Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations

LGBTQ+ health education for medical students in the United States: a narrative literature review

INTRODUCTION

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development.

METHODS

PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes.

RESULTS

One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions.

CONCLUSION

Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.

Abortion Education for Medical Students in an Era of Increased Abortion Restrictions

Following the Supreme Court's decision in Dobbs v Jackson Women's Health in June 2022, many states restricted or banned abortion. Medical educators have focused on how this change impacts abortion training for residents, but schools must also adapt undergraduate medical education. Medical schools provide the foundation for future physicians' knowledge and attitudes on abortion. Comprehensive, high-quality abortion education for all medical students is essential for the future of abortion care. Here, we present how education champions can lead curricular improvements in abortion education in the preclinical, clerkship, and postclerkship phases of undergraduate medical education.

Using ACGME milestones as a formative assessment for the internal medicine clerkship: a consecutive two-year outcome and follow-up after graduation

BACKGROUND

This study evaluated the utility of using Accreditation Council for Graduate Medical Education (ACGME) Milestones as a formative assessment tool for the fifth- and sixth-grade medical students' performance in their internal medicine (IM) clerkship and the same students' performance in their post-graduate year (PGY) IM training.

METHODS

Retrospective data were collected from 65 medical students completing the two-year IM clerkship in the academic years 2019 and 2020 and 26 of the above students completing their PGY-1 training at the same university hospital in the academic year 2021. Data included the assessment results of 7 of the ACGME IM Milestones, information on admitted patients assigned to the students, and surveys of the students' satisfaction.

RESULTS

The analysis included 390 assessment results during the IM clerkship and 78 assessment results during the PGY-1 training. Clinical teachers commonly rated level 3 to medical students in the IM clerkship, with PC-2 subcompetency receiving the lowest rating among seven subcompetencies. The levels of most subcompetencies showed stationary in the two-year IM clerkship. Significant improvement was observed in all subcompetencies during the PGY-1 training. The medical students in the second-year IM clerkship expressed higher satisfaction with implementing Milestones than in their first-year IM clerkship and perceived Milestones assessments' usefulness as learning feedback.

CONCLUSIONS

Using ACGME Milestones as a formative assessment tool in the IM clerkship yielded promising outcomes. Longitudinal follow-up of subcompetencies facilitated tracking students' development and providing constructive feedback.

Assisted Reproduction for a Same-Sex Couple: Interdisciplinary Preclinical Active Learning Module Combining Case-Based Small Group Discussion and Patient Panel

OBJECTIVE

Physicians often feel they are not equipped to serve the lesbian, gay, bisexual, and queer (LGBTQ) community, but integrating education that incorporates LGBTQ content and perspective into an already-condensed medical school curriculum is challenging. We developed a preclinical active learning module on assisted reproductive technologies (ART) in LGBTQ care, integrating clinical and basic science content with patient perspective.

METHODS

We created a module that combined a case-based small group discussion with a patient panel. We developed a case for discussion in collaboration with a female cis-gender same-sex couple who conceived through ART. A patient panel with the same couple followed the discussion. All first-year medical students attended both parts of the module. Prior to participation, students learned reproductive endocrinology and genetics concepts through lectures. After the module, students voluntarily completed an anonymous survey to evaluate self-perceived changes in familiarity and confidence with LGBTQ patients and satisfaction with the module.

RESULTS

Of the 126 students who attended, 72 (57%) completed the survey. Of these, 69 (95.8%) felt the module gave them better perspectives on LGBTQ patient experiences, and 66 to 69 (92-96%) agreed the small group discussion achieved its learning objectives on LGBTQ health barriers and the application of ART. Students valued the patient panel (84.7%) and cited a better understanding of reproductive barriers for LGBTQ patients as its most valuable point.

CONCLUSION

A preclerkship module combining a case-based small group discussion and patient panel on ART delivered in the context of a real-life LGBTQ patient experience provided an opportunity for the students to integrate basic science and clinical science knowledge to reflect on the healthcare needs of this patient population. Creating the case in collaboration with the same-sex couple and having them present their own experience provided an authentic perspective to students on reproductive healthcare issues and how they impact members of the LGBTQ community.

