Fostering Inclusive Approaches to Lesbian, Gay, Bisexual, and Transgender (LGBT) Healthcare on the Obstetrics and Gynecology Clerkship

Abstract

This article from the “To the Point” series prepared by the Association of Professors in Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC) provides educators with strategies for inclusion of Lesbian, Gay, Bisexual, Transgender (LGBT)-related content into the medical school curriculum. With a focus on the Obstetrics and Gynecology (OB/GYN) clerkship, we also address ways to enhance visibility of these curricula within existing clinical and teaching experiences.

Introduction

There has never been a time of greater challenge in the provision of a comprehensive medical education curriculum than our current time. Competition for elective time, increased student enrollment, widely distributed education sites with diverse faculty, and the desire to increase opportunities for teaching and engagement in matters of diversity, inclusion, and elimination of healthcare disparities are important considerations [1]. Competing priorities are ever-present, with special attention currently focused on measuring and reporting on the quality of the learning environment among medical students. With a survey regarding the number of LGBT-related curriculum content hours, the amount of time allotted to these subjects was deemed to be grossly inadequate [2].

This article from the “To the Point” series will offer educators ideas to address LGBT health advocacy education by highlighting opportunities within an existing curricular framework, the OB/GYN clerkship.

Needs Assessment

Disparities in the care of the LGBT community are largely attributable to social bias, stigma, and discomfort among providers [3]. Many practicing physicians do not routinely provide each patient the kind of comprehensive sexual orientation history and risk assessment that is necessary to highlight and manage LGBT-related health risk issues. It has been suggested that inclusion of a broader scope of information-gathering approaches could help patients overcome fears of mistreatment and by extension, reduce the risk of suboptimal healthcare experiences [4–6]. Perception of exclusion by their healthcare providers leads to underutilization of healthcare systems, as many LGBT patients can be apprehensive about discussing their gender identity or sexual orientation with medical providers and insurance carriers because of fear of mistreatment and/or denial of benefits [7, 8]. Some studies suggest that approximately 30% of lesbian patients are unwilling to be seen in a doctor’s office [7, 8]. In addition, the tendency for underutilization of healthcare systems may be, in part, attributed to fear of possible consequences of gender identity or sexual orientation disclosures [7]. Studies suggest that a high level of trust in the patient-physician relationship is necessary to address barriers relating to identifying and addressing specific chronic diseases that LGBT patients are managing [9].

Many schools are now including training for students on ways to address healthcare disparities throughout medical school curricula. These include the creation of curricular material focusing on LGBT-related and other health disparities as well as the training and development of specific faculty who are competent and willing to teach the content. The provision of time within the curriculum to teach the LGBT-specific content is challenging. But the creation of evaluation templates for LGBT-related content would ensure adequate coverage.

The obstetrics and gynecology clerkship is an already existing platform for provision of curricular content to address disparities in care and to teach about advocacy and inclusion. This is especially true since training students to care for female patients involves cultural competence and advocacy and patients transitioning from one gender to another frequently are encountered in OB/GYN departments. In addition, opportunities to enhance risk-based patient education, screening, and healthcare management exist already within this learning environment. Frequently, many patients in the gender transition continuum find themselves suspended between the Urologist’s and the OB/GYN’s offices [10]. The literature suggests that the LGBT group of patients tend to have decreased opportunities for timely screening and risk assessments relevant to the Periodic Health Examination [7]. The OB/GYN clinical clerkship offers capacity to broaden the scope of gender medicine and to cover these curricular threads comprehensively within an already robust and effective structure. In spite of this rotation having mostly female patients, the culture of inclusion around gender issues can be translated toward the care of all patients and be reinforced deliberately during other third year clinical experiences for a more comprehensive LGBT population approach.

Current Environment and Promoting a Culture of Inclusion

Cultural competence is an important construct for comprehensive risk assessment of underserved communities where barriers to communication exist [11]. Cultural competence does not exist without excellent communication, awareness, and comfort with patients. Several sources in the literature have suggested that many providers feel significant discomfort with the discourse and language necessary for the creation of a culture of inclusion [3]. Training that fosters the collection of a comprehensive sexual and social history for every patient would ensure that healthcare providers have skills and capacity to address risk and to focus on issues contributing to disparities in healthcare delivery [12, 13]. In addition, Snowdon challenges that mechanisms for identification of LGBT-competent doctors are lacking and proposes that this barrier can be ably addressed during the OB/GYN rotation [14] and faculty until the environment and beliefs are adapted to a new pattern of providing care and teaching [15]. Providing faculty development around common language and practice could ensure optimization of patient-doctor trust and promote sensitive conversations that can identify and define appropriate risk assessment of LGBT patients who present for care [16]. A 2-h novel cultural humility curriculum designed to address discrimination and stigma on LGBT communities is well described by Grubb et al. [17]. It addresses documented curricular deficits and health disparities and is designed for medical students. It can be easily incorporated into current clerkship structures to facilitate cultural humility training [17]. The core elements of this curriculum include pre-curricular readings, a 1-h didactic lecture, a 1-h “Patient as Professor” panel of LGBT-identified individuals and an interactive public discussion. Finding ways to include this content in clinical curricula and address these challenges will go a long way to changing the culture to reduce disparities in this patient population.

Fitting LGBT Awareness Training into the OB/GYN Curriculum

Currently, most curricula in the OB/GYN rotation offer many opportunities to incorporate case-based learning in small groups, patient-based panel discussions, objective structured clinical examinations, and interdisciplinary case-based experiences with OB/GYN, pediatrics, nursing, social work, and psychiatry [18]. Topics pertinent to the comprehensive care of the LGBT patient group which should be addressed within this framework include patient education and screening standards as well as chronic diseases that affect various aspects of female health. Common examples include chronic anovulation and polycystic ovarian syndrome, sexually transmitted infections including human papilloma virus and human immunodeficiency virus infections, intimate partner violence, substance abuse, and cancer (anal, breast, cervical, colon, endometrial and oropharyngeal).

