LGBTQ+ individuals (those whose identities include lesbian, gay, bisexual, transgender, and queer/questioning) are at disproportionate risk for poor health outcomes and negative experiences within the healthcare system. Despite this, discussion of health issues affecting LGBTQ+ populations (and the contributing systemic, societal, and cultural barriers) remain scarce in medical school curricula. In fact, the median time dedicated to LGBTQ+ health topics is about five hours.1 As a result, U.S. medical students and physicians report low preparedness and comfort in caring for LGBTQ+ patients, particularly transgender individuals.2
To proactively address this gap in medical education, topics on LGBTQ+ health disparities and care can be systematically integrated into the standard curriculum. Previous studies have demonstrated that increased exposure to vulnerable populations increases student knowledge and empathy in clinical practice.3 The Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity and Sex Development introduced 30 core competencies to improve curricular reform on issues affecting the LGBTQ+ population. Additionally, a recent call to action by Chriss, et al, in SGIM Forum introduced a framework for developing LGBTQ+ inclusive curricula in U.S. medical schools. This framework comprises five key steps: 1) assessment of institutional climate, 2) creation of an LGBTQ+ health education advisory committee, 3) integration of core competencies, 4) evaluation of progress, and 5) dissemination of results.4 Our work closely parallels this approach, which was successfully operationalized at our medical school.
Creating Our Action Group
The origins of our action group started with several motivated medical students connecting with a faculty member that had academic interests in LGBTQ+ health. Soon after, a school- and institution-wide Diversity and Inclusion task force developed, leading to a call to action to address LGBTQ+ health within the curriculum. Hence, the LGBTQ+ Curricular Action Group of the Cleveland Clinic Lerner College of Medicine (CCLCM) was formed, and is composed of faculty, administrative staff, and medical students developing an integrative LGBTQ+ health curricula for all students in our program.
Assessing the State of Our Curriculum
Following the assembly of our action group, we performed a needs assessment of our preclinical curriculum. We began by conducting an extensive review of peer-reviewed literature and, with the help of faculty content experts, created a comprehensive list of LGBTQ+ health topics for integration into the standard curriculum. At CCLCM, the preclinical curriculum is organ system-based and spans two years, with the first year focusing on physiology and the second focusing on pathophysiology. Students learn through traditional seminars, small group problem-based learning (utilizing clinical vignettes), as well as physical diagnosis and communication skills classes. As medical students in our action group progressed through the 2020-21 academic year, they prospectively recorded where, in their respective first- and second year-studies, additional LGBTQ+ content could be integrated to further enhance student knowledge. This content was also mapped to the 30 core competencies put forth by the AAMC, enabling us to objectively confirm the benefits of integrating such points into the preexisting curriculum.
In parallel, utilizing pre-existing literature, we designed an IRB-approved survey to assess the baseline knowledge, attitudes, and beliefs regarding LGBTQ+ health within our student body.5 Our initial survey was sent out at the beginning of the 2021-22 academic year and had a 64% response rate (33/64 students); survey results indicated that 63.6% (21/33 respondents) of first- and second-year students are interested in learning additional LGBTQ+ health topics, and few relied on the existing preclinical curriculum for this information—illustrating a clear need for this work.
Integrating LGBTQ+ Health Content
Starting in the 2021-22 academic year, we sought to integrate LGBTQ+ health content into existing seminars, based on the needs assessment conducted the previous year. To facilitate this, we utilized a student-driven approach where students created a collated document containing suggested integration points relevant to each organ system. Then, medical students organized and led meetings with the course directors of each organ system block and shared our findings, including the curricular setting in which the specific health information was currently being delivered (i.e., seminar, problem-based learning), suggested LGBTQ+ health integration points, the corresponding peer-reviewed literature supporting our identified health information, and the corresponding AAMC competencies we would be meeting by including this information in our curriculum (see Table). A faculty “champion” liaison from our action group also attended these meetings to help mitigate the potential effect of a power dynamic between medical students and faculty. During these meetings, we suggested integrating these points into pre-existing seminars by adding one or two additional PowerPoint slides to the current lecture, utilizing the corresponding peer-reviewed literature. We term this the One Slide Approach, wherein our student-driven model relieves the burden on faculty by offering to share relevant literature or creating a draft slide. Course directors would not need to create any new seminars or eliminate any existing seminars to include this information, nor would seminars need to alter their content in a drastic fashion—they need to simply include “one more slide.” Given the simplicity of this approach, and the significant uptake we have seen in our program, we believe this is broadly adaptable to any medical school with a seminar-based curriculum.
Evaluating and Disseminating Our Work
Given the cyclic nature of the academic year, our model for curricular integration enables us to iteratively assess our group’s progress. As our action group entered its second year of work, rising second-year students assessed the status of previously suggested integration points, allowing us to identify uptake across the preclinical curriculum. Over the course of the 2021-22 academic year, 57.6% (34/59) of the suggested LGBTQ+ health topics were successfully integrated into the standard curriculum, and our group continues to meet with course directors annually to review the success of content integration and identify barriers for inclusion. Complementary to this process, we will send out our student survey annually, providing insight into student knowledge as they start medical school, while also enabling direct assessment of the impact of our preclinical curricular reform on student knowledge, attitudes, and beliefs over time. As we enter our new academic year, we look forward to sharing the success of our intervention as well as lessons learned throughout the process.
In summary, our Action Group implemented a systematic process to improve curricular inclusion of LGBTQ+ core competencies, in accordance with the framework presented by Chriss, et al. To further promote integration of core competencies and remove faculty burden, we incorporated a “One Slide Approach” in which students create tailored PowerPoint slides for easy addition to faculty presentations. Additionally, we established practices for annually assessing the curriculum’s efficacy in conveying these competencies to students. Through this process, we hope to better prepare medical students to provide care to LGBTQ+ patients while regularly evaluating our methods and facilitating similar processes at other medical programs.
Acknowledgements: We thank Henry Ng, MD, Robert Dean, MD, Neil Mehta, MD Gustavo Roversi, William Patterson, Saloni Lad, and Brenda Lowe.