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Improving Culturally Competent and Inclusive Health Care for LGBT Patients Through Resident and Staff Education

By Jennifer Hammonds,LCSW and Alicia Markley, MPAS, PA-C

Bob arrived to establish receive care in our rural site clinic. As the nurse was going through the rooming process with the patient, she noticed he seemed very apprehensive about answering questions. Bob began to open up to the nurse about a recent negative experience he had at a local emergency room. He had presented to the ER for abdominal pain. Throughout the visit, Bob could hear the ER staff at the nurse’s station, laughing, joking about him, and speaking negatively about him and his concerns. This experience was traumatic, and fear of having this happen again had caused him to put off seeking medical care for some time. The nurse was rightfully upset on the patient’s behalf and wanted to put him at ease in our clinic.

This is a glaring example of health disparity, but why was Bob treated differently? Bob is a transgender individual. Bob’s legal name is Barb.

Research has shown that LGBTQ patients experience higher levels of discrimination, stigma, and stress and are at higher risk for poor health outcomes. Our primary goal is to provide quality patient care for our patients. All our patients. This nurse took a step back and looked at her ability to provide culturally competent care for this patient. She naturally wanted to treat this, and every patient respectfully, but she knew that she had some obvious questions about how to address certain situations.

This incident sparked a conversation between the two of us. As a whole, the clinics seem to be adept at being LGBTQ sensitive toward our adolescent patients, but we weren’t sure about our adult population. How comfortable is our nursing staff in asking patients for pertinent, though sensitive, health information? Do our front desk staff know how to address patients when their insurance card information differs from the information provided by the patient? Is our clinic known in the community as being LGBTQ friendly, or are we missing the big picture? We quickly realized that we were uncertain about many of these things. Questions often spark the need for answers, so we decided to embark on a project, one that would, hopefully, highlight our strengths, as well as areas in need of improvement.

We decided to begin simply, with a survey of all staff, nurses, faculty, residents, and social workers, to determine our comfort level, knowledge base, and understanding of LGBTQ patients and their healthcare needs. We used a SurveyMonkey tool, knowing full well that this was a less-than-scientific method of data collection.It nonetheless served our purpose of information gathering.

The responses were quite interesting. Many professionals expressed having only basic knowledge of LGBTQ patient needs but were willing to learn anything we could teach them. A few identified as being a member of the LGBTQ population and were delighted to learn of our project intent. The feedback received engaged us fully, and we made it our goal to find the best resources to educate ourselves and provide the best quality care to all patients in our community.

Herein lies the rub—the two clinics within our residency program provide two vastly different perspectives. One is located within the University City limits with a significantly diverse population. The other resides in a homogenous, rural area that has limited exposure to people of different backgrounds. As our goal of education began to take shape, it was necessary to consider our audience as well. Luckily for us, the National LGBTQ Health Education Center had a tremendous amount of learning material, PowerPoint presentations, and seminars available for use. Both clinics were receptive and engaged with the material presented, and subsequent nonscientific polling suggested that the exercise was a beneficial one.

Throughout this process, we both deepened our own intellectual and emotional understanding of our patients and cemented our belief that our colleagues were dedicated to providing the most positive and beneficial care to our patients, no matter their gender or orientation. We plan to revisit these training materials yearly with hope that we can continue to grow and fulfill our mission of meeting health care needs through education, patient care, research, and service to the community.

Lessons From an Unlikely Land – Reflection From the Recent Trip to Cuba by STFM

The 1966 AMA Report of the Ad Hoc Committee on Education For Family Practice (aka “The Willard Report”) affirmed an AMA House of Delegates assertion “…that family practice is important for optimal health care…” while also expressing concerns over the adequacy of the future supply and preparation of the family practitioner. The report argued “that there is a need for a new kind of specialist in family medicine, educated to provide comprehensive personal health care…”  soon thereafter, in 1969, the 20th major specialty, “Family Practice,” was born to great promise and hope.

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Richard Streiffer MD    University of Alabama

 

Today, despite compelling and robust international evidence of the importance of a well-trained, accessible, and ample family physician workforce to the health of a population, we remain well short of that goal in the United States. I believe that many family physicians feel a sense of collective disappointment in this failing, and clearly many are dissatisfied with the narrowing scope and role of the family physician. Many are frustrated by the perception of the collective failure of family medicine to have a greater influence on the nation’s health  as envisioned at our discipline’s launch.  

Still, family physicians aspire to the role which Ian McWhinney clearly laid out his classic Textbook of Family Medicine, where he said that the comprehensive family physician:

  • sees every encounter as an opportunity for prevention
  • sees himself or herself as part of the community-wide network of supportive health care agencies
  • views his or her practice as a “population at risk”
  • visits patients in their homes and “should share the same habitat as their patients” 
  • is a manager of resources.

