A Call for LGBTQ Content in Graduate Medical Education Program Requirements

Abstract

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health–related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face a series of well-documented health disparities,^1,2 which are often explained using the minority stress model.³ First applied to the LGBTQ community by Ilan H. Meyer, the minority stress model posits that interpersonal and structural experiences of stigma, prejudice, and discrimination contribute to poorer health outcomes. For instance, physicians lacking cultural sensitivity and relevant clinical competence may create negative experiences for LGBTQ patients who may then avoid seeking future care, which, in turn, can lead to poorer health outcomes.⁴

In 2010, Lambda Legal published its landmark study When Health Care Isn’t Caring, which revealed the extent of LGBTQ individuals’ negative experiences in health care.⁵ Nearly 56% of individuals who are lesbian, gay, or bisexual; 63% of people with HIV; and 70% of transgender and/or gender-nonconforming individuals experienced some type of negative encounter with a physician.⁵ Negative experiences ranged from excessive precautions to outright denial of care.⁵ Ongoing disparities in care and outcomes of LGBTQ individuals—exposed, in part, by the Lambda Legal report—led organizations like the National Academy of Medicine,⁴ The Joint Commission,⁶ and the U.S. Department of Health and Human Services⁷ to release reports (in the early 2010s) that called for the health care sector to systematically address these issues through research; changes to clinical practice; and improvements in undergraduate medical education (UME), graduate medical education (GME), and continuing professional development. In response, over the last decade, some training programs—particularly at the UME level—have updated their curricula to include LGBTQ-related content; however, there have been several problems associated with these decentralized changes: (1) high levels of variability across programs, (2) uncertain effectiveness in improving LGBTQ patient care, and (3) a lack of effective mechanisms to evaluate the extent and impact of these changes.

Although the academic medical community must continue to improve LGBTQ health-related education at every level of the medical education continuum, given the recent implementation of major revisions to the GME Common Program Requirements by the Accreditation Council for Graduate Medical Education (ACGME), now is the time to reform the approach within GME to help eliminate bias against LGBTQ patients. The community simply must institute requirements for the inclusion of LGBTQ-specific topics in GME, as appropriate for each specialty, using the developments and lessons learned at the UME level over the past decade as a framework.

The Social Context of Delivering Care to LGBTQ Patients

Before discussing LGBTQ-specific curricular content at either the UME or GME level, it is first useful to consider the sociohistorical context in which physicians care for LGBTQ patients from the minority stress and life course perspectives. The life course perspective examines “how events at each life stage can influence later stages, both from an individual (biological and social) and environmental (cultural and contextual) aspect.”^8(p4) Combined with the minority stress perspective, it provides a powerful framework for understanding how experiences of interpersonal and structural stigmas at earlier stages of life can contribute to poorer social and health outcomes in later stages of life. Thus, physicians and medical educators should briefly consider how historic and contemporary events affect the health outcomes of LGBTQ patients both right now and in the future.

In 1972, 3 years after the Stonewall Riots, Dr. John E. Fryer delivered a consequential speech to the American Psychiatric Association (APA). Using a voice modulator, mask, and baggy suit to conceal his identity out of fear of professional repercussions, Dr. Fryer described his experiences working as a gay psychiatrist at a time when the APA classified homosexuality as a mental illness.⁹ One year later, the APA removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, and Dr. Fryer’s speech is often cited as a driving factor in the decision. Although the APA’s actions represented a significant step in deconstructing institutionalized medical stigma against gay Americans, many elements perpetuating stigma remained in health care. During the AIDS crisis, for instance, physicians, professional organizations, and government commissions debated the physician’s ethical obligation to treat AIDS patients¹⁰—and over 311,000 people died of AIDS before the advent of highly active antiretroviral therapy in 1995.¹¹ Efforts to improve health care for the LGBTQ population must recognize that this history lives on through its members. LGBTQ people who were in their twenties and thirties during Stonewall, John Fryer, and the height of the AIDS epidemic are now patients in their seventies and eighties who face unique health challenges due—in no small part—to their social history.⁸ Similarly, physicians and medical educators must consider how current events will influence the health of these vulnerable populations. How do—and how will—the 2019 ban on transgender people serving openly in the military,¹² the ongoing debate over the physician’s ethical obligation to treat transgender patients,^13,14 and the experiences of over 74,000 LGBTQ 13–17-year-olds who are expected to undergo conversion therapy by the time they turn 18¹⁵ affect the health of the members of this community? Considering this history and medicine’s ongoing failure to fully meet the needs of sexual and gender minorities, medical educators must take meaningful steps to promote justice for this community by reducing and eliminating the disparities it experiences.

