Transgender Youth Standardized Patient Encounters

The purpose of this learning activity is to allow learners to practice their gender-affirming communication skills through standardized patient encounters (SPEs). Two SPEs were developed and embedded within a larger Transgender Youth Curriculum originally comprised of online learning modules. The online modules can be found on MedEdPORTAL¹. The training that was required for implementation of the SPEs and the impact of the SPEs being incorporated into the curriculum on learner skills and self-efficacy have been previously described². We now aim to share the SPE cases and learning assessments. The SPEs were conducted in-person in our institution’s simulation center from 2017-2020. However, the SPEs can be adapted to be done virtually, with no direct in-person contact. 

Our SPEs were conducted with the following target learners on a 4-week Adolescent Medicine rotation: 4th year medical students, 1st year psychiatry residents, 1st year pediatrics residents, and nurse practitioner trainees. Two standardized patient encounter cases were created. One case focuses on Jane Dalton, who is a 16-year-old who identifies as female and was designated male at birth. The second case focuses on Kel Carl, who is a 16-year-old who identifies as male and was designated female at birth. The case description and training instructions are included in Appendix A (Jane) and Appendix B (Kel). The learning objectives for the activity are to: 

• Obtain a gender history from a gender diverse youth.
• Obtain a psychosocial history from a gender diverse youth using the HEADSS psychosocial framework. 
• Query a youth’s affirmed name and affirmed pronouns and consistently use them throughout the encounter.
• Explain the need for the pubertal exam for consideration of gender-affirming medications.
• Prepare the patient for the pubertal exam.
• Describe necessary steps for a youth under the age of 18 to initiate gender-affirming medications. 
• Provide basic counseling on gender-affirming medications appropriate for a patient’s affirmed gender and pubertal stage.

For the activity, learners are instructed to review online modules prior to the SPE activity. For our curriculum, SPE sessions were held one half-day per 4-week rotation with 4-6 learners. Each learner completed 2, 20-minute encounters (2 SPEs were ran simultaneously). Before entering the standardized patient’s clinic room, learners review the instructions posted on the outside of the room (Appendix C for Jane case and Appendix D for Kel case). Additionally, if the learner asks the standardized patient about doing a physical exam to assess sexual maturity rating, the learner is to not do that part of the exam. Instead, the standardized patient will point to a paper with the results of the exam (Appendix E). Learners are informed when half of their time is remaining and when 5 minutes are remaining in the encounter.

For each SPE, an assigned faculty member observes the encounter via closed circuit television monitoring and completes the faculty observer checklist which focuses on taking pertinent history and counseling elements (Appendix F for Jane and Appendix G for Kel). After each SPE, the learner is instructed to reflect on their encounter by completing a learner checklist which is identical to that of the faculty checklist (Appendix F for Jane and Appendix G for Kel). The standardized patient also completes a standardized patient checklist that focused on interpersonal communication (Appendix F for Jane and Appendix G for Kel). The faculty member then leads a 10-minute reflection section during which they ask the learner to name 2 things that went well with the encounter and 1-2 things they can stretch themselves to improve upon with the next SPE or when they care for a gender diverse youth. This is then to be followed up with feedback from the faculty member and the standardized patient. After completion of both SPEs, learners complete a post-SPE survey that captures learner satisfaction and self-efficacy (Appendix H). Although our SPEs were conducted in-person in a simulation center with actors, other centers could use our cases and assessments with actors via a virtual platform or use our cases in role-playing scenarios. Appendices (please note use of both names; the learner is not supposed to know the standardized patient’s chosen name until during the encounter): 

• Appendix A: John_Jane Dalton Case
• Appendix B: Kelly_Kel Carl Case
• Appendix C: John_Jane Dalton Presenting Situation and Instructions
• Appendix D: Kelly_Kel Carl Presenting Situation and Instructions
• Appendix E: Kel Carl and Jane Dalton Physical Exam Findings
• Appendix F: John_Jane Dalton Standardized Patient Skills Checklist
• Appendix G: Kelly_Kel Carl Standardized Patient Skills Checklist
• Appendix H: Post-Standardized Patient Encounter Survey Assessment

This work was primarily supported by the UCSF Academy of Medical Educators Innovations Funding for Education Grant. Additional support was provided by the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under a Cooperative Agreement UA6MC27378 for the Adolescent and Young Adult Research Network, by the HRSA/MCHB Leadership Education in Adolescent Health (LEAH) training grant T71-MC00003, by the UCSF Office of Diversity and Outreach, and by the Robert Wood Johnson Foundation Amos Medical Faculty Development Program. 

References:

1. Vance SR, Buckelew SM, Dentoni-Lasofsky B, Ozer E, Deutsch MB, Meyers M. A Pediatric Transgender Medicine Curriculum for Multidisciplinary Trainees. MedEdPORTAL. 2020; 16:10896. https://doi.org/10.15766/mep_2374-8265.10896 
2. Vance SR, Dentoni-Lasofsky B, Ozer E, Deutsch MB, Meyers MJ, Buckelew SM. Using Standardized Patients to Augment Communication Skills and Self-Efficacy in Caring for Transgender Youth. Acad Pediatr. 21(8):1441-1448 https://doi.org/10.1016/j.acap.2021.05.010