Taking the Time to Learn About Transgender Health Care

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Rebecca Bak, MD, MPH

A few weeks after I met a young transgender woman in our urgent care and had offered to become her primary care doctor, she sent me an email with a link to a small study in which only 41% of endocrinologists felt competent to provide transgender care. In her email, she thanked me for being the first doctor to ask about her chosen gender pronouns and for taking the time to learn about transgender health care.

I am a family doctor working in rural New Mexico, 2 years out of residency. I still often feel like I am working just outside my comfort zone—when I’m reducing a dislocated shoulder, managing a retained placenta, or caring for a young patient who had ingested a liquid poison. I’ve learned to rely on my colleagues, consult specialists when needed, and read—a lot. At the end of residency, I still didn’t feel comfortable with interpreting complicated EKGs, so I set up a rotation with a cardiologist and went through page after page of EKGs. I still don’t feel completely comfortable providing rheumatologic medications to patients (and my patient population has a large number with rheumatoid arthritis), so I read up and call the specialists.

Family doctors, whether working rurally or urban, are often expected to work just outside their comfort zone. I did my residency in Rhode Island and, though the nearest city with the preeminent hospital was 15 minutes away, many patients with complicated illnesses chose to continue care with us because they felt more comfortable with their family doctors, they couldn’t afford bus fare, or they were caregivers to others and wanted to stay close to home.

We, family doctors, should be at the forefront of providing medical care, including hormone therapy, to our transgender patients. We are present for our patients from birth to death, during severe medical illnesses, at moments of depression and anxiety, and also during moments of joy. It is a statement of acceptance to continue caring for our patients who are making the momentous decision to transition to a body that feels right to them.

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Notes on the Ethics of Reflection

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Sharon A. Dobie MCP, MD

It is important that we reflect and write about the work we do with patients. As we reflect, we create a narrative that sometimes becomes a written piece. We cannot really tell our stories without including the patients because it is actually our perception of the patients and their stories. And yet, we also have a covenant of confidentiality with our patients. Beyond what HIPAA says, we live within ethical considerations that must protect our patients.

What then can we do when we write and then want to share that writing with a friend, in a blog, or for a journal submission?

When writing about patients, we must respect these ethical considerations. In an evolving set of guidelines, the best practice remains to show what we write to the person about whom we wrote. That is what I encourage writers to do whenever possible. It can be scary and it is always fruitful. You might learn more about the story, about the person, about yourself, and the bias inherent in your viewpoint. That information might lead you to add to or edit your reflection. Then what you have is a co-creation, and your patients will feel valued and respected. Alternatively, these conversations may also clarify reasons to not publish the piece.

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Clinical Teaching for LGBT Health at the Point of Care

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Sarah E. Stumbar, MD, MPH

“Do you live with your husband, too?” the second-year medical student asked, innocently enough. It was our first visit with this patient, a healthy middle-aged African American woman. We were just chatting, trying to get to know her, and I had picked up on little clues in our conversation that had already led me to conclude that there was no husband in the picture. The medical student, though, didn’t seem to have picked up on this and, I thought, was trying to get at her sexual history by asking, instead, about her husband.

A few seconds of an awkward, heavy silence followed his question, until the patient forcefully said, “I’m an independent woman.” There was no room left open in her tone for further discussion, and our conversation quickly moved onto other topics.

Later, after the visit, I challenged the medical student to go back to that question and think of all of its assumptions: a heterosexual relationship, the need for a husband to have a child, the assumption that asking about a husband equated to asking a sexual history. I could see the student processing all of this, as he squinted his eyes and stated, “I come from a very conservative family.”

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