Transgender Actors School Med Students in Appropriate Care

Megan Brooks

June 20, 2017

By acting out scenarios commonly seen in the clinic, real-life transgender actors can help medical residents learn to provide more sensitive care to transgender patients, new research shows.

"The opportunity to interact with a transgender patient in a low-stakes setting during medical training increased trainees' comfort during future real-world outpatient encounters," lead researcher Richard E. Greene, MD, director of gender and health education, NYU Langone Medical Center, New York City, said in a news release.

"Even those who had baseline knowledge of care for transgender patients before the study found that learning in this safe, simulated way added value in helping them provide more sensitive care for transgender patients," Dr Greene added.

The study was published online June 15 in the Journal of Graduate Medical Education.

Bridging the Gap

"There is obviously a huge gap between talking about something conceptually and having to actually do it in practice," Dr Greene told Medscape Medical News.

"Trans patients often report that when they show up in clinic, providers are not as sensitive as they could or should be or don't know the right questions to ask. So we developed this program to give our learners the opportunity to have this experience and exposure to a transgender patient in a low-stakes environment and make some mistakes if they needed to."

For the study, a trained standardized patient/transgender actress acted out a common scenario in a primary care clinic setting and rated 23 internal medicine residents on their ability to communicate and to leave the patient satisfied with the interaction.

In the scenario, a transgender actress played the role of a patient who was taking the antiandrogen hormone spironolactone for reducing masculinization plus the feminizing hormone estradiol. In the enactment, the patient presented with hypertension and hyperkalemia and was interested in undergoing orchiectomy.

As learning objectives, the residents were tasked with exploring and respecting the patient's treatment goals in light of her hormonal transition therapy and making a plan for managing her hypertension and hyperkalemia.

Other learning objectives included asking questions that indicated sensitivity, such as asking about a patient's preferred pronoun and gender identity, and learning how to conduct discussions regarding sexuality, sexual activity, and associated risks.

Overall, the results indicated that good communications skills helped some residents overcome their lack of transgender-specific clinical acumen and that going through this scenario training with a transgender actress helped them to shed preconceptions and be better prepared for the clinic, the researchers report.

The average scores on a newly designed behavioral measure achieved by the residents were 89% for overall communication and 85% for satisfaction.

However, results also showed that fewer than two thirds of residents made the patient feel comfortable (61%) or asked directly about their gender identity (61%).

"This underscores the need to include transgender standardized patients in our teaching and curricula. Without them, a substantial gap in care remains," said Dr Greene.

Many residents did effectively ask the patient for medically relevant information regarding transition. They also recognized that spironolactone was the cause of hyperkalemia and understood the importance of this medication to the patient's hormonal status. However, only a quarter of them discussed possible remedies for the high potassium level, and only 39% offered treatment for hypertension.

"Residents felt prepared for this case despite finding it challenging to discuss transgender identity and health issues," the authors report. They note that feedback from faculty and the transgender actress helped residents identify learning needs, including how to ask directly about transition, the need to understand appropriate terminology, the importance of admitting a lack of knowledge to a patient, and the importance of putting aside preconceptions about a patient's identity.

To implement this curriculum requires a space to conduct the clinical examination and the employment of a transgender-identified actor/actress, who in the study was paid $25 per hour.

"We advocate for the use of transgender actors to play transgender roles, as their insights about patient experience are imperative to provide appropriate feedback. We recognize that finding transgender actors in some communities may be difficult and recommend partnering with local community centers to identify potential [standardized patients]," the authors conclude.

"We have a culture in medicine where we sort of treat everyone the same, but when there are health disparities involved, that doesn't always work, because if you don't acknowledge the disparities, you can't overcome them," Dr Greene told Medscape Medical News. "What we showed with this study is that with good psychosocial skills, you can make a patient feel generally comfortable or generally at ease."

"Important Task"

"Given that 1.4 million adults identify as transgender across the United States, it is imperative that physicians be prepared to address transgender-specific healthcare needs in an empathic and affirming way," Ellen C. Meltzer, MD, internist and medical ethicist at Weill Cornell Medicine and New York–Presbyterian Hospital in New York City, who was not involved in the study, told Medscape Medical News.

"Educators like Dr Greene are taking on the important task of training our future physicians to care for transgender patients. Like all of our patients, these individuals have unique needs that, if left neglected, can have significant, negative consequences for both their health and well-being," said Dr Meltzer.

"Engaging standardized patients to teach and evaluate medical knowledge and empathic communication skills is incredibly valuable, as it provides an opportunity for learners to practice new skills in a supportive, low-stakes environment, rather than the high-stakes realm of actual clinical care," she added.

The study had no commercial funding. The authors and Dr Meltzer have disclosed no relevant financial relationships.

J Grad Med Educ. Published online June 15, 2017. Full text

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