Taylor Changemaker Catalyst Award recipient Shana Zucker is a current MD/MPH/MS degree candidate the Tulane University School of Medicine, with ambitions to revolutionize the integration of LGBTQIA+ health into medical education. Starting with the “Queericulum,” an online module case-based learning program she developed and implemented at TUSOM, the Changemaker Catalyst Award has provided her with opportunities and momentum to disseminate her work and attend conferences, with the aim of making the curriculum a national standard.

 

Chapter 1: The Beginning – 11.30.17

 

“I have an idea, and I was hoping for some guidance,” I remember saying, sitting in the office of Dr. Myo Thwin Myint, my advisor for the Tulane Organization of Gays and Allies. As opposed to his spacious office in the Tulane Medical School with large windows and a big, comfy couch–the kind of place where creativity would thrive–we were meeting in his office at the VA: small, windowless, gray, no cellular or Wifi signals, the very picture of a workspace of productivity, efficiency, and bureaucracy. This office is no fit for this man, a young and incredibly accomplished, triple-board certified physician, educator, and researcher. Here, I explained to him my frustration with the lack of cultural competence generally among physicians today, rooting in the fact that there is minimal undergraduate medical education pertinent to queer health, apart from the perpetuation of the same one-dimensional picture of The Gay Patient, to which all that is relevant is HIV/AIDS or mental illness. I had just come across the Association of American Medical Colleges’ (AAMC) Integrating LGBT Health into Medical Education, which is a publication outlining numerous ways to teach LGBTQIA+ health, and included sample materials. I explained to Dr. Myint that I wanted to use the provided case-based scenarios as a jumping off point to develop a mandatory curriculum for all first year students at Tulane, and was hoping he could advise me as it was built, and help me advocate for its implementation on the administrative level. And, as a good public health student, I explained my plans to evaluate the subsequent curriculum’s efficacy in developing knowledge, attitude, and competence with regard to providing culturally competent and appropriate treatment for queer patients. It was here, in this small, gray room, where the spark began. In this space, that could appear in the dictionary next to the word “confined,” that Dr. Myint gesticulated with large arm movements as he declared “Dream bigger, Shana!” Here, the Queericulum began.

 

For background, the LGBTQIA+ population is a particularly vulnerable population in health care; there are tremendous health disparities, including, but not limited to, higher risk of depression, suicide attempts, traumatic stress disorders, eating disorders, smoking, substance abuse, unplanned pregnancies, and STIs. There is decreased access to preventive care, resulting in higher cancer risk with poorer outcomes due to later detection, as well as obesity and its secondary morbidities. There is also a higher risk of homelessness. Within the healthcare setting, queer patients frequently face mistreatment by healthcare professionals, ranging from implicitly-biased comments and glances, to blatant refusal of care. Consequently, LGBTQIA+ individuals suffer from significant health disparities, often being unable to seek care when needed. “Multiply marginalized” people, such as people of color, folks who are not neurotypical, and those with different accessibility needs (to name a few), with one or more of these minority gender and/or sexuality identities are at even higher risk of facing barriers to care. Given these disparities, it would seem natural that extra attention would be devoted to addressing these unique health needs in medical education. However, after doing research, I found that most medical schools neglect these topics preclinically; the standard education of a medical student with regard to queer health and wellness is learning while on the wards. Essentially, an already vulnerable population is being treated by unprepared, under-educated medical students, who are expected to learn the intricacies of LGBTQIA+ health on the fly during their first encounter with those bearing these identities (Wilson 2014). This could lead to students relying upon ill-conceived stereotypes, that have far reaching effects, including creating a hostile environment for the patient, resulting in hesitancy to seeking healthcare in the future. In terms of pre-clinical curricula, most medical schools do not include important LGBTQIA+ topics in their mandatory curricula, while some do have electives in which students who are interested can seek out this information. When taught in a preclinical setting, the inclusion of LGBTQIA+ health is one-dimensional, as previously mentioned, typically within the context of sexual history-taking, discussion of HIV/AIDS, and mental health. While this population may be at higher risk for these conditions, their lack of inclusion of discussing queer patients throughout the curriculum creates a dangerous and false impression that, at first look, LGBTQIA+ individuals must be specifically screened for STIs, HIV/AIDS, and mental illness, but straight, cisgender individuals should not.