Inclusion of Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Other Related Identities Content in Australian Physical Therapy Curricula: Perceived Barriers and Priorities for Inclusive Education

INTRODUCTION

Providing culturally responsive, patient-centered care is crucial for ensuring safe and positive health care experiences for individuals with diverse gender identities and sexual orientations. Doing so requires adequate training and knowledge of the health professionals involved in those health care experiences.

REVIEW OF LITERATURE

Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) experience significant barriers to health and positive health care experiences. In physical therapy, research has identified that individuals who identify as LGBTQIA+ experience discrimination, discomfort, and lack of practitioner knowledge about health needs. The aim of this study was to determine how, and to what extent, content related to LGBTQIA+ individuals is included in Australian physical therapy curricula as well as perceived barriers to inclusion.

SUBJECTS

Physical therapy program directors (PDs) as of January 2022 for all Australian universities that deliver physical therapy programs (n = 24).

METHODS

A Qualtrics survey was emailed to PDs to collect quantitative and qualitative data regarding the inclusion and mode of delivery of LGBTQIA+ content, as well as the perceived importance, and barriers to inclusion, of LGBTQIA+ curricula.

RESULTS

Twenty-four (100%) universities (PD or proxy) responded to the survey. More than 62% (15/24) of PDs reported that their programs included LGBTQIA+ content with 88% (21/24), indicating that LGBTQIA+ content is relevant to the physical therapy curriculum. Time devoted to LGBTQIA+ content ranged from 0 to 6 (median 2-4) hours across any year, delivered primarily in general or foundational courses (37%). Perceived lack of trained faculty (14/22; 64%) and time (13/22; 59%) were barriers to the integration of LGBTQIA+ specific content into the curriculum.

DISCUSSION

Our results indicate that the physical therapy curriculum may be contributing to ongoing negative experiences of individuals identifying as LGBTQIA+ with physical therapy encounters. Although most (87%) physical therapy program leaders in Australia believe that LGBTQIA+ specific content is relevant to the training of new graduates, content is included in only 62% of curricula. Perceived barriers to inclusion of LGBTQIA+ specific curriculum were a lack of time and appropriately trained faculty. Externally developed content is available to address limited expertise within programs, but faculty may require guidance on how to overcome perceived lack of time (ie, space in the curriculum).

CONCLUSION

Most Australian physical therapy programs include LGBTQIA+ content to a limited extent in their curricula, indicating a lack of perceived importance relative to other topics. In this way, Australian universities are maintaining the pervasive heteronormativity of the physical therapy profession and are complicit in the ongoing health disparities between the LGBTQIA+ and heteronormative communities.

Developing medical professionalism in care of gender nonconforming patients: Reflections of second-year medical students after a curricular experience with gender nonconforming people and allies

INTRODUCTION

Negative healthcare experiences persist for gender nonconforming individuals. Clinician-related factors, including lack of comfort with gender nonconforming persons and unexamined personal biases, present barriers to equitable and affirming healthcare. We explored the effects of contact with gender nonconforming individuals in preclinical medical education through a structured curricular intervention designed to build medical and humanistic knowledge and stimulate the development of medical professionalism surrounding the care of gender nonconforming individuals.

METHODS

A curricular module (didactic prework, time-synchronous online panel discussion, and post-event written reflection) was implemented in a second-year preclinical course in a large multi-campus Midwestern medical school. The module was based on pedagogical foundations of contact theory and reflective writing. Post-event written reflections were investigated using thematic analysis.

RESULTS

Analysis of 355 written reflections revealed three major themes (moments of insight, topics of confusion, connections to professional identity formation) and eight sub-themes. The findings demonstrated emerging gender professionalism and the importance of contact in professional development.

DISCUSSION

Contact with gender nonconforming people and the use of written reflections can encourage self-examination and foster professional identity formation among preclinical medical students. Modeling gender-affirming approaches may help counteract negative cultural messages about gender nonconforming people, aiding development of inclusive future physicians.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

Physiotherapists vary in their knowledge of and approach to working with patients who are LGBTQIA+: a qualitative study

QUESTION

What are the attitudes, beliefs and knowledge gaps of physiotherapists in Australia regarding working with patients who identify as LGBTQIA+?