Current Practices of Incorporating an LGBTQ-Specific Curriculum into UME

Students entering U.S. medical schools have a diverse range of sociocultural backgrounds; they have completed varying undergraduate (baccalaureate) and graduate courses; and they have engaged in all manner of volunteer and work experiences. Given these differences, UME represents the first opportunity for medical educators to ensure that all physician trainees have the same foundational understanding of sexuality and gender—just as they do biochemistry or genetics. In 2011, Obedin-Maliver and colleagues reported that U.S. and Canadian medical schools dedicated a median of 5 hours to LGBTQ-related health education.¹⁶ Given the depth and breadth of LGBTQ health issues, such time is inadequate to prepare future physicians to care for LGBTQ patients. Furthermore, our own experiences at the Vanderbilt University Medical School Program for LGBTQ Health indicate that UME students want to learn more about LGBTQ health and LGBTQ issues to better serve people who are LGBTQ and their families: Our program was born out of a call from our medical students who told us that they were not prepared to care for LGBTQ individuals due to gaps in our curriculum. As a result, we integrated LGBTQ-specific topics throughout our UME curriculum, even creating an optional certificate program, to better serve our students and their future patients.

Since the release of the Obedin-Maliver et al study, the Association of American Medical Colleges (AAMC) has published its first set of guidelines for incorporating LGBTQ-specific content into UME curricula.¹⁷ These AAMC guidelines suggested the multimodal integration of LGBTQ health-related topics through the use of didactic instruction, case-based learning, and clinical rotations, and the guidelines cite several programs as examples of best practices. For instance, in our own interdisciplinary, basic science course “Brain, Behavior, and Movement,” we teach first-year medical students about the neurobiological bases of sexual orientation and gender identity. Additionally, our faculty have interviewed LGBTQ patients about their experiences obtaining health care in Nashville, Tennessee, and, importantly, we provide students with the opportunity to ask questions. These efforts to integrate LGBTQ-specific material into the curriculum, combining didactic education with patient exposure, are critical to introducing trainees to the provision of clinically and culturally competent care for sexual and gender minorities. Only by thoughtfully building upon this exposure at the GME level will medical educators reduce and eliminate the disparities in care experienced by the LGBTQ community.

Other medical schools have carried out similar curricular reforms in recent years. The University of Louisville School of Medicine, for instance, has piloted a curriculum—the eQuality curriculum¹⁸—that follows the AAMC’s guidelines for the multimodal integration of LGBTQ-specific topics into UME. Louisville reports that LGBTQ-specific topics have been integrated into 33 hours of existing curricula and that 17.5 hours of LGBTQ-specific information have been added.¹⁹ Other institutions—such as the University of California, San Francisco; New York Medical College; the Medical College of Wisconsin; and the University of Mississippi—have completed similar efforts.

These changes represent exciting progress in reforming the UME approach to LQBTQ-related content, but medical educators must consider current limitations in improving LGBTQ patient care. First, the academic medicine community does not know how widespread these curricular reform efforts are since (to our knowledge) no researchers have released a comprehensive report on LGBTQ-related content in UME since Obedin-Maliver et al in 2011.¹⁶ Second, the community does not know how changes compare across programs, or—importantly—how effective these changes are in improving LGBTQ patient care. Notably, however, recent literature suggests that more curriculum time is not, by itself, sufficient to prepare future physicians to effectively and compassionately care for LGBTQ patients.^20,21 This literature does not suggest that didactic hours are an ineffective component in preparing future physicians to care for LGBTQ patients but, rather, that new physicians must also gain exposure to LGBTQ patients to best care for them. This clinical exposure is where GME must bridge the gap. Residents and fellows must have opportunities to work with LGBTQ patients and build on the foundations of their UME experience. Ultimately, such opportunities arise only through intentionality, which is why the academic medicine community must begin discussing frameworks and best practices for incorporating LGBTQ-specific content into the GME curriculum.

