Qualitative data
Semi-structured interviews
Sampling of faculty (n=3) and residents (n=2) was conducted until saturation of information was achieved (n=5). Three themes and corresponding sub-themes (Table 1) were identified from semi-structured interviews. These themes were mentioned in all five interviews and were used to create the AHD and OSCE station. Verbatim quotations are provided below, and this is not an exhaustive list.
Table 1. Theme and sub-themes
Theme
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Sub-themes
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- Access to health care
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- Lack of formal education
- Provider discomfort
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- Health inequities
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- Reflexivity
- Preserving safety
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- Multi-disciplinary care
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Theme 1: Access to health care
Participants described the challenges that transgender patients face in accessing health care services. Participants explained that the lack of formal education and clinical inexperience likely contributes to adverse health outcomes, patient mistrust and overall health care avoidance, as one resident commented:
So far, [in residency] I don’t think I’ve had any exposure, really, in transgender health. [In medical school], we did have some teaching about being sensitive, in general, with patients ... it was more teaching how to care for patients who come from difficult dynamics or suspecting abuse and how to be more caring…but nothing formally about transgender health. (R2)
All participants acknowledged their personal discomfort in providing care to transgender patients due to lack of formal training, and this was consistent throughout interviews with faculty and residents. Simple tasks such as performing the physical exam, using gender neutral terminology (e.g., chest versus breast), or filling out routine test requisitions elicited discomfort amongst participants. As one faculty said: “We got a call from the emergency room because [the residents] weren’t sure if they should order different types of cultures or investigations or what they should do in this case” (F2). This was confirmed by a resident:
And then even after when they were in the room, and we were examining them … and the other residents not being very familiar with the type of surgeries that were done or the change in anatomy… [We didn’t know how] to properly address the concerns of the patient. (R1)
Theme 2: Health inequities
Most participants acknowledged their own reflexivity and bias but did pay specific attention to the health care inequities faced by transgender patients. Participants highlighted the importance of acknowledging this before and during a provider-patient interaction to avoid transference or negative emotion. For example, one faculty reflected:
The bigger challenge is it’s not just top or bottom surgery, here’s the masculinizing or feminizing therapy, it’s more about how do we make sure that we’re addressing those [health] inequities. The more people are aware of health inequities ... that’s a really important thing. It’s bigger than just gender … it’s anything that makes it difficult for people to access safe care… this is just one of the lenses to look at that issue. (F3)
In their role as physicians, all participants acknowledged the importance of creating a safe space during a clinical encounter. Faculty were more prepared to apologize for mistakes or using the incorrect pronouns, but residents did acknowledge that they would consult resources or senior mentors before the interaction to minimize error and preserve safety. As one faculty commented:
I think that’s it a bit more of a unique issue on that basis… and [as doctors], sort of learning about what to do for these patients is less clear to us… It’s just less clear about what the care needs of that population might be. (F1)
Theme 3: Multi-disciplinary care
Whether multi-disciplinary care involves consulting an alternative specialty (e.g., Endocrinology, Hematology/Thrombosis), allied health services (Social Work, Psychotherapy), or senior leadership/faculty, all participants discussed the importance of a team-based approach to patient care. Faculty were more comfortable and aware of the consultants/services available to them, especially within the surrounding community, e.g., network of referring providers. One faculty mentioned: “This makes people feel safe, and sort of sets the culture for the rest of the health care team” (F1) and another faculty confirmed:
Everyone has their role to play, but as a physician … your role typically is as the leader - so you really need to set the expectation of not making assumptions and being clear on how to care for a patient and respect their gender identity. (F2)
Quantitative data
Academic half day
Twenty-two residents completed the pre-AHD survey, and twenty-three participants completed the post-AHD survey (Figure 3). One data point was omitted from statistical analysis. The AHD was provided to residents across postgraduate year one to three; residents did not self-identify what year of training they were in. The average score across all questions significantly increased after the AHD session (2.68 +/- 1.21 vs. 3.56 +/- 0.647, p = 0.042).
OSCE
Thirty-one residents participated in the OSCE. On the global rating scale, one resident was scored as extremely deficient; 17 (54%) residents were scored as acceptable, and 13 (42%) residents were scored as exemplary. On the EPA scale, no (0%) residents were scored as requiring the supervisor on-site; 4 (13%) residents were scored as “supervisor on-site and checks all findings”; 7 (23%) residents were scored as “supervisor on-site and checks key findings”; 18 (58%) residents were scores as “supervisor off-site and available”; and 2 (6%) residents were scored as “distant supervisor with post-hoc debrief”. The residency program committee identified that anticoagulation management and management of cardiovascular disease would be key skills for an Internal Medicine resident to master, and so these domains were highlighted in results (Figure 4). As it pertains to management of anticoagulation, 0 residents were scored as extremely deficient, 14 (45%) residents were scored as acceptable, and 14 (48%) residents were scored as exemplary. Two data points were missing. As it pertains to management of cardiovascular disease, no residents were scored as extremely deficient, 13 (42%) residents were scored as acceptable, and 13 (42%) residents were scored as exemplary. Five data points were missing (Figure 4).