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Research Article

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

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Article: 1947172 | Received 12 Dec 2020, Accepted 21 Jun 2021, Published online: 02 Jul 2021

ABSTRACT

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.

Introduction

Health disparities in the lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) communities have been well documented in recent years. Most well-known are the disproportionate rates of sexually transmitted infections (STIs) in men who have sex with men (MSM) and male-to-female (MtF) transgender patients[Citation1]. In addition, there has been research documenting increased behavioral risks among sexual and gender minority (SGM) people, including higher smoking rates, obesity, depression and other mental health disorders, and mortality from certain cancers[Citation1]. SGM individuals also show lower health-care utilization, in part due to perceived and real discrimination from health-care providers[Citation1]. A national survey of transgender patients found that 19% had been refused care due to their gender identity or expression, 28% reported being verbally harassed in a medical setting, and one-fourth of survey participants had delayed needed care because of disrespect and discrimination from medical providers[Citation2]. Reports have shown that SGM people often choose not to disclose their sexual orientation or gender identity to health-care providers due to actual or anticipated discrimination[Citation3]. This fear is not unwarranted: A survey of medical students published in 2015 found that 46% expressed explicit bias against SGM and 82% had some form of implicit bias[Citation4].

A 2011 study found that the median number of hours that a medical student in the US is exposed to SGM content is 5 hours[Citation5]. The same study found that though students were taught to ask patients: ‘Do you sleep with men, women, or both?,’ students felt they were not given enough instruction on how to counsel patients on safer sex behaviors for those who reported same-sex sexual practices. Another study showed that most medical students rated their school’s curriculum as ‘fair’ or worse in preparing them to care for SGM patients[Citation6]. Students reported feeling most prepared to address human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) and felt less prepared addressing sex reassignment surgery and gender transitioning for transgender and gender nonconforming patients[Citation6].

In 2014, the Association of American Medical Colleges (AAMC) released their seminal 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[Citation7]. This publication offers guidance to implement 30 recommended competencies for affirming LGBTQI care. The present study sought to answer the question: To what degree does the George Washington University (GW) core medical curriculum address important SGM competencies and topics for medical students?

Materials and methods

Participants and setting

We conducted an audit of pre-clinical medical curricula since all students are exposed to this content. Clinical content varies based on clinical rotations and sites, and is unlikely to include SGM content unless it is specifically sought by the student.

Study design

The authors compared the content to the AAMC competencies [Citation7] and to learning objectives established by Vanderbilt University. Content was catalogued as fully, partially, or not addressing content based on a previously developed protocol[Citation4].

Data sources

Data sources included the curriculum database, the 2016–2017 Clinical Skills and Reasoning (CSR) manual, professional development session notes, lecture notes from one student (NA), and student feedback on the accuracy of findings. Faculty feedback provided additional information on curricular changes after 2017.

Procedures

A medical student (NA) reviewed content from lectures and searched the curriculum database for learning objectives that included keywords: lesbian, gay, bisexual, trans, LGB, GLB, LGBT, MSM, WSW, MTF, FTM, homosexual, intersex, sex development, DSD, sexual orientation, and gender dysphoria. The database generated a report including the course title, block, and session objectives. The CSR manual was examined for keywords and topics. NA assessed professional development sessions and preclinical lectures by reviewing personal notes from coursework.

A matrix was compiled that displayed each AAMC competency domain and competency statement along with sessions that addressed the competency, format, and specific examples (see ). AAMC competency domains mirror the recommendations of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties; however, the competency statements under each domain illustrate competence in specific SGM health areas that medical students should be aware of, able to assess, and/or able to manage clinically[Citation8]. A separate table () compares content with Vanderbilt learning objectives.

Table 1. Medical school curricular alignment with association of American medical colleges competencies to improve health care for LGBTQI individuals

Table 2. Partially covered AAMC competencies

Table 3. Medical school curricular alignment with Vanderbilt topics for LGBTQI health

Member checking by four additional students and one faculty member confirmed the findings.

Results

The pre-clinical curriculum met 10 of the 30 AAMC competencies (see ). Of the eight AAMC competency domains, the most competencies fully addressed fell under the domains of patient care, knowledge for practice, practice-based learning, and interpersonal/communication skills. For example, within the patient care domain, the curriculum adequately addressed content to help students sensitively elicit relevant information about sex anatomy, sex development, sexual behavior, sexual history, sexual orientation, sexual identity, and gender identity and also covered assessing unique health risks and tailoring physical exams, counseling, and treatment recommendations for SGM patients. Within the knowledge for practice domain, the curriculum appropriate included content on 1) the differences between sex and gender; gender expression and identity; gender discordance v. nonconformity v. dysphoria; and sexual orientation, identity and behavior; and 2) typical sex development and etiologies of atypical development. Within the interpersonal and communication skills domain, the development of rapport with diverse SGM patients was adequately covered. For documentation of all fully addressed competencies, see .

Examples of competencies not at all met included: 1) identifying important clinical questions specific to SGM patients and finding evidence from research to inform clinical decision-making; 2) respecting the sensitivity of clinical information and considerations of when and how to communicate information about SGM status to others; 3) awareness of how SGM status might affect health-related beliefs; 4) acceptance of shared responsibility for eliminating bias in healthcare; 5) understanding the challenges faced by SGM health-care professionals; 6) navigating legal and policy challenges affecting the health and health care of SGM persons; 7) identifying SGM-affirming resources to support behavioral health; 8) partnering with community-based organizations to eliminate bias from health care and support SGM patient health; and 9) identifying strategies for reform to improve SGM health care. For documentation of all competencies not at all addressed, see .

