worked on (Appendix E).

Results

During this pilot, one-third (n = 64) of the fourth-year medical school class completed the half-day workshop with this transgender SP case included. Based on the session evaluation, which all 64 students completed, medical students found this new case both a welcome addition and largely effective. Less than 36% of students strongly agreed that their prior medical training had prepared them to effectively care for their transgender patients. However, nearly 80% of students involved in this pilot agreed or strongly agreed that this transgender patient scenario increased their knowledge and skills to effectively provide medical care for transgender patients. Observational data from the debrief discussions also revealed that medical students perceived gaps in their medical training regarding LGBT health and expressed interest in their program incorporating more information on transgender health.

Discussion

As an initial introduction to clinical skills and professionalism training, this scenario was effective. The addition of this case to the Essentials of Clinical Practice and Professionalism course exposed a gap in the curriculum as a whole with regard to transgender health. Specific medical questions aside, medical students lacked basic communication skills for interacting with transgender patients, though they expressed a desire to make transgender patients feel comfortable.

While no formalized faculty development was provided for leading the large-group debriefing section, the physician author, Abbas Hyderi, who debriefs this case has extensive experience working with LGBT populations. We suggest that faculty who do not have relevant experience be provided with materials or opportunities to learn about transgender health issues, in order for them to be able to offer appropriate feedback and conduct a relevant and nonjudgmental discussion.

The measurement of effectiveness for this SP case is limited in its size, generalizability, and implications. The findings were drawn from a relatively small number of students (n = 64), only one-third of the fourth-year class, as this was only a pilot. Similarly, this was part of an eight-case session, but if that is not a format other schools use, the case is adaptable to other formats. Lastly, while we measured students’ reactions and the information that they gained, it was beyond the scope of this activity to assess whether having undergone the case will impact their behavior in practice and/or outcomes for transgender patients.

In the future, we plan to adapt this scenario so it becomes clearer to medical students that the patient is extremely reluctant to visit the doctor's office and is only doing so because their partner is pressuring them. The reason for the visit being access to life insurance caused trouble for some students, as they focused too much on expecting the catch of the communication challenge to involve life insurance rather than the patient's reluctance. While we developed this case for clerkship students, it would also be appropriate for medical students earlier in their training, as well as residents or physicians unfamiliar with transgender patient care.

Appendices

A. SP Cynthia.docx

B. SP Michael.docx

C. Learner Instructions.docx

D. Debriefing Questions.docx

E. Evaluation Questions.docx

F. Terminology.docx

All appendices are peer reviewed as integral parts of the Original Publication.