Elsewhere around the world, this model of the comprehensive, familiar, accessible, prevention- and community-oriented family physician is not only alive and well, but is fundamental to health systems, most of which have better outcomes than here. 

In January 2020, 25 STFM members spent a week in Havana, Cuba, where we visited one such system—the resource-frugal health care system that the Cubans have built is admired around the world for its achievements. A major motivation in visiting Cuba was to see a model where the family doctor is central and deeply inculcated into the very design of the system. 

During our week, we visited and had talks and conversations at numerous representative facilities in the greater Havana area, including a family doctor/nurse consultorio, a polyclinic, a maternity care specialty hospital, a maternity home, a diabetes specialty care center, Centro de Investigación y Desarrollo de Medicamentos (CIDEM – Cuba’s Center for Drug Research and Development), Escuela Nacional de Salud Pública  (ENSAP – the national school of public health), the Facultad Manuel Fajarod campus of the Universidad de Ciencias Médicas de la Habana (The University of Medical Sciences of Havana), and Escuela Latinoamericana de Medicina (ELAM- the Latin American School of Medicine). We also experienced the culture and values of this fascinating Caribbean land, one that at times seems stuck in the 1950s, yet whose people are happy, positive, appreciative of our presence, and have achieved so much not just in medicine, but in science, music, arts and the humanities. 

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To understand the health achievements in Cuba, it’s critical to appreciate that the “developing country” conditions—illnesses and disparities of access to care that characterized the country at the time of the Cuban Revolution in the middle of the 20th century—have been eliminated. Today, despite economic and political challenges, the overall health measures of the Cuban population are near to, and in some areas above that of the United States, and all achieved at a fraction of the per capita costs.  

How have they done this? First, health care is accessible and guaranteed for all, and prevention is first and foremost to their method. Public health and medicine, as well as attention to social determinants of health, are largely integrated compared to the United States, where the fields have largely pursued separate tracks in training and practice. In addition to these principles that guide them, the Cubans are able to articulate clear priorities that drive their resources, attention, and approach. For example, virtually every health professional we met talked about the importance of prevention and of the role of the family doctor, and how pregnant women and their babies followed, closely by the growing elderly population, are at the top of their priority list.  

Perhaps most fundamental to their success has been the foundation provided by the network of the neighborhood-based family doctor-nurse consultorio dyads. Each family doctor/nurse pair lives in a neighborhood where they care for a defined population that they can describe in some detail at the drop of a hat. They use population health methods to conduct risk stratification for their patients, and track their patients with simple, low-tech techniques like daily logs, family (paper) charts, manual screening registries, and home visits. The family doctors are in turn supported through a team of health professionals that includes an epidemiologist based out of the larger hub called the polyclinic. These polyclinics are served by general and specialty hospitals, and a series of subspecialized clinical and research institutes. Throughout the system, the role and importance of the family doctor for implementation and follow-up of any plan is reinforced. 

One of the other more remarkable institutions we visited is ELAM—the Latin American Medical School in Havana—where some 100 US citizens are studying medicine along with thousands of other young people mostly from developing countries from around the world. The Americans do so at no cost to themselves, with only the expectation that they return to their home and serve as physicians in communities with a need. We were privileged to meet with a group of these US students over dinner and learn how unique and special they are. Mostly underrepresented in medicine students, largely from economically disadvantaged backgrounds, 100% fluent in Spanish, predominantly women, disproportionately interested in family medicine careers, and well trained in public health, community involvement in health care, and low-tech, patient-centered care, they are admirably committed to the principles of population health and returning to practice in an underserved community of the United States.  

Most fascinating, this diverse group of Americans is studying in Cuba by choice. Few of them even considered or applied to US medical schools, opting purposefully for the Cuban model out of conviction of its superiority for their future service in communities of need. By training side by side with Cuban medical students and living and working in this system, these Americans are experiencing firsthand the value of the family physician-nurse team’s knowledge of their patients and the neighborhood influences; of the role of the community assessment and home visits; of the potential of prevention and lifestyle change; of how to judiciously use precious resources and a low-tech approach; and of systematic data collection to inform population-oriented priorities.

The burning question for me throughout the trip was “Are there lessons here that we might apply back home?”  Mind you, there’s no delusion here, though at times we were admiring, and perhaps a bit euphoric and somewhat envious. We all knew that this was Cuba—that quirky little embargoed island just off the coast of Florida. Our size, political, and cultural differences from Cuba are significant, so that adoption of a system like theirs is neither realistic nor advisable for the United States. Yet, there are lessons to learn from the principles upon which their successes are based, the most important one being the value of the family doctor to a health system and its ability to improve population health. 

