The Prevalence of Lesbian, Gay, Bisexual, and Transgender Health Education and Training in Emergency Medicine Residency Programs: What Do We Know?

The Institute of Medicine, The Joint Commission, and the U.S. Department of Health and Human Services all have recently highlighted the need for cultural competency and provider education on lesbian, gay, bisexual, and transgender (LGBT) health. Forty percent of LGBT patients cite lack of provider education as a barrier to care. Only a few hours of medical school curriculum are devoted to LGBT education, and little is known about LGBT graduate medical education. The objective of this study was to perform a needs assessment to determine to what degree LGBT health is taught in emergency medicine (EM) residency programs and to determine whether program demographics affect inclusion of LGBT health topics. An anonymous survey link was sent to EM residency program directors (PDs) via the Council of Emergency Medicine Residency Directors listserv. The 12-item descriptive survey asked the number of actual and desired hours of instruction on LGBT health in the past year. Perceived barriers to LGBT health education and program demographics were also sought. There were 124 responses to the survey out of a potential response from 160 programs (response rate of 78%). Twenty-six percent of the respondents reported that they have ever presented a specific LGBT lecture, and 33% have incorporated topics affecting LGBT health in the didactic curriculum. EM programs presented anywhere from 0 to 8 hours on LGBT health, averaging 45 minutes of instruction in the past year (median = 0 minutes, interquartile range IQR = 0 to 60 minutes), and PDs support inclusion of anywhere from 0 to 10 hours of dedicated time to LGBT health, with an average of 2.2 hours (median = 2 hours, IQR = 1 to 3.5 hours) recommended. The majority of respondents have LGBT faculty (64.2%) and residents (56.2%) in their programs. The presence of LGBT faculty and previous LGBT education were associated with a greater number of desired hours on LGBT health. The majority of EM residency programs have not presented curricula specific to LGBT health, although PDs desire inclusion of these topics. Further curriculum development is needed to better serve LGBT patients. El Institute of Medicine, la Joint Commission y el Department of Health and Human Services han subrayado recientemente la necesidad en la competencia cultural y la educación sanitaria de los profesionales sanitarios sobre lesbianas, gays, bisexuales y transexuales (LGBT). El 40% de los pacientes LGBT reconoce una falta de formación de los sanitarios como una barrera en la atención médica. Sólo unas pocas horas del programa universitario de medicina está dedicada a la formación en LGBT, y se sabe poco sobre la formación médica de postgrado sobre LGBT. El objetivo de este estudio fue evaluar qué grado de formación sanitaria sobre LGBT se enseña en los programas de residencia de Medicina de Urgencias y Emergencias (MUE) y determinar si las características de las personas que realizan el programa afectan a la inclusión de temas sanitarios sobre LGBT. Se envió un enlace de encuesta anónima a los directores del programa de residencia de la MUE a través de la lista del servidor del Council of Emergency Medicine Residency Directors. La encuesta descriptiva de 12 ítems preguntó el número de horas reales y deseadas de formación saniataria sobre LGBT en el pasado año. También se buscaron las barreras percibidas para la educación sanitaria sobre LGBT y la demografía del programa. Hubo 124 respuestas a la encuesta de una respuesta potencial de 160 programas (porcentaje de respuesta del 78%). Un 26% de los encuestados contest que nunca había presentado una clase específica sobre LGBT, y un 33% ha incorporado temas que afectan a la salud de LGBT en el plan de estudios. Los programas de MUE presentaron en cualquier lugar de 0–8 horas de formación sanitaria sobre LGBT, con un promedio de 45 minutos de formación en el pasado año (mediana de 0 minutos, RIC 0 a 60 minutos), y los directores del programa apoyan la inclusión en cualquier lugar de 0 a 10 horas de tiempo dedicado a la formacion sanitaria sobre LGBT, con un promedio recomendado de 2,2 horas (mediana 2, RIC de 1 a 3,5 horas). La mayoría de los encuestados tienen profesores (64,2%) y residentes (56,2%) LGBT en sus programas. La presencia de profesores LGBT y la formación sanitaria previa sobre LGBT se asociaron con un mayor número de horas deseadas sobre formación sanitaria sobre LGBT. La mayoría de los programas de residencia en MUE no ha presentado un plan de estudios específico para formación sanitaria sobre LGBT, aunque los directores del programa desean la inclusión de estos temas. Es necesario el desarrollo de un programa futuro para atender mejor a los pacientes LGBT. In 2011, the Institute of Medicine published “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding,” which brought national attention to the health care needs of lesbian, gay, bisexual, and transgender (LGBT) people.1 Soon after, The Joint Commission and the U.S. Department of Health and Human Services