Education Columns

by Lynn M. Wilson, DO, Beth Careyva, MD, Judith Sabino, MPH, Nyann Biery, MS, Lehigh Valley Health Network

According to a 2018 Gallup poll, 4.5% of Americans identify as LGBTQ. LGBTQ individuals, and particularly older LGBTQ adults, may be more likely to experience health disparities, mental health disorders, and suicide due to stigma, social isolation, and prior discrimination.^1,2 Additionally, LGBTQ older adults are more likely than their heterosexual peers to be diagnosed with HIV, STIs, tobacco use disorders, and overweight/obesity.^3-5 Despite the unique health needs and disparities within this diverse population, many medical students, residents, and faculty report feeling inadequately prepared to care for LGBTQ patients.⁶ A prior survey of medical school deans noted that the average training in LGTBQ health during the preclinical and clinical medical school curriculum amounted to an average of 5 hours.⁷ The American Academy of Family Physicians suggests that prior LGBTQ-focused education has been insufficient and recommends that residencies develop curriculum to address this gap.⁸

Lehigh Valley Health Network (LVHN) is an integrated health system providing ambulatory and inpatient care across 95 clinical specialties serving communities in central and eastern Pennsylvania. Over the past several years, multiple education sessions regarding LGBTQ health have been implemented for medical students, family medicine residents, attending physicians, and staff; these sessions are nested within a larger organizational initiative aimed at enhancing the care and well-being of the LGBTQ community. As these sessions were not developed by a centralized entity within the network, they have variable structures and evaluations. 

A needs assessment conducted with a survey of clinicians found that the primary educational interests within family medicine included available health and community resources, transgender care, providing culturally respectful care, health disparities, and LGBTQ identities and cultures. These identified areas of interest were used to develop educational programming for clinicians and staff on LGBTQ terminology, barriers to care and stigma as root factors for health care disparities, and respectful communication skills to foster inclusive services for individuals who identify as part of the LGBTQ community. Education on these topics was provided at grand rounds, continuing education sessions, specialty-specific conferences, and department, practice, or unit-based educational sessions. Sessions incorporated Coming Out Stories,¹¹ role playing at department meetings, Safe Zone training,¹² podcasts,¹³ and blog posts.¹⁴ Multifocal medical student programming included World Café and panel conversations with individuals from LGBTQ communities. Students and residents informally highly recommended the activities continue for future classes. Some departmental divisions, such as the Section of Geriatrics, undertook additional education on LGBTQ health, apart from the priorities that had been identified by the needs assessment.

As part of LVHN’s larger initiative, education on LGBTQ older adults was held at four family medicine practices. The objectives of the session were to evaluate changes in health professionals’ knowledge, perceptions, and attitudes toward LGBTQ older adults after viewing Gen Silent. Providers and staff were recruited via email to attend 45-minute lunch sessions, which included viewing a 25-minute educational version of the documentary Gen Silent followed by a brief discussion.⁹. Pre- and postsession surveys were comprised of questions previously utilized by Porter et al.¹⁰ Links to complete the presession survey online were sent to all practice staff members via email. Seventeen individuals (N=17) met inclusion criteria by viewing the film and completing both pre- and postsession surveys. There was a significant change (P<.05) between the mean scores of two of the Likert scale statements “I am aware of policy disparities between heterosexual and lesbian, gay, bisexual, and transgender older adults” (pre 2.76+1.15; post 3.88+0.86), and “I know that LGBTQ older adults face additional barriers to care in comparison to their heterosexual peers” (pre 3.94+1.09; post 4.47+0.72). Those with previous training were less likely than those without to change their response to any given statement.

Additional learning opportunities included a 2-hour session for primary care clinicians that utilized a partnership with a local community-based organization (CBO) to plan a panel with older adult members of the LGBTQ community. The goals of the session were to increase awareness of barriers to care for LGBTQ older adults, provide tips and techniques for improving interactions with LGBTQ older adults, and strategies for improving LGBTQ older adult patient experiences. A member of the CBO’s leadership team facilitated the panel. Panelists were asked about their experiences coming out to their health care team and interactions with health providers and staff throughout their life. The evaluations of the panel indicated that this was a positive experience for the health care providers in the room, and that the session helped them to identify ways they could better care for members of the LGBTQ community. Ninety-five percent of attendees felt they would apply what they learned to their work/job.

Conclusions

Our experience shows that it is feasible to use a multimodal approach to provide LGBTQ clinical education, including innovative programming regarding geriatric patients, to a large department of family medicine. Institutions may use our individual sessions alone or in combination to enhance the care and well-being of individuals in the LGBTQ community through improved clinical training and cultural competency for students, residents, and practicing clinicians in family medicine.

References

1. Emlet CA. Social, economic, and health disparities among LGBT older adults. Generations. 2016;40(2):16-22.
2. American Geriatrics Society Ethics Committee. American Geriatrics Society care of lesbian, gay, bisexual, and transgender older adults position statement: American Geriatrics Society Ethics Committee. J Am Geriatr Soc. 2015;63(3):423-426. https://doi.org/10.1111/jgs.13297
3. Centers for Disease Control and Prevention. HIV Among Gay and Bisexual Men. Atlanta: CDC; 2017. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf. Accessed February 27, 2020.
4. Struble CB, Lindley LL, Montgomery K, Hardin J, Burcin M. Overweight and obesity in lesbian and bisexual college women. J Am Coll Health. 2010;59(1):51-56. https://doi.org/10.1080/07448481.2010.483703
5. Lee JG, Griffin GK, Melvin CL. Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control. 2009;18(4):275-282. https://doi.org/10.1136/tc.2008.028241
6. Beagan B, Fredericks E, Bryson M. Family physician perceptions of working with LGBTQ patients: physician training needs. Can Med Educ J. 2015;6(1):e14-e22. https://doi.org/10.36834/cmej.36647
7. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977. https://doi.org/10.1001/jama.2011.1255
8. American Academy of Family Physicians. Lesbian, Gay, Bisexual, Transgender Health: Recommended Curriculum Guidelines for Family Medicine Residents. AAFP Reprint No. 289D. Leawood, KS: AAFP; 2013. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint289D_LGBT.pdf. Accessed February 27, 2020.
9. Maddux S. Gen Silent [Motion Picture]. Glendale, AZ: Interrobang Productions; 2011.
10. Porter KE, Krinsky L. Do LGBT aging trainings effectuate positive change in mainstream elder service providers? J Homosex. 2014;61(1):197-216. https://doi.org/10.1080/00918369.2013.835618
11. Bolger M, Killermann S. Coming Out Story. The Safe Zone Project; 2018.  https://thesafezoneproject.com/activities/coming-out-story/. Accessed February 27, 2020.
12. Bolger M, Killermann S. Safe Zone Training. The Safe Zone Project (2018) Retrieved from https://thesafezoneproject.com. Accessed February 27, 2020.
13. Defenbaugh N. Episode 12: Coming Out to Your Physician: Caring for Members of the LGBTQIA Community.[Podcast]. Health Stories; April 19, 2018. http://nicoledefenbaugh.com/blog/uncategorized/episode-12-coming-out-to-your-physician-caring-for-members-of-the-lgbtqia-community/. Accessed February 27, 2020.
14. Lehigh Valley Health Network. Coming Out to Your Doctor as an LGBTQ Patient. LVHN News. https://news.lvhn.org/coming-out-to-your-doctor-as-an-lgbtq-patient/. Published October 11, 2019. Accessed February 27, 2020.