DESIGN

Qualitative design using a custom online survey.

PARTICIPANTS

Physiotherapists currently practising in Australia.

METHODS

Data were analysed using reflexive thematic analysis.

RESULTS

A total of 273 participants met the eligibility criteria. Participating physiotherapists were predominantly female (73%), aged between 22 and 67 years, residing in a large Australian city (77%) and working in musculoskeletal physiotherapy (57%), in private practice (50%) and hospital (33%) settings. Almost 6% self-identified as part of the LGBTQIA+ community. Only 4% of the participants had received training related to healthcare interactions or cultural safety for working with patients who identify as LGBTQIA+ in the context of physiotherapy. Three main themes regarding approaches to physiotherapy management were identified: treating the whole person in context, treating everyone the same, and treating the body part. Gaps in knowledge were primarily related to understandings of the relevance of sexual orientation and gender identity to physiotherapy and health issues specific to LGBTQIA+ patients.

CONCLUSION

Physiotherapists can be considered to approach gender identity and sexual orientation in three distinct ways and suggest a range of knowledge and attitudes about working with patients who identify as LGBTQIA+. Physiotherapists who consider gender identity and sexual orientation to be relevant to physiotherapy consultations appear to have higher levels of knowledge and understanding of this topic and may also understand physiotherapy as multifactorial and not only biomedical.

Developing Standards for Cultural Competency Training for Health Care Providers to Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Persons: Consensus Recommendations from a National Panel

Purpose: Lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual and other sexual and gender diverse persons (LGBTQIA+ or SGD persons) experience barriers to equitable health care. The purpose of this article is to describe a collaborative process that resulted in core cultural competency recommendations addressing training for those who provide health care and/or social services to LGBTQIA+ patients. Methods: In 2018 and 2019, Whitman-Walker Health, a Federally Qualified Community Health Center in Washington, DC, and the National LGBT Cancer Network purposively selected leaders of community clinics and community-based organizations, cultural competency trainers, and clinicians and researchers with expertise in SGD health with diverse lived experiences to develop consensus-based cultural competency recommendations. Recommendations were developed through a synthesis of peer-reviewed studies, publicly accessible curricula, and evaluations of SGD cultural competency trainings; two in-person convenings; and iterative feedback from diverse stakeholders. Results: Five anchoring recommendations emerged: (1) know your audience; (2) develop and fine-tune the curriculum; (3) employ both adult and transformational learning theories; (4) choose multiple effective trainers; and (5) evaluate impact of training. These recommendations promote an ongoing process of individual and organizational improvement and a stance of humility rather than competence to be mastered. Conclusion: By setting core cultural competency standards for all persons involved in health care and social services, these recommendations complement existing clinical competency recommendations to advance SGD health equity.

An audit of the medical pre-clinical curriculum at an urban university: sexual and gender minority health content

Most medical students receive inadequate preparation to care for sexual and gender minority (SGM) patients. A review of one urban medical school's pre-clinical curriculum was conducted to assess coverage of appropriate SGM health content. Curricula that fully or partially addressed American Association of Medical Colleges (AAMC) core competencies for SGM health were categorized in an Excel spreadsheet. For partially met competencies, content that addressed the competency along with what was needed to fully address the competency were documented. AAMC SGM competencies that were not addressed at all were also noted. As a secondary source for triangulation, curricular topics were compared to SGM health content prioritized by Vanderbilt, a leader in championing inclusion of SGM content in medical curricula. Of the 30 AAMC competencies, 10 competencies were addressed, 11 were partially addressed, and 9 were not addressed. Gaps were noted in the AAMC domains of professionalism, systems-based practice, interprofessional collaboration, and personal/professional development. Among Vanderbilt topics, the George Washington University (GW) curriculum lacked content in intersex health, sexually transmitted infections (STIs) in lesbians, vaginitis in lesbians, efficacy of anal microbicides, anal Pap smears, and anal cancer risk and treatment for men who have sex with men (MSM). Despite these weaknesses, GW clocked greater than the national average at 7.5 hours of SGM content. This study provides a roadmap for curricular enhancements needed at GW as well as a prototype for other institutions to audit and improve curricular coverage on SGM health.

Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted 6-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the 6-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.

Sexual Dysfunction in Men Who Have Sex With Men

INTRODUCTION

Historically, sexual health research has focused on men who have sex with women (MSW) and most research examining the sexual health of men who have sex with men (MSM) has focused on HIV transmission. Despite a high prevalence of sexual health disorders among MSM, there is limited research that has evaluated the diversity of sexual issues in these patients.

OBJECTIVES

The purpose of this review is to describe the unique sexual behaviors, concerns, and dysfunctions of MSM by evaluating the literature on sexual health in this specific patient population.

METHODS

A PubMed literature search was conducted through December 2020 to identify all relevant publications related to the sexual health, sexual practices, and sexual dysfunction of MSM. Original research, review articles, and meta-analyses were reviewed, including comparisons of sexual behavior and dysfunction between MSM and non-MSM populations and between gay/bisexual men and heterosexual men. Approximately 150 relevant articles were reviewed and 100 were included in the manuscript.

RESULTS

Minority stress can lead to an increase in high-risk sexual behavior, sexual dysfunction, and mental health disorders in MSM. MSM engage in a variety of sexual behaviors, which can lead to differences in sexual dysfunction, such as anodyspareunia during receptive anal intercourse. MSM have higher rates of erectile dysfunction than non-MSM counterparts. MSM have unique activators of sexual pathologies, such as insertive anal intercourse for Peyronie's disease. Prostate cancer treatment may cause MSM to change sexual roles and practices following treatment due to ED, anodyspareunia, or decrease in pleasure from receptive anal intercourse after prostatectomy.

CONCLUSION

MSM have been neglected from sexual medicine research, which translates to disparities in health care. Further research that focuses on the MSM population is necessary to better educate healthcare practitioners so that MSM patients can receive adequate care that is tailored to their specific needs. PJ Cheng, Sexual Dysfunction in Men Who Have Sex With Men. Sex Med Rev 2021;XX:XXX-XXX.

Fostering Early Preclinical Experiences for Developing Knowledge, Skills, and Confidence in Key Residency Competencies Through Participation in a Medical Student Research Training Program

Periods of academic transition are challenging and require medical students to adjust to new environments and expectations. Commonly cited areas of struggle include integrating into the interprofessional health care team, communication, organization and time management, and self-regulated learning. Consciously designing opportunities early in the preclinical curriculum to help students gradually build these competencies can be achieved within existing research training programs or projects. This perspective article reflects on how the medical student research training program at the Oakland University William Beaumont School of Medicine supports student growth in these areas beginning in the first year, so that students can directly apply these skills as they progress to the clinical years and beyond.

Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender

INTRODUCTION

Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care.

METHODS

We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules.

RESULTS

Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable.

DISCUSSION

This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.

Developing and Implementing Curricular Objectives for Sexual Health in Undergraduate Medical Education: A Practical Approach

PROBLEM

In 2014, medical students at the Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) first drew attention to perceived gaps in the sexual health curriculum. The authors used Kern and colleagues' model for curriculum development to review and update the existing curriculum.

APPROACH

To develop longitudinal sexual health curricular objectives for undergraduate medical education (UME), the authors reviewed existing specialty- and organization-specific objectives. Then, an iterative process guided by clear criteria was used to develop feasible objectives, which were refined through stakeholder feedback. As these objectives were being finalized in 2017, UME sexual health competencies were first published; the authors mapped their objectives to these, as possible. The medical school's course activities and assessments were mapped to the authors' sexual health objectives to identify curricular gaps and unplanned redundancies.

OUTCOMES

This process resulted in 12 sexual health curricular objectives that are adaptable by other institutions. In mapping the FIU HWCOM curriculum to these objectives, specific gaps and assessment weaknesses emerged. With stakeholder support obtained through a strong curricular management structure, the work of modifying content to address gaps has begun.