issued comprehensive plans for LGBT health.2, 3 All stress the need for education of health care providers on LGBT health. LGBT people experience multiple health care disparities and have less access to health insurance and services. It is estimated that approximately 9 million Americans, or 3.5%, identify as lesbian, gay, or bisexual, while 0.3% are transgender.4 Forty percent of LGBT patients cite lack of provider education as a barrier to care, and large numbers report refusal of care, poor treatment, and verbal abuse from providers.1, 3, 5 As a result, many patients avoid medical treatment, including emergency care. Currently, the Accreditation Council on Graduate Medical Education emergency medicine (EM) residency curriculum does not include LGBT-specific education.6 There has been little published on LGBT resident education and none in the EM literature. The Council of EM Residency Directors (CORD) has previously examined education regarding underserved minorities, but did not include LGBT patients.7 In undergraduate medical education, U.S. and Canadian medical schools average less than 5 hours of LGBT-specific content, and 33% report no clinical hours for LGBT health.8 This paucity of education leaves students entering EM ill-prepared. As national organizations and government agencies focus on the neglected health care needs of LGBT people, it is necessary and essential that EM responds with appropriate educational tools to train emergency physicians. As a first step toward this goal, the authors conducted a needs assessment of EM residency program directors (PDs) to characterize the prevalence of content and needs related to LGBT education, examine barriers to curricula, and assess program demographics associated with extent of LGBT education. This was a survey study using an anonymous link created in SurveyMonkey. The link was sent to U.S. EM residency PDs via the CORD listserv. Two reminders were sent within the following 2 weeks. There are 160 accredited programs in EM in the United States, and typically all are represented on the CORD listserv.9 The study was approved by the institutional review board (IRB) at Louisiana State University. The survey was modeled after a published survey on the prevalence and barriers for evidence-based medicine education in EM residency programs.10 A draft was presented to both the Louisiana State University IRB and the Emory University Department of Emergency Medicine research committees. Both contain survey design specialists. Input was used to clarify questions and reduce bias. Based on feedback, the number of hours of curriculum was changed to an open response from a choice of ranges (Data Supplement S1 available as supporting information in the online version of this paper, questions 5 and 6), and metropolitan size was changed to standard ranges (Data Supplement S1, question 2). Respondents were provided the e-mail address for the primary author for concerns; however, none were forwarded. Our primary outcome was identifying the percentage of programs that had ever presented LGBT content, either as a dedicated lecture or by incorporating content into other instructional formats. Secondary outcomes included the number of hours of LGBT health education presented in the past year, and the number of hours desired in future years. Secondary outcomes also included any program demographic correlation with amount of LGBT education, both presented and desired, and any perceived barriers to LGBT education. Survey answers were aggregated into Microsoft Excel and analyzed using Statistical Analysis System (SAS 9.2). Frequency distributions for each item were performed. Kruskal-Wallis and Mann Whitney U-tests were used to compare group means. Hours of actual and desired LGBT health education were each tested separately against each demographic variable questioned for association using chi-square tests. If a respondent cited a range of desired hours, the lower number of the range was used for analysis. The U.S. Census Bureau standards for regions and divisions of the U.S. were used for regional analysis.11 A total of 124 surveys were completed out of a potential 160 programs (response rate of 78%). The demographic findings are summarized in Table 1. Twenty-six percent of EM programs had presented a lecture on LGBT health, and 33% reported some incorporation of LGBT health in the curriculum. EM PDs reported presenting from 0 to 8 hours on LGBT health, averaging 45 minutes (median = 0 minutes, interquartile range IQR = 0 to 60 minutes), whereas the time desired for LGBT health ranged from 0 to 10 hours (average of 2.2 hours, median = 2 hours, IQR = 1 to 3.5 hours; Figure 1). A minority of respondents (16%) felt that no time should be spent on LGBT health. The most frequently chosen barrier by EM PDs was “lack of need” (71 of 124, 59%). Other barriers included lack of interested faculty (28 of 124, 23%), funding (seven of 124, 6%), time (41 of 124, 34%), and other (12 of 124, 10%). Comments under the “other” category reflected that some had not previously considered the need. A comparison of mean didactic hours per year that respondents