About a decade ago, Mitchell Lunn, MD, noticed he was receiving little instruction on providing care to the lesbian, gay, bisexual, and transgender (LGBT) community while a student at Stanford University School of Medicine, even though these patients faced documented disparities in disease burden and access to care. So, he did something about it.
In 2007, Lunn and fellow students approached Stanford faculty about adding more LGBT care topics to the curriculum. In response, faculty asked them to research what other medical schools were doing. Lunn and his classmates began searching, but the literature was slim. So they designed their own study, surveying medical education deans in the United States and Canada.
The results, published in 2011 in the Journal of the American Medical Association, found a median of five hours devoted to LGBT care in the medical school curriculum. More than one-third of survey respondents reported zero hours on LGBT care during students’ clinical education.
“I’m gay myself, and I don’t know a single LBGT person who hasn’t had to educate their doctor about their needs,” said Lunn, now an assistant professor of medicine at the University of California, San Francisco, School of Medicine and cofounder of Stanford’s LGBT Medical Education Research Group.
Over the last few years, however, medical schools have started to make an earnest effort to incorporate LGBT patient care into their curricula and to help close LGBT health disparities.
“This is patient-centered care,” said Lunn, “but it requires a lot of practice and skill to make sure you’re opening up the doors for those sensitive conversations.”
Moving the curriculum toward inclusive care
In 2014, the AAMC released the first guidelines to assist medical schools in training students to care for LGBT and gender nonconforming patients, as well as for those born with differences of sex development. The guidelines include 30 competencies to improve health care for the LGBT population, which can be integrated into existing curricula.
Research has found that lesbians are less likely to receive preventive services for cancer and LGBT youth are more likely to attempt suicide. To close those gaps and others, the University of Louisville School of Medicine is serving as the national pilot site for integrating the AAMC LGBT care competencies into medical school curricula. Known as the eQuality project, the initial pilot year for first- and second-year students concluded in spring 2016.
Overall, Louisville curriculum developers created about 12 to 15 hours of new content and enhanced about three dozen hours of the existing curriculum, said Amy Holthouser, MD, who serves on the eQuality steering committee. In the new curriculum, students learn how to use inclusive and affirmative language when taking a patient’s sexual history and receive new content on the spectrum of human sexuality.
“This is patient-centered care, but it requires a lot of practice and skill to make sure you’re opening up the doors for those sensitive conversations.”
Mitchell Lunn, MD
University of California, San Francisco, School of Medicine
Involvement and feedback from the Louisville LGBT community has been essential to revamping the curriculum and underscoring the medical school’s commitment to inclusive care, according to Stacie Steinbock, MEd, director of the LGBT Center’s satellite office on Louisville’s Health Sciences Center campus. “We’re trying to be an institution that demonstrates in every way possible that we’re going to give excellent care to all patients,” added Holthouser, an associate professor of medicine and pediatrics at the School of Medicine.
At Case Western Reserve University School of Medicine in Cleveland, LGBT-inclusive activities began more than 20 years ago when students heard a panel of physicians speak about the challenges of being an openly gay or lesbian provider, said Kathy Cole-Kelly, MS, MSW, a professor of family medicine and codirector of the school’s Foundations in Clinical Medicine seminars. Over the years, however, the focus shifted more toward patient experiences.
Today, first-year medical students at Case Western receive four hours of required instruction on LGBT patient care. On the topic of transgender health, for instance, students learn about transgender terminology and the potential barriers to care and work to uncover any personal biases they may have about transgender people. One of the goals, Cole-Kelly said, is for students to understand that “acknowledging issues of sexual orientation and gender identity is a professional need.”
Recent pre- and post-session surveys of first-year medical students found they were positively benefiting from the LGBT-focused education, Cole-Kelly said. “The basic skills of building trust and sensitivity are universal and something we’re teaching constantly. But this is giving [students] comfort with language and questions that they haven’t experienced before.”
Nelson Sanchez, MD, an assistant professor of clinical medicine at Weill Cornell Medical College and chair of the college’s LGBT committee, also emphasized inclusive communication when educating on LGBT care. About five years ago, Sanchez began giving first-year medical students a review of LGBT-related terms, disparities, and communication skills.
During the lecture, Sanchez offers a variety of ways to create a welcoming environment for LGBT patients. He suggests using conversation starters—for example, “Tell me about your last relationship”—that let patients disclose information at their own pace. He also discusses ways to make the physical clinical environment inclusive, such as displaying positive images of same-sex couples. Sanchez said the school’s curriculum committee is currently working to expand instruction on providing LGBT patient care throughout the first two years of medical school.
“For some, it’s personal,” said Sanchez, who identifies as a gay man. “For many of us, we feel a responsibility to our peers and to ourselves to help institutions of higher learning become inclusive of LGBT people.”