New doctors trained to overcome LGBT health care gap
■ Some medical schools and residencies are equipping the next generation of doctors to care for this underserved patient population, but education in the area is lacking.
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In four years of medical school, most students average only five hours of education on the health needs of lesbian, gay, bisexual and transgender patients.
An estimated 3.4% of Americans identify themselves as LGBT, and many face health risks due largely to social stigma and a lack of understanding about their medical experiences and needs, said a 2011 Institute of Medicine report.
Overall, medical schools and residency programs are doing an unacceptable job of working to eliminate those disparities through education, said Patricia A. Robertson, MD. She is professor and Endowed Chair of Obstetric and Gynecologic Education in the Dept. of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, School of Medicine.
Research indicates that most medical schools are not doing enough to prepare future physicians to address the needs of LGBT patients, said Hector Vargas, executive director of the Gay and Lesbian Medical Assn.
“To not teach about their health needs — there is just no excuse,” Dr. Robertson said.
But some schools and residency programs are trying to give physicians-in-training insight into LGBT patients and ensure these patients’ health needs are addressed and treated.
In New York, for example, Beth Israel Medical Center and St. Luke’s-Roosevelt Hospital Center teamed up with Callen-Lorde Community Health Center and began offering a two-week program for medical residents in September. The residents spend time shadowing a physician at the health center, which serves primarily LGBT patients.
“They have two weeks to have the experience of an LGBT-affirmative environment and to really interact in a place where patients feel secure and safe,” said Jay Laudato, the health center’s executive director.
Educators say there is a need for more training programs. A survey of 132 medical schools in the U.S. and Canada found that schools spend an average of five hours on LGBT issues. Nine schools reported no hours of LGBT health taught during preclinical years, and 44 reported no hours during clinical years, said the study in the Sept. 7, 2011, issue of The Journal of the American Medical Association.
A separate 2009-10 survey of 275 physicians by the GLMA and the American Medical Association found that almost 40% of physicians received no formal training on LGBT issues during medical school, residency or postgraduate training, Vargas said.
Baligh R. Yehia, MD, who completed his residency training in internal medicine three years ago, doesn’t recall any lectures on LGBT issues during his medical school or residency training.
“The only context I remember was while learning how to take a sexual history, but LGBT health care is much more than that,” said Dr. Yehia, an instructor in the Dept. of Medicine at the Perelman School of Medicine at the University of Pennsylvania.
Despite a dearth of training in the area, Vargas said more medical educators are recognizing the importance of incorporating LGBT health into their curricula. “The tide is changing,” he said.
Programs launched in New York and Nashville
Vanderbilt University School of Medicine in Nashville, Tenn., launched its program for lesbian, gay, bisexual, transgender and intersex health in February as part of major curriculum reforms at the school, said Jesse Ehrenfeld, MD, MPH, co-director of the program and assistant professor of anesthesiology and biomedical informatics.
The program offers teaching points and other resources to help faculty integrate LGBT topics into their courses. As a result, the subject has been incorporated across the school’s four-year curriculum, Dr. Ehrenfeld said. For example, in emergency medicine course work, students learn about the high prevalence of attempted suicide among LGBT youths and how to identify sexual orientation when collecting a patient history.
“It’s easy to put this material into an elective, and a lot of schools have done this, but I think it’s better integrated into the broader curriculum,” Dr. Ehrenfeld said.
In New York, about six students have completed the program at Callen-Lorde so far. Although that initiative is new, the center has served as a training site on LGBT health for medical students and residents from around the world for many years, said Anita Radix, MD, MPH, who specializes in HIV care at the Callen-Lorde. Students say the experience is eye-opening because many have had limited experience with LGBT patients.
“It’s so important for them to come and see how we provide care and to be around the community,” Dr. Radix said.
Keith Egan, a third-year student at the University of New England College of Osteopathic Medicine in Biddeford, Maine, approached administrators his first year and persuaded them to incorporate LGBT health into the curriculum. Now students attend a panel discussion with members of the LGBT community.
“Hearing their stories firsthand really opens your eyes to the difficulties these patients can have when they go into the health care system,” Egan said. “The LGBT population is one that has historically been misunderstood and discriminated against by both the general public and by the medical profession. This inequitable treatment has resulted in very real — and very detrimental — health disparities for LGBT patients.”
More than two-thirds of osteopathic medical schools require education on LGBT health, said Tyler Cymet, DO, associate vice president for medical education at the American Assn. of Colleges of Osteopathic Medicine.
“It is recognized as an issue that can be better addressed with education, and osteopathic medical schools are increasingly including the topic in the required and elective courses offered,” Dr. Cymet said.
Pathway to trust
LGBT patients face numerous disparities, such as limited access to employer-based health care, lower rates of screening for common health conditions and higher rates of mental health issues, said Gabriel Garcia, MD, a gastroenterologist/hepatologist and professor at Stanford University School of Medicine in California. He is faculty adviser to the school’s LGBT Medical Education Research Group.
Lack of training in LGBT health perpetuates inequities in health outcomes through continued stereotyping and stigmatization, he said. A 2007 survey of 736 California physicians found that at least one in six felt uncomfortable providing care to gay patients.
“Quality patient-provider relationships are the foundation for good health outcomes,” Dr. Garcia said. “LGBT people, as all others, need health care providers they can trust and with whom they can develop genuine, respectful and mutually beneficial relationships.”
The UCSF School of Medicine has been training medical students about LGBT health for about a decade, Dr. Robertson said.
Second-year students can participate in a 2½-hour program that includes a patient panel discussion with a gay man, a lesbian and a transgender individual. All students are required to participate in small group talks after the session.
“They each tell stories of a time they were really discriminated against by the health care system because they came out as LGBT to their providers,” Dr. Robertson said.
Students learn about the impact of discrimination by health professionals. Patients who feel they are being judged by their physician are less likely to follow medical advice or return for important follow-up care, she said.
During their fourth year of medical school, UCSF students also have the option of doing a rotation at Lyon-Martin Health Services, a clinic in San Francisco that focuses on lesbians and transgender people.
Barriers to LGBT understanding
The Assn. of American Medical Colleges recommends that medical schools help students master the knowledge, skills and attitudes necessary to provide comprehensive care for LGBT patients, said Marc Nivet, EdD, AAMC chief diversity officer. But schools can face barriers to implementing LGBT health into their courses. Society as a whole has been reluctant to talk about issues of gender identity, sexual orientation and heterosexual norms, he said.
“There is still a very real tension surrounding these issues, similar to issues of racism and discrimination, which makes them difficult to engage in,” Nivet said.
Another challenge is a lack of expertise in LGBT health among faculty, Dr. Robertson said. Many medical school faculty haven’t been trained in the subject, and there hasn’t been substantial research in the area until recently.
In November, the GLMA is publishing Recommendations for LGBT Equity & Inclusion in Health Professions Education. The publication will include resources for students, staff, faculty and others involved in health profession education to improve their climate and curriculum around LGBT health, Vargas said.
“Training in LGBT health is imperative for quality health care and better health outcomes for LGBT patients,” Vargas said. “These programs help ensure that physicians and all health professionals not only create a welcoming environment for LGBT patients but that they are also knowledgeable about the specific health issues that may face LGBT people.”