believed should be devoted to LGBT health showed geographic-based differences. There were differences between PDs responses in the Northeast (mean, 3.17 hours; SD ±2.329 hours, median 2.0 hours, IQR 1 to 5 hours) compared to the South (mean ± SD = 1.75 ± 2.00 hours, median = 1.0 hours, IQR = 1 to 2 hours; U = 210.5, p = 0.006) and the West (mean ± SD = 1.73 ± 1.387 hours, median = 1.0 hr, IQR = 0 to 1; U = 107.5, p = 0.048). There were no differences in mean hours of desired LGBT health education between other geographic regions. There was a positive association between the presence of LGBT faculty and previous delivery of LGBT education (chi-square with one degree of freedom = 15.69, p = 0.009). In addition, prior presentation of LGBT topics was associated with support for additional hours of education (chi-square with one degree of freedom = 7.67, p = 0.006). No other demographic factors correlated with previous LGBT health education or support for future inclusion. The majority of respondents had knowledge of LGBT faculty (64%) and residents (56%) in their programs. The knowledge of LGBT residents was different by region (chi-square = 12.08, df = 3, p = 0.007), with the Northeast being most aware of LGBT residents (Northeast 21 of 27, 78%; Midwest 23 of 40, 58%; South 19 of 35, 54%; West 5 of 19, 26%). The knowledge of LGBT faculty did not differ statistically by region (Northeast 20 of 27, 74%; Midwest 25 of 40, 63%; South 20 of 35, 57%; West 12 of 19, 63%). We found that only 26% of EM residency programs ever presented a specific LGBT lecture, and a meager 33% ever incorporated topics on LGBT health into their curricula. EM training programs averaged 45 minutes last year on LGBT health (SD ± 1.38 hours, range = 0 to 8 hours). This suggests a substantial lack of education of EM residents on LGBT health needs. We found no association of most demographic factors with inclusion or support of LGBT curriculum, including the offering of same-sex domestic partner benefits or metropolitan size, which was unexpected. We were also surprised that 36% of PDs are unaware if their program extends same-sex domestic partner benefits. We did find an association between known LGBT faculty and the previous presentation of any LGBT didactics. Perhaps this relates to program environment or faculty advocacy. Positive influences of faculty and leaders on LGBT campus environment, learning, and scholarship have previously been described.12 In addition, past curriculum made it more likely for a PD to support additional hours, suggesting an available prepared curriculum may benefit EM curriculum planners. A small but significant number of PDs (16%) did not support the inclusion of LGBT-specific education. Whether this reflects personal belief, perceived lack of need, or other factors was not assessed. The most cited barrier was perceived lack of need (59%). It is not clear if this represents that education is not needed, or if PDs lack an awareness of the need. Additional barriers included time, lack of interested faculty, and funding. Current pressures on health care make it difficult to protect faculty time for education, and competing interests for conference time must be balanced with many factors. Lack of inclusion of LGBT health education in the model of EM clinical practice is another barrier, in our opinion. To close the gap, we propose the development of an LGBT educational curriculum that can be shared on all levels of EM education. A survey on underrepresented minority education found lectures (94%), grand rounds (79%), and journal club (71%) were used.7 We envision a curriculum of a minimum of 2 hours in length, ideally repeated twice during residency. Topics should include communication, health disparities, legal and ethical considerations, specific needs and complications of transgender patients, and professionalism. Data were self-reported and thus subject to response bias. The survey was sent to PDs, and they may defer curriculum to other faculty. Because it was an anonymous survey, we had no mechanism to eliminate duplicate responses. Although survey experts at two institutions reviewed our survey, it was not pilot tested. There are unique challenges to performing research on LGBT populations. Our survey asked PDs for knowledge of LGBT faculty and residents, but it is impossible to know the actual number, especially since visibility may be limited by a majority of states not having employment nondiscrimination laws protecting LGBT employees. To our knowledge, this is the first survey to examine lesbian, gay, bisexual, and transgender education in EM residency programs. Our needs assessment suggests that consistent formal training is rare and that program directors desire more lesbian, gay, bisexual, and transgender education than is currently provided. These findings may inform future efforts to develop lesbian, gay, bisexual, and transgender curricula to prepare trainees to provide care to this sizable minority population with unique needs, who deserve competent and knowledgeable physicians trained in those needs. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.