NEXT STEPS

New assessments specific to these sexual health objectives are needed, especially within the clinical curriculum. Assessment of these objectives may be strengthened through the development of new sexual-health-related entrustable professional activities (EPAs) nested within the broader Core EPAs for Entering Residency being piloted. When data on learning outcomes are available, the process of targeting curricular improvement will begin.

Student Journal Club to Improve Cultural Humility with LGBTQ Patients

Health degree programs provide opportunities to reduce disparities in care for LGBTQ patients by exposing students to LGBTQ communities and current health issues. However, LGBTQ content is mostly absent from medical school curricula. This mixed method assessment study, conducted during the 2018 to 2019 academic year, examined the feasibility of implementing a medical student journal club focused specifically on LGBTQ health issues as a complementary training tool to support efforts to create an inclusive educational environment. Compared to the pre-test, mean response scores increased for most of the parameters including familiarity with LGBTQ healthcare issues, confidence in the ability to identify harmful medical provider practices, and reading and assessing scientific literature. Qualitative data showed increased confidence, comfort and knowledge about LGBTQ health barriers. This study offers a framework for using a journal club to provide an effective platform for enhancing students' LGBTQ cultural humility and research literacy.

A Novel Curriculum for Medical Student Training in LGBTQ Healthcare: A Regional Pathway Experience

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face considerable health disparities, often due to a lack of LGBTQ-competent care. Such disparities and lack of access to informed care are even more staggering in rural settings. As the state medical school for the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine (UWSOM) is in a unique position to train future physicians to provide healthcare that meets the needs of LGBTQ patients both regionally and nationally.

OBJECTIVE

To describe our methodology of developing a student-driven longitudinal, region-wide curriculum to train medical students to provide high-quality care to LGBTQ patients.

METHODS

A 4-year LGBTQ Health Pathway was developed and implemented as a student-led initiative at the UWSOM. First- and second-year medical students at sites across the WWAMI region are eligible to apply. Accepted Pathway students complete a diverse set of pre-clinical and clinical components: online modules, didactic courses, longitudinal community service/advocacy work, a scholarly project, and a novel clinical clerkship in LGBTQ health developed specifically for this Pathway experience. Students who complete all requirements receive a certification of Pathway completion. This is incorporated into the Medical Student Performance Evaluation as part of residency applications.

RESULTS

The LGBTQ Health Pathway is currently in its fourth year. A total of 43 total students have enrolled, of whom 37.3% are based in the WWAMI region outside of Seattle. Pathway students have completed a variety of scholarly projects on LGBTQ topics, and over 1000 hours of community service/advocacy. The first cohort of 8 students graduated with a certificate of Pathway completion in spring 2020.

CONCLUSIONS

The LGBTQ Health Pathway at UWSOM is a novel education program for motivated medical students across the 5-state WWAMI region. The diverse milestones, longitudinal nature of the program, focus on rural communities, and opportunities for student leadership are all strengths and unique aspects of this program. The Pathway curriculum and methodology described here serve as a model for student involvement and leadership in medical education. This program enables medical students to enhance their training in the care of LGBTQ patients and provides a unique educational opportunity for future physicians who strive to better serve LGBTQ populations.

The Science and Value of Diversity: Closing the Gaps in Our Understanding of Inclusion and Diversity

Diversity drives excellence. Diversity enhances innovation in biomedical sciences and, as it relates to novel findings and treatment of diverse populations, in the field of infectious diseases. There are many obstacles to achieving diversity in the biomedical workforce, which create challenges at the levels of recruitment, retention, education, and promotion of individuals. Here we present the challenges, opportunities, and suggestions for the field, institutions, and individuals to adopt in mitigating bias and achieving greater levels of equity, representation, and excellence in clinical practice and research. Our findings provide optimism for a bright future of fair and collaborative approaches that will enhance the power of our biomedical workforce.