For competencies partially met, most often intersex content was missing. An example of a partially met competency was the performance of a complete, accurate and sensitive physical exam across the SGM patient lifespan. While the content included an explanation of the difference between gender expression and anatomy, awareness that repeat genital exams by multiple providers could be traumatizing – particularly for intersex patients – was not covered. For a full description of partially met competencies along with what content was covered and what was not, see .

Of Vanderbilt topics, 22 were addressed, 5 were partially addressed, and 5 were not addressed. Curricula lacked content on STIs and vaginitis in lesbians, efficacy of anal microbicides, anal Pap smears, increased heart disease in lesbians, anal cancer risk in men who have sex with men (MSM), and lesbian nulliparity and cancer risk. Exploration of bias was done in professional development sessions, but how bias affects SGM patients specifically was not addressed. Small group sessions included two cases and five standardized patient scenarios which portrayed SGM patients, most of which involved gay men with HIV.

Discussion

Restatement of key findings

Overall, 28 sessions were found to include relevant material specific to SGM patients. Three sessions (LGBTQ Health Basics, Transgender Medicine, and LGBQ Health) focused specifically on SGM topics. These three sessions were mandatory and totaled 7.5 hours. A strength of the current curriculum was the opportunity for students to interact with the SGM community. While patient panels were well rated by students, some students expressed a desire for greater diversity among volunteers who were mostly white and of higher socioeconomic status. This critique reflects a lack of intersectionality in the curriculum. Gaps in addressing AAMC competency domains primarily included areas of professionalism, systems-based practice, interprofessional collaboration, and personal and professional development.

Comparison to other findings

This curricular audit indicated that GW’s medical school curricula met more AAMC competencies for SGM health care than some other institutions that have conducted similar assessments and but less than others who have taken a leadership role in implementing SGM health-care curricula. For example, GW met 10 AAMC competencies fully compared to 7 fully met by Georgetown’s medical school curricula[Citation9]. Yet, institutions, such as the University of Louisville, Kentucky [Citation10,Citation11] and the University of California Davis [Citation12] have made greater strides in addressing medical student competence for serving SGM patients by taking a systems approach to reform of curricula.

Explanation of differences among findings

A recent review of institutions leading SGM curricular change in health-care professional schools noted that empowered, motivated champions for change; available content expertise; alignment with organizational culture; institutional commitment; and inclusive strategic planning were keys to successful SGM health curricular change[Citation13]. A key lesson learned from that review was ensuring that responsibility for inclusion of SGM health content is spread across faculty, not dependent on one or few faculties [Citation13]. Medical schools that wish to bolster SGM health content can leverage these lessons learned to facilitate change.

Limitations

This study was limited to a review of the preclinical curriculum at one point in time at one institution. Only one medical student conducted the review. The search terms used do not reflect the full spectrum of terms that SGM individuals use to identify themselves.

Strengths

This study is among the earliest systematic assessments of a medical school curriculum in regard to AAMC-endorsed medical student competencies for SGM health. The triangulation of data from the curriculum database, student notes, and faculty and review of findings are a strength of the study.

Next steps

Recommendations to address unmet competencies include diversifying standardized patients, case vignettes, and group discussions. More content on lesbian, bisexual, transgender, and intersex health needs; physician roles in challenging policies that perpetuate SGM inequities; and system-level strategies to provide more affirming SGM health care are warranted. After this assessment, clinical cases and standardized patient scenarios which portrayed SGM patients were expanded to include a lesbian woman seeking a referral for family planning, an elderly woman grieving over the loss of a female partner, a same-sex couple in the emergency room with suspected domestic violence, and a young man visiting a new provider who expresses shame regarding his attraction to other men. Additionally, an introduction of lesbian STIs and a bisexual standardized patient case has been added.

Resources

Resources available to improve SGM content in medical schools include the AAMC publication of core competencies for providing affirming SGM health care[Citation7], the Med Ed Portal[Citation14], the National LGBT Health Education Center[Citation15], the GW Cancer Center[Citation16], the University of California San Francisco Center of Transgender Excellence[Citation17], the World Professional Association for Transgender Health (WPATH)[Citation18], the Endocrine Society[Citation19], and InterAct and Lambda Legal[Citation20].

Conclusions

A growing awareness of the health risks and health-care needs of SGM individuals demands responsive curricula from medical schools. This study models a systematic way to identify gaps to target curricular enhancements in medical education and training – specifically by applying new curricular standards and by leveraging insights from a student investigator as an experiential researcher.

Overall, this study suggests the need for thoughtful integration of content into the medical school curriculum to better prepare students to care for SGM patients. Enhanced curricula should include helping students recognize gaps in science; make medical management decisions when clinical evidence is lacking; tailor physical exams; identify community resources for SGM patient support; understand legal context for SGM patients; address lesbian-specific health concerns; and address SGM subpopulations’ needs for health screening and medical management.

List of Abbreviations

AAMC: Association of American Medical Colleges

GW: The George Washington University

LGBTQI: Lesbian, gay, bisexual, transgender, queer, and intersex

SGM: Sexual and gender minorities

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the The George Washington University Gill Fellowship.

References

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