Suggested Reading 

Bhardwaj N, Skinner D. Primary Care in Cuba: considerations for the US. J Health Care Poor Underserved. 2019;30(2):456-467.   https://doi.org/10.1353/hpu.2019.0041

Campion EW, Morrissey S. A Different Model—medical care in Cuba.” N Engl J Med. 2013;368(4):297-299.() https://doi.org/10.1056/NEJMp1215226

Gorry C. Your primary care doctor may have an MD from Cuba: Experiences from the Latin American Medical School.” MEDICC rev. 2018;20(2):11-16.

Gorry C. Cuba’s family doctor-and-nurse teams: a day in the life.” MEDICC Rev 2017;19(1):6-9.

Keck C, Reed GA. The curious case of Cuba.” Am JPubHealth. 2012;102.8:e13-e22.

Ladden M, Mende S. Field Notes: c. Robert Wood Johnson Culture of Health Blog. https://www.rwjf.org/en/blog/2015/01/field_notes_whatcu.html. Posted January 29.  Accessed February 27, 2020.

Dwamena A. Why African-American Doctors Are Choosing To Study Medicine In Cuba.  The New Yorker. https://www.newyorker.com/science/elements/why-african-american-doctors-are-choosing-to-study-medicine-in-cuba. Published June 6, 2018. Accessed February 27, 2020.

Frist B. A Look Inside Cuba’s Family Clinics. Forbes.https://www.forbes.com/sites/billfrist/2015/10/07/a-look-inside-cubas-family-clinics/. Published October 7, 2015. Accessed February 27, 2020.

Hamblin J. How Cubans Live as Long as Americans at a Tenth of the Cost. The Atlantic. https://www.theatlantic.com/health/archive/2016/11/cuba-health/508859/. Published November 29, 2016. Accessed February 27, 2020.

An Innovative Way to Teach Hospital Leadership and Administration in Residency

by Andrea Heyn, MD, University of Arizona, Tucson.

As a family medicine resident, I have spent countless hours learning how to treat chronic medical conditions in the clinic, delivering and caring for newborn babies, and managing hospitalized patients. However, I have always wanted more experience in hospital leadership and administration, as I am fascinated by what goes on behind the scenes. I had the opportunity to participate in a leadership program offered by my residency, but it did not give me the firsthand exposure I envisioned, so I took the opportunity to design an elective that would give me experience to find out if this could be part of my career.

The elective was 2 weeks long, and consisted of two portions. I worked hands-on with Bethany Bruzzi, DO, one of the family medicine resident attendings, who was the hospital’s new chief medical officer. The first portion of the elective revolved around self-reflection and assessment. I received a 360 evaluation, completed by my supervisors, direct peers, those whom I supervise, and support staff such as the medical assistants and receptionists. This helped me identify my strengths and weaknesses with regards to effective communication and interpersonal relationships. Additionally, as part of this self-reflection process, I read several books and articles on personal development. One particular article, Connect, Then Lead, from the Harvard Business Review, helped me refine how I interacted with my co-residents as a senior resident, which was particularly helpful as someone who is a direct communicator.

The second portion of the elective involved my participation in various meetings and discussions. Each morning, we had daily hospital rounds with social workers, physicians, and nurses to discuss the discharge needs of patients. One specific example was of a patient who had been admitted for multiple weeks without a next of kin, awaiting a public fiduciary. We consequently spent hours working with the court liaison on streamlining the process of assigning a public fiduciary for future patients. We had phone meetings with the IT department advocating for physicians’ requests for changes and additions to the EMR system, with one particular meeting focused on revising discharge templates. We also met with representatives from various departments who were part of the Quality and Safety Council to discuss quarterly initiatives for the hospital.  This meeting was dynamic and progressive, with changes implemented as a direct result of feedback from staff and physicians. However, what I found most interesting was the budget discussion. I now appreciate the challenge of attempting to meet the needs of so many, from doctors requesting new ultrasounds, to the kitchen needing new stoves, while staying within the budgetary constraints. Finally, I got to sit in on the Executive Stewardship meeting and watched as the needs of the hospital were negotiated from a corporate level.

I am grateful for the opportunity to have worked alongside Dr Bruzzi. As a female physician, she is an inspiration to me as I prepare to graduate from residency and advance my career. Her promotion to CMO of this teaching hospital as a family physician speaks strongly to the dynamic role family physicians, particularly women, have in the medical arena.

This rotation has brought me to further appreciate the collaborative effort that is required to effect positive change in a multidimensional setting, where the needs of each player – patients, staff, nurses, residents, and attendings—vary tremendously. Furthermore, as I interview for jobs, prospective hires like to hear about my interest in future leadership positions, and discuss my goals and potential mentoring strategies.  I would encourage other residents to pursue leadership and administrative experiences via this direct approach. For those already in leadership roles, I ask you to create an opportunity for residents like myself to inspire and encourage us to become future leaders in family medicine.