Incorporating LGBT Health in an Undergraduate Medical Education Curriculum Through the Construct of Social Determinants of Health

INTRODUCTION

The AAMC has provided a resource to medical schools for implementing curricular change in lesbian, gay, bisexual, and transgender (LGBT) health education. However, studies have identified that many health professionals who do not feel comfortable in their ability to provide quality care for LGBT patients do not perform complete sexual histories routinely and/or harbor bias towards these patients or their sexual practices. This situation underscores the continued need for further education on this topic.

METHODS

Based on a needs assessment survey of medical students and faculty, we developed a 1-hour didactic lecture to provide instruction on how social determinants of health impact the care of LGBT patients. Students were not required to have any prerequisite knowledge for the session. A content expert in LGBT health taught the lecture using Microsoft PowerPoint in a traditional medical school lecture hall.

RESULTS

The lecture was given to 180 third-year medical students. A total of 63 students (35%) responded to the retrospective pre- and postlecture survey. After the didactic lecture, students reported a statistically significant change in their knowledge of the lecture objectives.

DISCUSSION

The didactic lecture was able to increase students' knowledge of how social determinants impact the health of LGBT patients. The lecture can be incorporated into a longitudinal curriculum on LGBT health. Additional work and research are needed on increasing comfort in faculty teaching.

Deaf and Hard-of-Hearing Learners in Emergency Medicine

Approximately 23% of Americans over age 12 have some level of hearing loss.1 Emergency departments can reduce healthcare barriers for deaf and hard-of-hearing (DHoH) patients through improved patient-physician communication. DHoH students, once they become physicians, may provide one mechanism for reducing existing healthcare disparities and communication barriers for DHoH patients, and may be more adept with patients facing other communication barriers. A renewed interest in disability access and a commitment to social justice has increased efforts toward the inclusion of individuals with disabilities in medical education and training. Despite this increased interest and a growing number of DHoH students entering medical education, DHoH students continue to be dissuaded from specialty careers such as emergency medicine (EM) over concerns regarding effective communication and ability. Given the academic medicine communities' commitment to diversity, a recounting of the successful inclusion of DHoH students in EM can benefit medical education and practice. In this account, the authors reflect on the successful experiences of a visiting DHoH medical student in an academic EM rotation at a Level I trauma hospital that serves a diverse population, and they identify the potential challenges for DHoH students in an EM setting, offer solutions including reasonable accommodations, and provide commentary on the legal requirements for providing full and equal access for DHoH students. We secured permission from the student to share the contents of this article prior to publication.

Comprehensive Internal Medicine Residency Curriculum on Primary Care of Patients Who Identify as LGBT

PURPOSE

Graduate medical education curricula that provide training on LGBT healthcare are limited. The purpose of this study was to create and evaluate an LGBT curriculum for internal medicine (IM) residents.

METHODS

The implicit association test (IAT) measuring implicit bias toward gay individuals was administered as part of a needs assessment. The curriculum was developed by a multidisciplinary team, with objectives derived from the Association of American Medical Colleges' curricular recommendations and the Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Surveys assessed residents' perceptions of the importance of primary care for LGBT patients, and their knowledge of and confidence in providing primary care to LGBT patients. Faculty also rated the usability of the curricular materials.

RESULTS

The IAT showed a slight preference for straight people compared with gay people, with an average "D score" of 0.27 ± 0.42. The importance of receiving education about the primary care of LGB patients was rated as high across the pre- to postsurveys. Knowledge improved with participation in the curriculum (average overall score: 42% pre- vs. 66% postsurvey, p < 0.0001). Participants' confidence in their ability to provide information to LGBT patients about resources for community engagement and to implement gender-neutral practices in their clinics increased significantly (p < 0.05).

CONCLUSION

This curriculum pilot demonstrated an improvement in IM residents' knowledge of and confidence in providing care to LGBT patients. Our results suggest that curricular materials can be developed by experts in LGBT health and utilized effectively by nonexpert faculty to increase residents' knowledge and confidence regarding LGBT healthcare.