 

Further, there is a paucity of literature about introducing LGBTQIA+ health into the pre-clinical curriculum. The cornerstone publication that started the movement towards incorporating these topics pre-clinically was published in the esteemed Journal of the American Medical Association; at that time, the researchers found that “the median reported time dedicated to LGBT-related topics in 2009-2010 was small across US and Canadian medical schools, but the quantity, content covered, and perceived quality of instruction varied substantially” (Obedin-Maliver 2011). Further, when examining what concepts pertaining to LGBTQIA+ health were taught in these curricula, apart from sexual and gender orientation, the most discussed topics were HIV and STIs (Obedin-Maliver 2011). Disappointingly, not much has changed since that publication. One medical school has been considered the pioneer in such studies of LGBT pre-clinical curricula; that said, after corresponding with their current students, it was revealed that the curricular changes were fleeting, as they were instituted predominantly due to the efforts of one student, who has since moved on to residency. According to the American Association of Medical Colleges, the Case Western and Weill Cornell Schools of Medicine have also made steps to incorporate LGBTQIA+ education preclinically, but have only done so in the elective setting (Krisberg 2017). In April 2017, Utamsingh et. al published a comprehensive literature review identifying publications detailing LGBT healthcare-focused interventions. Of the thirteen papers meeting their inclusion criteria, one of them was describing an intervention pioneered by Tulane University School of Medicine in 2012; notably, this program has been discontinued. Of the thirteen programs, eleven of them were under three hours. Of the two greater than three hours, only one was required for all students (Utamsingh 2017). Given these results, I identified a significant need for change: a method to educate medical students preclinically with evidence-based information that would provide physicians with cultural humility and appropriate best practices for queer patients.

 

Since then, with the assistance of one of my peers and Dr. Myint’s guidance, as well as the support of Tulane University School of Medicine faculty, who accepted the idea instantaneously, we created and piloted a mandatory eight hour online curriculum for all first year students, divided into two 4-hour sessions of time set aside for students to complete, with an accompanying research-based assessment of the quality of the curriculum. Not being one to resist a pun opportunity, I named it the “Queericulum,” which consists of 6 case-based scenarios adapted from the aforementioned Integrating LGBT Health into Medical Education publication, each with 2-3 assigned readings. After reading, students answer 4-7 multiple-choice questions, written by my peer and I, which will be automatically scored by TUSOM’s learning and quiz-taking platform, Canvas, which is collecting all of the de-identified data I need. This is a massive shift within the realm of queer health education, as this is now the only program that is mandatory, let alone of significant length and largely intersectional, including modules discussing toxic masculinity and negative attitudes towards queerness in various ethnic and cultural groups. As for the evidence-based assessment of the curriculum, while all first year students are required to complete the curriculum, opting in to the research portion is optional. It entails completing a demographic questionnaire, a validated survey tool assessing one’s clinical preparedness, attitudes, and knowledge with regard to caring for LGBTQIA+ persons in a health care setting, and the release of their scores on the modules—all combined as a unit but with anonymity preserved—for analysis.

 

In developing this online, module-based curriculum, I thought that this set up was a convenient way for Tulane to easily implement this important content. As for analyzing its impact, to me, that was just “what you do” when you create an intervention, as I had learned in my public health classes. This is where Dr. Myint’s advice became crucial. “Dream bigger!” An online curriculum to me meant easy for Tulane, but Dr. Myint pointed out the potential scale. My analysis to ensure that the curriculum achieved its objectives was simply best practice to me, but Dr. Myint pointed out the opportunity for scientific validity. “Dream bigger” meant go national, disseminate results, go further, think bigger: you have a revolution in your hands.

 

It was at this time when I was awarded the Taylor Changemaker Catalyst Award, and its name fulfilled its function: it created a spark. My ideas became bigger and brighter than the small, gray, VA office. Everything was in color—rainbow, if you’ll forgive the pride-related pun. Being a Changemaker Catalyst recipient poised me to seize the day. Not long after being granted this award, I was notified that there was an upcoming deadline proposals for a medical education conference, specifically on the theme of paradigm shifts. At first, I only gave it a passing glance. But then, I returned to the email. This is what I am doing. Still, my data collection is not complete. But, as it turns out, this conference was accepting proposals even without complete datasets. I ruminated on the idea at first, but ultimately was emboldened—I am a Changemaker Catalyst! It is my responsibility with this award to put myself out there! I submitted an abstract. I will not hear back as to whether it has been accepted until January (hopefully I’m not jinxing myself here), but even then, this moment was a turning point for me. I remembered reading an article that cited a study suggesting that women only apply for positions for which they think they are 100% qualified, whereas men apply if they feel they meet 60% of the criteria (it turns out that this was not an evidence-based study, but it did spark a conversation and further studies on the subject). I resolved to put myself out there. Since then, I have applied for an additional two talks and two awards.

 

Additionally, I was selected as a speaker during TUSOM’s LGBT Health Week, I had the opportunity to share my work and process as one of featured speakers. In a room of my peers, I pointed out the deficits in our curriculum. I displayed practice questions from one of the “question banks” on which students rely in preparing for exams wherein the scenarios begin “A homosexual man” and the answer choice was related to HIV/AIDS every single time.* Since that talk, I have been viewed as a leader and advocate for the LGBTQIA+ community, and have been able to promote changes throughout the entire preclinical curriculum to be more inclusive.

