Use of Standardized Patients in Endocrinology Fellowship Programs to Teach Competent Transgender Care

Mary O. Stevenson; R. Craig Sineath; J. Sonya Haw; Vin Tangpricha


J Endo Soc. 2020;4(1) 

In This Article

Abstract and Introduction


Purpose: Transgender and gender-nonconforming individuals have unique health care needs and have difficulty accessing health care services because of a lack of qualified health care providers, insurance coverage, mistreatment, and bias by the medical community. Medical trainees and physicians report a lack of education in, and exposure to, the clinical care and unique aspects of this field. We assessed the use of a standardized patient as a tool to evaluate 4 core medical competencies (patient care, medical knowledge, professionalism, and interpersonal communication) of endocrinology fellows at a single training program.

Methods: Endocrine fellows were evaluated by faculty in different aspects of transgender care and completed a self-assessment before and after the exercise. Faculty viewed the fellows during the Objective Clinical Structured Examination. Fellows were provided feedback by a faculty member and the standardized patient after the exercise.

Results: Deficits were found in patient care and professionalism. Fellows scored well in medical knowledge. Fellows did not report an improvement in comfort and communication skills after the exercise. Interestingly, fellows' self-assessment scores in several domains declined after the standardized patient encounter, highlighting an occasion for self-reflection and growth within the realms of cultural competency and medical knowledge.

Main conclusions: We conclude that use of standardized patients to teach medical competencies in transgender medicine may be one approach to improve exposure to, and training in, transgender medicine. Endocrine fellows still had discomfort treating transgender individuals after the standardized patient encounter and require other training activities that may include didactics and clinical case discussions.


Over the past decade, there has been an increasing awareness within the medical community regarding the need to provide and improve education in transgender health care within all levels of training.[1,2] Medical students as well as internal, family and emergency medicine, plastic surgery, urology, and otolaryngology residents have all reported a lack of structured curriculum and knowledge in transgender-related content.[3–6] Endocrinology fellows also describe inadequate educational guidance and training in this field.[7] In a 2017 survey of 198 second-year endocrinology fellows, 58.9% reported that their training program provided dedicated content in transgender care.[7] Of those who reported dedicated teaching, 40% had received less than 2 hours of content per year, and those who had received education or seen more transgender patients in their training were, not surprisingly, more likely to be confident in treating patients with hormone therapy.[7] Barriers to implementing transgender-specific education interventions include limited curricular time, lack of competency among faculty, and poor institutional support.[5]

To address the need for improved training in transgender-related health care topics, many endocrinology fellowship programs are implementing formal education strategies. In a web-based survey of endocrinology program directors done in 2016, there were 54 responses from 104 programs.[1] Of those who responded, 35 of the 54 programs (72.2%) provide dedicated teaching on transgender health topics.[1] These teaching methods include direct patient care, lectures, small group discussions, online modules/webinars, and elective rotations.[1] None of the 54 program directors reported use of patient simulation as a means of teaching transgender care.[1]

The Objective Structured Clinical Examination (OSCE) is a teaching tool that was introduced in 1975 and consists of various stations in which a learner or trainee is asked to interact with a standardized patient (SP, or actor) for a specified amount of time within the context of a given medical scenario.[8] The OSCE has been used in more than 50 countries across 5 continents, within various health professional settings (medicine, dentistry, pharmacy, nursing) and in varying phases of education (undergraduate, postgraduate, and continuing professional development).[9] It has been found to be a reliable and valid tool in assessing skills through varying fields and levels of training.[10–13] There has only been one published case demonstrating the use of OSCE as a tool for training internal medicine/primary care residents in transgender health care.[14] The use of the OSCE and SP in teaching transgender-competent care therefore represents an untapped educational tool and requires further evaluation. In this paper, we provide data on the effectiveness of using the OSCE and SP in teaching transgender competency for endocrinology fellows, specifically.

The purpose of this study was to evaluate the acceptability and effectiveness of an OSCE in providing training and feedback in the delivery of endocrine care for transgender individuals. A single case vignette of a transfeminine patient seeking hormone therapy was used to test 4 of the 6 core medical competencies established by the Accreditation Council for Graduate Medical Education: medical knowledge, patient care, professionalism, and interpersonal and communication skills.[15] Faculty and the SP provided immediate feedback in these competencies following the exercise. Endocrinology fellows provided data regarding their medical knowledge of transgender medicine before and after the exercise.