“I want to break free”: Integrating LGBTQ health competencies throughout the medical education continuum

Although evolving, medical schools have traditionally been slow to embrace social change in the curriculum.¹ Take, as an extreme example, a 2019 Wall Street Journal essay published by the former Dean of the University of Pennsylvania School of Medicine Dr. Stanley Goldfarb entitled, “Take Two Aspirin and Call Me by My Pronouns.”² In the essay, Goldfarb lambasts the “inculcation of social policy” in modern medical education and argues that these ideas have no place in a profession aimed at maximizing the “quality and effectiveness of health care”. More recently, a 2022 Wall Street Journal essay by the Editorial Board further criticized medical education for obliging future doctors “to learn how health relates to ‘systems of oppression.”³

Even outside of medical education, many individuals may intrinsically know this supposition to be false. In an increasingly networked and multicultural society, social determinants of health (environmental factors impacting health and functional ability) have been identified as a significant effector of health disparities and a priority area for the Department of Health and Human Services’ (HHS) Healthy People 2030 national objectives.⁴ Practicing clinical medicine without a solid understanding of these topics is willful ignorance of an essential prognostic indicator.

Many minoritized communities experience the negative effects of social determinants of health. Personal examples include the frustration of being unable to access pre-exposure prophylaxis (PrEP) for HIV prevention in a primary care setting, or the countless times I’ve been asked whether I have sex with “men, women, or both” as close-ended options for a sexual history. Though referral to an infectious disease clinic may appear to be a small inconvenience from a clinician perspective, the widespread inaccessibility of PrEP in the primary care setting contributes to a perception of inadequate cultural competency and reframes LGBTQ sexual health as a disorder of “high risk homosexual behavior (ICD10: Z72.52)”. With these ideas in mind, I joined an effort at Cleveland Clinic Lerner College of Medicine (CCLCM) to reevaluate how LGBTQ issues are addressed in the curriculum.

Previously, courses lumped all LGBTQ-related subjects into one lecture, often in the “Doctoring” course and not in the basic science courses. This provides the benefit of easy organization and consistency in depth of coverage of topics, but falls short in many areas. Suppose a student is absent for this session? Suppose the session is optional? Studies support spaced repetition as an effective system to help learners acquire and retain a myriad of items in their memory.⁵ Why then should we introduce students to these concepts only once? By keeping to a traditional system of lumping all LGBTQ topics together, we miss an opportunity to address the health of the LGBTQ+ community as integral to the teaching of basic and clinical sciences. Though the exact number of hours likely ranges significantly between schools, a JAMA study suggests that the national average of time spent on LGBTQ care during both preclinical and clinical years was just 5 hours.⁶

After conducting a curricular needs assessment, we approached this problem by identifying areas of possible content integration and presenting individual seminar leaders with only one slide on a LGBTQ topic relevant to their lecture. This affords the opportunity to create a longitudinal thread of knowledge, rather than a single isolated lecture, throughout the preclinical years of medical education. Over the grand scheme of a two-hour seminar, this is a small ask, but it substantially contributes to students’ knowledge over the course of the preclinical curriculum. We describe our approach and process in an upcoming issue of SGIM Forum. Our initial survey of preclinical students indicated that 63.6% (21/33 respondents) of first and second-year students were interested in learning additional LGBTQ+ content. Towards that end, we have integrated 57.6% (34/59) of our group’s suggested learning points into the preclinical curriculum thus far.⁷ This successful model of curricular integration has been adopted by other interest groups, as is for example a curriculum action group addressing the health of people with disabilities.

Working with seminar leaders to integrate relevant concepts was one thing, but watching these lectures be delivered with classmates was an entirely fresh experience. For example, we worked with a cardiologist to incorporate the physiologic effects of gender-affirming hormone replacement therapy on cardiac performance indexes. As these slides were covered in lecture, fellow students expressed that they had not previously made a connection between sex hormones and cardiac performance. Beyond providing an understanding of the difference between sex and gender, this slide spurred students to interrogate their understanding of physiology – an unintended benefit of our efforts. As we continue our efforts in this area, we hope that even critics of our work will see how clearly this can lead to more effective and high-quality healthcare.

-Will Patterson, Brady Greene, Jason Lambrese, MD, and Monica Yepes-Rios, MD

Will Patterson is a third year MD/MPH student at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (CCLCM) and is originally from Philadelphia, PA. He was involved in HIV/PrEP implementation research prior to matriculation and is a member of the CCLCM diversity and inclusion task force LGBTQ curriculum action group. @willmpatterson

Brady Greene is a third year MD/MS student at CCLCM and is originally from Smithfield, Rhode Island. He was involved in neglected tropical disease drug discovery research prior to matriculation and is a member of the CCLCM diversity and inclusion task force LGBTQ curriculum action group. @bradydgreene

Dr. Lambrese is a child and adolescent psychiatrist at the Cleveland Clinic, and assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and an assistant dean for student affairs at Case Western Reserve University School of Medicine. He serves as the faculty lead on the CCLCM diversity and inclusion task force LGBTQ curriculum action group.

Dr. Yepes-Rios is an internist at the Cleveland Clinic. She is an Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University, and Assistant Dean, Diversity Equity and Inclusion. She is passionate about investing in an inclusive learning environment and in the care of underserved communities. @MonicaYepesRios

References:

1. Blood AD, Farnan JM, Fitz-William W. Curriculum Changes and Trends 2010–2020: A Focused National Review Using the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II. Academic Medicine. 2020;95(9S):S5-S14. doi: 10.1097/ACM.0000000000003484
2. Stanley Goldfarb. (2019, September 12). Take Two Aspirin and Call Me by My Pronouns. Wall Street Journal. https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291
3. The Editorial Board. (2022, July 26). Medical Education Goes Woke. Wall Street Journal. https://www.wsj.com/articles/medical-training-goes-woke-association-of-american-medical-colleges-doctors-11658871789
4. U.S. Department of Health and Human Services. (2020). Healthy People 2030. Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople
5. Tabibian, B., Upadhyay, U., De, A., Zarezade, A., Schölkopf, B., & Gomez-Rodriguez, M. (2019). Enhancing human learning via spaced repetition optimization. Proceedings of the National Academy of Sciences of the United States of America, 116(10), 3988–3993. https://doi.org/10.1073/PNAS.1815156116/SUPPL_FILE/PNAS.1815156116.SAPP.PDF
6. Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., Wells, M., Fetterman, D. M., Garcia, G., & Lunn, M. R. (2011). Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA, 306(9), 971–977. https://doi.org/10.1001/JAMA.2011.1255
7. Greene BD, Shu J, Bowen K, Hopkins M, Lambrese J. The “One Slide Approach”: An Adaptable Model To Enhance Medical Student Pre-Clinical LGBTQ+ Education. SGIM Forum. 2022;45(10):11, 13, 16.