 

Finally, I had the opportunity to attend the Symposium on LGBT Health and Aging, sponsored by the Ochsner Health Network Diversity and Inclusion; PRIDE, Ochsner’s LGBT Resource Group, and NOAGE: New Orleans Advocates for GLBT Elders. In the opening keynote speech, the president of NOAGE, Jim Meadows, specifically acknowledged the dearth of queer health teaching in medical education. As the symposium progressed, I interacted with social workers and licensed therapists and heard various perspectives that all pointed to the same thing: we want to see positive change in how LGBTQIA+ individuals are treated in healthcare (and all other realms, but specifically healthcare). One particularly striking moment was during the “Creating a Welcoming Environment” workshop, in which the short film “Vanessa Goes to the Doctor” was shown. This lighthearted video created by the National LGBT Cancer Network to improve LGBT cultural competence is an excellent way of showing the importance of every factor that adds up in the queer health experience, and how every action can have an impact on whether a queer patient will return for healthcare. I especially loved that the video showed the story of Vanessa, a trans woman of color, as trans WoC are the women who have the most negative healthcare encounters, and face the most violence compared to any group in the United States. In this workshop, we discussed not only the ways in which a more welcoming environment can be created for LGBTQIA+ individuals, but also how we could be agents of change to make this happen.

So what’s next? Fingers crossed on the conferences, talks, and awards. But more importantly, the first year students at TUSOM have finished the first half of the Queericulum, which means I have the data from the second half to look forward to! From there, I will be able to look at the data and see if the Queericulum has a statistically significant impact on students. From there, I will advocate for its implementation at medical schools across the country. And the Changemaker Catalyst designation has opened my eyes to even more things I can do. I now have plans for adaptations to the curriculum to make it relevant for physicians in different stages of their careers, from residency, to fellowship, to continuing medical education. I have ideas for how to work with faculty to have them present clinical vignettes that incorporate the stories of LGBTQIA+ people—already, one of the genetics professors adapted one of her questions about calculating population-based risks of inheritance to include “the sister and her partner are considering a sperm donor…”

 

There is more changemaking to be done. And I am catalyzed. This is only the beginning.

 

Want to familiarize yourself with LGBTQIA+ related terminology? Here is a great resource from the University of Mary Washington: http://prismblog.umwblogs.org/queer_dictionary/

 

Want to read the studies that have largely influenced my project? Here they are, cited below, with links for those easily accessed online to the public:

 

1. Association of American Medical Colleges. “Integrating LGBT Health into Medical Education.” Association of American Medical Colleges. Available online at: https://www.aamc.org/initiatives/diversity/431600/integrationvideo.html.
2. Bidell, Markus P. “The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS): Establishing a New Interdisciplinary Self-Assessment for Health Providers.” Journal of Homosexuality 64, no. 10 (08/24, 2017): 1432-1460.
3. Chester, S. D., J. M. Ehrenfeld, and K. L. Eckstrand. “Results of an Institutional LGBT Climate Survey at an Academic Medical Center.” LGBT Health 1, no. 4 (Dec, 2014): 327-330.
4. Eckstrand, K. L., J. Potter, C. R. Bayer, and R. Englander. “Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations.” Academic Medicine : Journal of the Association of American Medical Colleges 91, no. 7 (Jul, 2016): 930-935.
5. Krisberg, K. “New Curricula Help Students Understand Health Needs of LGBT Patients.” https://news.aamc.org/diversity/article/bring-lgbt-patient-care-medical-schools/
6. Mulitalo, K. E. and J. Romano. “Educational Competencies for Care of Patients Who Are/May be LGBT, Gender-Nonconforming, and/or Born with DSD.” The Journal of Physician Assistant Education : The Official Journal of the Physician Assistant Education Association 26, no. 4 (Dec, 2015): 208-211.
7. Obedin-Maliver, J., E. S. Goldsmith, L. Stewart, and et al. “Lesbian, Gay, Bisexual, and transgender-related Content in Undergraduate Medical Education.” JAMA 306, no. 9 (09/07, 2011): 971-977.
8. Wilson, C. K., L. West, L. Stepleman, M. Villarosa, B. Ange, M. Decker, and J. L. Waller. “Attitudes Toward LGBT Patients among Students in the Health Professions: Influence of Demographics and Discipline.” LGBT Health 1, no. 3 (Sep, 2014): 204-211.

 

*Note: I am a founding contributor for a national Step 1 preparation question bank, and know that certain identifiers are included in questions only when they are clinically relevant (yes, “a homosexual man” is at higher risk for HIV/AIDS, which is why that identifier may be used in a question). However, when used in the first sentence, and in such a way that a student does not need to know the science in order to be able to answer the question, that is problematic, and promotes the false equivalency of “homosexual man” = “HIV/AIDS.” Further, since this is the only way that “the homosexual man”—the only representation of any LGBTQIA+ persons in medical curricula or examinations—is portrayed, it diminishes the personhood as well as fuller medical picture of queer patients, reducing all to one condition.