Systematic Mapping of Relationship-Level Protective Factors and Sexual Health Outcomes Among Sexual Minority Youth: The Role of Peers, Parents, Partners, and Providers

Sexual minority youth (SMY) experience elevated rates of adverse sexual health outcomes. Although risk factors driving these outcomes are well studied, less attention has been paid to protective factors that potentially promote health and/or reduce negative effects of risk. Many factors within interpersonal relationships have been identified as protective for the sexual health of adolescents generally. We sought to systematically map the current evidence base of relationship-level protective factors specifically for the sexual health of SMY through a systematic mapping of peer-reviewed observational research. Articles examining at least one association between a relationship-level protective factor and a sexual health outcome in a sample or subsample of SMY were eligible for inclusion. A total of 36 articles reporting findings from 27 data sources met inclusion criteria. Included articles examined characteristics of relationships with peers, parents, romantic/sexual partners, and medical providers. Peer norms about safer sex and behaviorally specific communication with regular romantic/sexual partners were repeatedly protective in cross-sectional analyses, suggesting that these factors may be promising intervention targets. Generally, we found some limits to this literature: few types of relationship-level factors were tested, most articles focused on young sexual minority men, and the bulk of the data was cross-sectional. Future work should expand the types of relationship-level factors investigated, strengthen the measurement of relationship-level factors, include young sexual minority women in samples, and use longitudinal designs. Doing so will move the field toward development of empirically sound interventions for SMY that promote protective factors and improve sexual health.

Queer Frontiers in Medicine: A Structural Competency Approach

In 2014, the Association of American Medical Colleges (AAMC) published a report proposing qualifiers of competence to guide medical educators towards training physicians to appropriately care for individuals who are or may be lesbian, gay, bisexual, transgender (LGBT); gender nonconforming (GNC); and/or born with differences in sex development (DSD). These qualifiers provide content and context to an existing framework heavily used in competency-based medical education, emphasizing individual and interpersonal abilities to enhance care delivered to individuals identifying as LGBT, GNC, and/or born with DSD. However, systemic and societal forces including health insurance, implicit bias, and legal protections significantly impact the health of these communities. The concept of structural competency proposes that it is necessary to consider these larger forces contributing to and sustaining disease and health in order to fully address identity-based health needs. Competing competency frameworks for addressing diversity may be counterproductive to the ultimate goal of improving health outcomes among diverse communities. In this article, frameworks are reconciled by proposing structural competency as one approach for teaching identity-based health-related competencies that can be feasibly implemented for medical educators seeking to comply with the AAMC's recommendations. This article aims to "queer"-or to open up-possibilities in medical education in an effort to ultimately support the provision of equitable and responsible health care to people who are LGBT, GNC, and/or born with DSD through the use of innovative frameworks and teaching materials.

Sexual Health Competencies for Undergraduate Medical Education in North America

INTRODUCTION

The number of hours spent teaching sexual health content and skills in medical education continues to decrease despite the increase in sexual health issues faced by patients across the lifespan. In 2012 and 2014, experts across sexuality disciplines convened for the Summits on Medical School Education and Sexual Health to strategize and recommend approaches to improve sexual health education in medical education systems and practice settings. One of the summit recommendations was to develop sexual health competencies that could be implemented in undergraduate medical education curricula.

AIM

To discuss the process of developing sexual health competencies for undergraduate medical education in North America and present the resulting competencies.

METHODS

From 2014 to 2016, a summit multidisciplinary subcommittee met through face-to-face, phone conference, and email meetings to review prior competency-based guidelines and then draft and vet general sexual health competencies for integration into undergraduate medical school curricula. The process built off the Association of American Medical Colleges' competency development process for training medical students to care for lesbian, gay, bisexual, transgender, and gender non-conforming patients and individuals born with differences of sex development.

MAIN OUTCOME MEASURES

This report presents the final 20 sexual health competencies and 34 qualifiers aligned with the 8 overall domains of competence.

RESULTS

Development of a comprehensive set of sexual health competencies is a necessary first step in standardizing learning expectations for medical students upon completion of undergraduate training.

CONCLUSIONS

It is hoped that these competencies will guide the development of sexual health curricula and assessment tools that can be shared across medical schools to ensure that all medical school graduates will be adequately trained and comfortable addressing the different sexual health concerns presented by patients across the lifespan. Bayer CR, Eckstrand KL, Knudson G, et al. Sexual Health Competencies for Undergraduate Medical Education in North America. J Sex Med 2017;14:535-540.

