A Call for LGBTQ Content in Graduate Medical Education Program Requirements.

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

Meeting the Patient Care, Education, and Research Missions: Academic Medical Centers Must Comprehensively Address Sexual and Gender Minority Health.

While sociopolitical advances have improved the rights of sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, queer [LGBTQ+] persons), they continue to face a health system that discriminates against them and does not provide competent, comprehensive care. Despite calls for advancing research, there remains limited sexual and gender minority health research funding, mentorship, and institutional support. Academic medical centers are best suited to systematically tackle disparities and improve care for all sexual and gender minority people through their tripartite missions of patient care, education, and research. In this article, the authors outline discrimination experienced by LGBTQ+ persons and highlight the unique disparities they experience across access and outcomes. The authors posit that by systematically improving clinical care of, incorporating education and training about, and research with LGBTQ+ people into their core missions, academic medical centers can dramatically change the health care landscape. Academic medical centers can eliminate health disparities, expand necessary research endeavors about sexual and gender minorities, and prepare the health care workforce to address the unique needs of these overlooked populations.

Health professional student preparedness to care for sexual and gender minorities: efficacy of an elective interprofessional educational intervention.

Lesbian, gay, bisexual, transgender, queer, and intersex people have unique health and health care needs that are inadequately met. An eight-hour symposium was developed at the George Washington University (GW) to better prepare health professional students and faculty to care for sexual and gender minority patients. This study compared surveyed learner knowledge, attitudes, and clinical preparedness, as well as perceived value of interprofessional learning, before and after the symposium. Learners at post-test were compared to an interprofessional group who did not attend the symposium. Results indicated statistically significant improvements for confidence in all learning objectives (p < .05) and for two of three factors (knowledge and clinical preparedness) of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS). In contrast to the comparison group, symposium participants at posttest rated higher on learning objectives, the attitudes and knowledge LGBT-DOCSS factors, and perceived value of interprofessional learning as measured by four items from the Interprofessional Learning Scale. This innovation is a starting point to address an identified learning gap. Findings support the benefit of greater curricular integration of sexual and gender minority health content through interprofessional learning to ensure preparedness of all practitioners.

Evaluation of a gender-affirming healthcare curriculum for second-year medical students.

BACKGROUND: Transgender medicine is an emergent subfield with clearly identified educational gaps. AIMS: This manuscript evaluates a gender-affirming healthcare curriculum for second-year medical (M2) students. METHODS: Students received a survey assessing Gender Identity Competency in terms of skills, knowledge and attitudes regarding transgender and gender non-conforming (TGNC) issues. The authors administered the survey before and after the delivery of the curriculum. The curriculum included five online modules, a quiz, a 3-hour case-based workshop and a 2-hour interactive patient-provider panel. RESULTS: Approximately 60% of M2 students (n=77) completed both preassessments and postassessments. The following showed a statistically significant improvement from preassessment to postassessment: student Gender Identity Competency, t(76) = -11.07, p<0.001; skills, t(76) = -15.22, p<0.001; and self-reported knowledge, t(76) = -4.36, p<0.001. Negative attitudes did not differ (p=0.378). Interest in TGNC issues beyond healthcare settings did not change (p=0.334). M2 students reported a significant change in experience role-playing chosen pronouns in a clinical setting, t(76) = -8.95, p<0.001. CONCLUSIONS: The curriculum improved students' gender-affirming medical competency, knowledge and skills. The development of a sustained, longitudinal curriculum is recommended in addition to the continuing education of faculty to reinforce this expanding knowledge and skills base and to address discomfort working with this population.

The Research Centers in Minority Institutions (RCMI) Translational Research Network: Building and Sustaining Capacity for Multi-Site Basic Biomedical, Clinical and Behavioral Research.

The Research Centers in Minority Institutions (RCMI) program was established by the US Congress to support the development of biomedical research infrastructure at minority-serving institutions granting doctoral degrees in the health professions or in a health-related science. RCMI institutions also conduct research on diseases that disproportionately affect racial and ethnic minorities (ie, African Americans/Blacks, American Indians and Alaska Natives, Hispanics, Native Hawaiians and Other Pacific Islanders), those of low socioeconomic status, and rural persons. Quantitative metrics, including the numbers of doctoral science degrees granted to underrepresented students, NIH peer-reviewed research funding, peer-reviewed publications, and numbers of racial and ethnic minorities participating in sponsored research, demonstrate that RCMI grantee institutions have made substantial progress toward the intent of the Congressional legislation, as well as the NIH/NIMHD-linked goals of addressing workforce diversity and health disparities. Despite this progress, nationally, many challenges remain, including persistent disparities in research and career development awards to minority investigators. The continuing underrepresentation of minority investigators in NIH-sponsored research across multiple disease areas is of concern, in the face of unrelenting national health inequities. With the collaborative network support by the RCMI Translational Research Network (RTRN), the RCMI community is uniquely positioned to address these challenges through its community engagement and strategic partnerships with non-RCMI institutions. Funding agencies can play an important role by incentivizing such collaborations, and incorporating metrics for research funding that address underrepresented populations, workforce diversity and health equity.