Integrating LGBTQ-Specific Curricular Content into GME

On June 10, 2018, the ACGME Board approved a major revision of its Common Program Requirements that then went into effect on July 1, 2019.²² Included in the revisions are core requirements for increasing the diversity and inclusion of GME programs and for expanding professional requirements to include new diverse patient groups. Specifically, Common Program Requirement IV.B.1.a).(1).(e) (hereafter, the Diverse Populations Requirement) specifies that residents must demonstrate the following competency:

respect and responsiveness to diverse populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origins, socioeconomic status, and sexual orientation.²²

Notably, this new Diverse Populations Requirement makes no explicit reference to gender identity—a regrettable gap.

With these changes to the ACGME Common Program Requirements comes a natural opportunity to address LGBTQ needs within GME. To do so, GME educators must first understand that most medical specialties have unique clinical considerations pertaining to sexual and gender minority health (see Table 1). While not all these topics could be included in every GME program, the fact that so many medical specialties have connections to sexual and gender minority health underscores the importance of including education around this basic element of human diversity throughout health professions education.

Table 1: Clinical Considerations for LGBTQ Individuals and Areas of LGBTQ-Related Research for 27 Major Medical Specialties

Next, given the breadth of LGBTQ-specific topics in 27 medical specialties, the ubiquity of LGBTQ patients across medical settings, and the ACGME’s aspirational Diverse Populations Requirement, the GME community should critically appraise the steps that program directors are taking to ensure their residents/fellows meet the requirement. Published literature on LGBTQ-specific curricula in GME suggests numerous gaps (see Table 2).

Table 2: Studies Related to LGBTQ Training in Graduate Medical Education

The first key takeaway from this literature is that the GME community lacks meaningful information on even whether residency programs incorporate LGBTQ-specific information in their curricula. Studies surveying program directors on the inclusion of LGBTQ-specific information in curricula exist for only emergency medicine,²³ plastic surgery,²⁴ psychiatry,²⁵ and urology²⁴—and these studies reveal that, depending on the specialty, anywhere between 18% and 70% of programs include no LGBTQ-related training. Concerningly, Morrison and colleagues found that some program directors would not include LGBTQ-specific training in their curricula unless mandated by the ACGME.²⁴ This troubling finding underscores the importance of making a systemic change to GME’s approach by operationalizing the Diverse Populations Requirement. Although, as noted, there is no program director survey-based study on the inclusion of LGBTQ-specific content for many medical specialties, a review of the ACGME Program Requirements is telling: Of 27 medical specialties, only psychiatry makes an additional reference to sexual orientation beyond the newly instituted Diverse Populations Requirement,²⁶ and no program’s requirements make additional references to gender identity. Even the program requirements for infectious disease, a subspecialty whose practitioners have cared heavily for LGBTQ patients by managing HIV/AIDS and providing preexposure prophylaxis, make no additional mentions of sexual or gender minorities.²⁷