Transgender Medicine Curriculum: Integration Into an Organ System-Based Preclinical Program

INTRODUCTION

There is a recognized and articulated need for health professionals to understand the definitions, health disparities, and medical management of transgender patients. This recognition comes organically from students requesting more information, and top-down from governing bodies such as the AAMC or the Liaison Committee on Medical Education. Surveys of North American medical schools indicate that training in transgender medicine (specifically, the process of transition) is infrequent and inadequate. One problem underlying this trend may be the lack of resources to help conceptualize and roll out a transgender medicine curriculum.

METHODS

Here, we report the integration of training in transgender medicine into the organ system-based course Endocrine-Reproduction. This transgender curriculum includes coverage of basic science, clinical management, ethics, and clinical skills. The curriculum leverages an already existing, health care disparity-focused curriculum but adds (1) a didactic component for dissemination and discussion of basic science principles applied to transgender patients and (2) a mock initial encounter between a physician and patient with gender dysphoria.

RESULTS

Following the first-time implementation of the transgender curriculum, students were surveyed, with a large majority reporting feeling more prepared to care for transgender patients.

DISCUSSION

We conclude that including a multidisciplinary transgender medicine curriculum in medical school advances the goal of creating safe, effective physicians by providing fundamental knowledge about an underserved population of patients, as well as exampled application of that knowledge.

The Priority of Intersectionality in Academic Medicine

Recent societal events highlight inequities experienced by underrepresented and marginalized communities. These inequities are the impetus for ongoing efforts in academic medicine to create inclusive educational and patient care environments for diverse stakeholders. Frequently, approaches focus on singular populations or broad macroscopic concepts and do not always elucidate the complexities that arise at the intersection between multiple identities and life experiences. Intersectionality acknowledges multidimensional aspects of identity inclusive of historical, structural, and cultural factors. Understanding how multiple identity experiences impact different individuals, from patients to trainees to providers, is critical for improving health care education and delivery. Building on existing work within academic medicine, this Commentary outlines six key recommendations to advance intersectionality in academic medicine: embrace personal and collective loci of responsibility; examine and rectify unbalanced power dynamics; celebrate visibility and intersectional innovation; engage all stakeholders in the process of change; select and analyze meaningful metrics; and sustain the commitment to achieving health equity over time. Members of the academic medical community committed to advancing health equity can use these recommendations to promote and maintain meaningful changes that recognize and respond to the multidimensional voices and expressed needs of all individuals engaged in providing and receiving health care.

Teaching Medical Students How to Ask Patients Questions About Identity, Intersectionality, and Resilience

INTRODUCTION

Medical education addressing people with sexual and gender minority (SGM) identities often focuses on sexual risk, is delivered in silos, and overlooks intersecting identities. SGM individuals-particularly those with coexisting stigmatized identities-experience a disproportionate burden of discrimination, which increases vulnerability to adverse health outcomes, especially when maladaptive coping behaviors are used to manage stress. Adaptive coping and resilience can develop in the context of identity affirmation and social support, for which sensitive clinician-patient interactions provide a crucial foundation. Guided by the AAMC publication Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD: A Resource for Medical Educators, this session introduced first-year medical and dental students to the concepts of identity and intersectionality, providing an opportunity to practice apropos interviewing techniques.

METHODS

This 2-hour session includes prework, a didactic presentation, role-play scenarios, and a small-group session. Prior to the session, faculty facilitators had small-group leadership experience, and students had already mastered social history taking. Electronic student and faculty surveys provided qualitative assessment.

RESULTS

Faculty and students reported that the session increased awareness of the health impact of identity and intersectionality and the clinician's role in establishing rapport. Suggestions included adding a prework video defining diversity terminology and a patient panel describing diverse identities and experiences.

DISCUSSION

Addressing health issues related to SGM and other sociocultural identities is challenging yet crucial. This innovative session gave students an opportunity to explore their unconscious biases and practice novel interviewing techniques in a supportive environment.