Competencies that can be addressed should include medical knowledge, interpersonal and communication skills (including cultural competence), patient care, and professionalism. Transitions of care should be a part of the curriculum as this allows students to discuss issues relevant to population health as well as understanding how interprofessional care and communication is significant for LGBT-related health priorities [8]. Many examples of curricular components (see Table 1) already exist on the online MedEdPORTAL and can be used as models to facilitate seamless adoption into the curriculum [3, 19]. Table 1 summarizes some practical strategies that could be implemented during the third year OB/GYN clerkship to support LGBT health advocacy education.

Table 1.

Examples of curricular components

Learning objective	Strategies	Resources
The student will be able to communicate with LGBT patients with appropriate attention to cultural competency	Case-based learning, clinical experience, role play/standardized patient	APGO Medical Student Educational Objectives (10th Edition) Educational Topic 5: Personal Interaction and Communication Skills
The student will take a comprehensive sexual and biopsychosocial history of LGBT patients	Case-based learning, clinical experience, role play/standardized patient, simulation	APGO Medical Student Educational Objectives (10th Edition) Educational Topic 1: History
The student will be able to identify healthcare disparities affecting LGBT patients, as well as resulting healthcare needs	Case-based learning, clinical experience, role play/standardized patient, simulation	Grubb H, Hutcherson H, Amiel J, Bogart J, Laird J. Cultural humility with lesbian, gay, bisexual, and transgender populations: a novel curriculum in LGBT health for clinical medical student. MedEdPORTAL Publications. 2013; 9:9542. 10.15766/mep_2374-8265.9542
The student will be able to list strategies for creating a welcoming and safe environment for LGBT patients	Case-based learning, clinical experience, role play/standardized patient, simulation	Grubb H, Hutcherson H, Amiel J, Bogart J, Laird J. Cultural humility with lesbian, gay, bisexual, and transgender populations: a novel curriculum in LGBT health for clinical medical student. MedEdPORTAL Publications. 2013; 9:9542. 10.15766/mep_2374-8265.9542

Addressing the hidden curriculum can also provide an opportunity to increase advocacy for the needs of LGBT students, trainees, and staff [20]. The Healthcare Equality Index (HEI) is a national LGBT benchmarking tool that evaluates healthcare policies and practices related to the equity and inclusion of LGBT patients, visitors, and employees [21]. Tools to facilitate training of faculty and students are also available for training through this website [21] (www.hrc.org). Other examples include the LGBT Center curricular map at the University of California at San Francisco, which includes content within each of the clinical years during the pediatrics, psychiatry and obstetrics and gynecology clerkships (www.hrc.org/hei/lgbt-training). In addition, LGBT health electives, forums, and faculty development along with onboarding activities for students and faculty on diversity programming are all ways that the content has been successfully incorporated. A recent Web-based platform was launched specifically for knowledge sharing for sex- and gender-specific medical education [22]. Opportunities for inter-professional education leading to LGBT-related curricular collaborations among nursing care, nutrition, social work, psychology, and dentistry could also be developed (http://egender.charite.de).

Assessment of Competency

Currently one challenge that exists is how to assess competency of the learner in his/her capacity to identify and screen LGBT patients to provide comprehensive care. Since several studies recognize discomfort of providers with the discourse and language, the documentation of gender preferences and sexual orientation which is low priority in electronic health records (EHR) [23] can be addressed. This makes the assessment of competency in the care of the LGBT populations of patients difficult. At many health centers, templates can now be built in to the EHR to capture the entire sexual orientation and gender preference during the history-taking function for every patient. This has resulted in an objective way to document and assess whether students and providers have addressed the subject matter with each patient during visits. In addition to assuring documentation that gender preferences are solicited, risk assessment and clinical assessment data collection systems can be monitored at mid-clerkship and end-of-clerkship providing feedback regarding learner competency to evaluate populations at risk. Using standardized LGBT patients to assess competency in communication skills can also be used as objective data to benchmark whether a student is culturally competent [24, 25]. All these can easily be facilitated during the OB/GYN clerkship and reinforced throughout the third year clinical experiences.

Conclusions

Academic health centers are poised to lead the way to the curricular change that is needed to remove healthcare disparities across all groups in our population. Using longitudinal approaches to education on LGBT-related issues across disciplines, starting in the preclinical years has been embraced by many medical centers. However, many opportunities in already existing OB/GYN clerkships offer ways to provide inclusion of issues affecting the care of the LGBT community of patients. Although the gender representation is limited, it serves as a platform to gain cultural competency which can be translated and reinforced on other clerkships as a report to all patients evaluated. Intentional faculty development on ways of building content into the clerkship goals and objectives, providing cultural humility training and providing resources in the electronic health record for capturing gender preferences in each patient’s medical records, can serve to guide incorporation of this content into the clerkship. Resources like online curricular modules and examples of content available on the MedEdPORTAL can be incorporated into the clerkship. These intentional approaches will go far in changing the culture that is required to remove healthcare disparities currently facing the LGBT population of patients.

This article provides guidance on ideas for curricular interventions and methods to incorporate learning opportunities for students to achieve competency in the care of this patient group during the OB/GYN clerkship. This presents an opportunity to review and incorporate some or all of this content within medical school curriculum without affecting current challenges of time constraints and insufficient faculty numbers which we now experience.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.