The second major takeaway from the literature is that residents lack the requisite knowledge and comfortability to care for LGBTQ patients. To illustrate, Streed and colleagues found that postgraduate year 1–3 residents scored between 50% and 52% on an exam designed to evaluate their knowledge of basic LGBTQ health-related topics,²⁸ and Hayes and colleagues found that residents and fellows, compared with medical students, reported feeling less comfortable interacting with LGBTQ patients.²⁹ These gaps naturally raise the question of how we, the community of educators, should work to fill them. First, GME educators must consider the 2 interrelated sides of LGBTQ health that need to be addressed: cultural competency (i.e., the ability to provide affirming care to LGBTQ patients) and clinical competency (i.e., familiarity with specialty-specific LGBTQ considerations such as those highlighted in Table 1). Studies in internal medicine, psychiatry, and pediatrics have tested discrete interventions aimed at increasing residents’ comfort, knowledge, empathy, and confidence in caring for LGBTQ patients. While each intervention proved effective at improving these metrics immediately post administration, Kidd and colleagues’ finding that residents reverted to their preintervention levels of empathy, knowledge, and comfort 90 days post intervention suggests the limits of isolated interventions.³⁰ Given this, medical educators should consider how to integrate LGBTQ-specific cultural competency topics into a larger longitudinal thread, thereby operationalizing the Diverse Populations Requirement. Several possibilities exist: Siegel and colleagues, for instance, provide 6 principles for integrating social determinants of health content into GME and similarly call on the academic medical community to address gaps in teaching about these important indicators³¹; Aysola and Myers provide principles for incorporating quality improvement and health equity into the curriculum³²; and Donald and colleagues outline the benefits of using a structural competencies approach in medical education to improve care for LGBTQ patients.³³ Importantly, using any one of these approaches provides an opportunity to address multiple issues of cultural competency and bias in GME so that reforms benefitting LGBTQ patients do not come at the expense of other disadvantaged patient groups.

Finally, each specialty must build upon this preceding cultural competency thread by integrating LGBTQ-specific clinical training as appropriate. We believe that developments at the UME level provide a useful framework for approaching these reforms, as well as several lessons: Academic physicians within each specialty should begin by defining learning objectives and competencies for LGBTQ-specific learning that are based on the most recent research and current evidence-informed best practices. Medical educators should then outline how GME programs can best incorporate the multimodal integration of LGBTQ-related topics into their current curricula so that residents and fellows can fulfill their learning objectives and competency goals. Some educators may be concerned that the addition of LGBTQ-related topics into GME would place an undue burden on program directors; we believe that the multimodal integration approach used in UME will be key to avoiding this problem. We have pointed out that program director surveys indicate that a few programs include LGBTQ-related topics already; the biggest issue is the substantial portion of programs that include nothing.

We suggest that, after outlining approaches to integrating LGBTQ-related topics into their curricula, select programs trial these reforms so that effectiveness can be measured and adjustments made, if necessary. We suggest this trial-and-reform step to avoid replicating the problem UME incurred: having little knowledge about whether curricular changes have been effective in improving LGBTQ patient care. Finally, we suggest that, using data from the trials and making any necessary adjustments, the ACGME implement these requirements nationally with appropriate monitoring, so the medical education community can continue to measure and report on progress.

Though our plan perhaps represents a more conservative approach, we believe it increases the likelihood that programs will achieve reforms in the right way, ultimately benefitting patients. Fortunately, this work has already begun in some specialties; medical educators have worked to develop an HIV primary care track in internal medicine and an LGBTQ area-of-distinction in psychiatry. Now, the community must build upon this momentum to address the long-standing dearth of LGBTQ-specific content in GME and thereby address the needs of an underserved patient community.

Conclusion

To conclude, GME programs must take responsibility for educating future physicians about LGBTQ patients; GME must stop placing that responsibility on already vulnerable LGBTQ patients. Requirements for interacting with specific patient populations are not without precedent (e.g., program requirements for internal medicine require residents to gain experience with geriatric patients—a demographic group that requires specific clinical and cultural competencies just as LGBTQ patients do.)³⁴

At the end of his speech to the APA, John Fryer called on the conference attendees to use their “skills and wisdom to help [gay men]—and us—grow to be comfortable with that little piece of humanity called homosexuality.”⁹ Though many changes to the benefit of the LGBTQ community have occurred since Fryer’s speech, the urgency and mission behind his words persist. Ultimately, the time for medical educators to use their skills and wisdom (and even policies) to reform GME for the benefit of LGBTQ patients is long overdue.

Acknowledgments:

The authors would like to thank Camille Ivey at the Vanderbilt University Eskind Family Biomedical Library for her assistance with their literature search. The authors would also like to thank the anonymous reviewers for their helpful feedback and suggestions for revision.