A equidade racial e a educação das relações étnico-raciais nos cursos de Saúde / La equidad racial y la educación de las relaciones étnico-raciales en los cursos de Salud / Racial equity and education of ethnic-racial relations in Health Care courses

Este artigo discute a prática da implantação da Política Nacional de Saúde Integral para a População Negra por parte dos gestores da educação dos profissionais de Saúde, problematizando a presença da temática "equidade racial em Saúde" no cotidiano das instituições de ensino superior (IESs). Esta pesquisa, composta por entrevistas em profundidade com 12 coordenadores de cursos da área da Saúde de três universidades do Estado de São Paulo, identificou que o novo marco normativo teve efeito positivo no que tange à recepção do tema nas grades curriculares observadas, mas que os coordenadores, no entanto, ainda demonstram desconhecimento ou discordância em relação à sua necessidade.(AU)

Este artículo discute la práctica de la implantación de la Política Nacional de Salud Integral para la Población Negra por parte de los gestores de la educación de los profesionales de Salud, problematizando la presencia del tema "equidad racial en Salud" en el cotidiano de las instituciones de enseñanza superior (IESs). Esta investigación, compuesta por entrevistas en profundidad con 12 coordinadores de cursos del área de la Salud de tres universidades del Estado de São Paulo, Brasil, identificó que el nuevo marco normativo tuvo efecto positivo en lo que se refiere a la recepción del tema en los cuadros curriculares observados, pero que los coordinadores, no obstante, todavía demuestran desconocimiento o discordancia en relación a su necesidad.(AU)

This article discusses the current implementation of the National Policy of Comprehensive Health for the Black Population, by the managers of health professionals' education, with the aim of proposing enhanced presence of the subject "racial equity in Health" in the day to day of higher education institutions (HEI). This research work contains in-depth interviews with 12 different coordinators of Healthcare courses from three universities in the State of São Paulo, Brazil and it has identified that the aforementioned normative frameworks have positively influenced the inclusion of such matters in the observed syllabuses. Nonetheless, those coordinators, in turn, still seem to show lack of knowledge or even disagreement with the mentioned policy.(AU)

Addressing Racism in Medical Education An Interactive Training Module.

BACKGROUND AND OBJECTIVES: Education of health care clinicians on racial and ethnic disparities has primarily focused on emphasizing statistics and cultural competency, with minimal attention to racism. Learning about racism and unconscious processes provides skills that reduce bias when interacting with minority patients. This paper describes the responses to a relationship-based workshop and toolkit highlighting issues that medical educators should address when teaching about racism in the context of pernicious health disparities. METHODS: A multiracial, interdisciplinary team identified essential elements of teaching about racism. A 1.5-hour faculty development workshop consisted of a didactic presentation, a 3-minute video vignette depicting racial and gender microaggression within a hospital setting, small group discussion, large group debrief, and presentation of a toolkit. RESULTS: One hundred twenty diverse participants attended the workshop at the 2016 Society of Teachers of Family Medicine Annual Spring Conference. Qualitative information from small group facilitators and large group discussions identified some participants' emotional reactions to the video including dismay, anger, fear, and shame. A pre/postsurvey (N=72) revealed significant changes in attitude and knowledge regarding issues of racism and in participants' personal commitment to address them. DISCUSSION: Results suggest that this workshop changed knowledge and attitudes about racism and health inequities. Findings also suggest this workshop improved confidence in teaching learners to reduce racism in patient care. The authors recommend that curricula continue to be developed and disseminated nationally to equip faculty with the skills and teaching resources to effectively incorporate the discussion of racism into the education of health professionals.

Implementing and evaluating an interprofessional minority health conference for social work and healthcare professionals.

Interprofessional education (IPE) is one strategy for addressing health inequities; however, little attention has been paid to continuing IPE for practicing social work and healthcare professionals. This article offers guidance to faculty in social work and health-related academic units on offering continuing IPE on the topic of minority health. An interprofessional group of faculty offered a day-long conference on minority health, ethics, and social justice. The conference goal was to promote interprofessional communication in a co-learning environment and promote dialogue on social determinants of health and health equity in the state. Data were obtained from surveys and analysis of work plans developed during the conference. Workshop participants were majority White (62%), social workers (79%), and practiced for 14 years on average. The most useful topics were dementia and polypharmacy. Takeaway strategies included interprofessional work, being mindful of access to resources, and engagement in continuing education. Lessons learned include plan in advance for all professions; recruit faculty and students from multiple departments to increase interprofessional diversity; offer strategies and incentives to increase student participation; be strategic about conference location and format; and identify a strategic format and theme. IPE is a means of preparing learners for working together in their future careers to provide high-quality patient-centred care and reduce health disparities. Professional development can provide an opportunity to enhance skills to address health disparities, and learning can be significantly enhanced when participants connect with colleagues from different professions, discuss diverse opinions, and share successful practices.

Inclusion of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Health in Australian and New Zealand Medical Education.

PURPOSE: This study aims at establishing the scope of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) health in Australian and New Zealand medical curricula. METHODS: We sent medical school curriculum administrators an online cross-sectional survey. RESULTS: The response rate was 15 medical schools (71%): 14 Australian schools and 1 New Zealand school. Respondents included program directors (n = 5; 33%), course coordinators (n = 4; 27%), Heads of School (n = 2; 13%), one Dean (7%), and three others (20%). Most schools (n = 9; 60%) reported 0-5 hours dedicated to teaching LGBTQI content during the required pre-clinical phase; nine schools (60%) reported access to a clinical rotation site where LGBTQI patient care is common. In most schools (n = 9; 60%), LGBTQI-specific content is interspersed throughout the curriculum, but five schools (33%) have dedicated modules. The most commonly used teaching modalities include lectures (n = 12; 80%) and small-group sessions (n = 9; 60%). LGBTQI content covered in curricula is varied, with the most common topics being how to obtain information about same-sex sexual activity (80%) and the difference between sexual behavior and identity (67%). Teaching about gender and gender identity is more varied across schools, with seven respondents (47%) unsure about what is taught. Eight respondents (53%) described the coverage of LGBTQI content at their institution as "fair," two (13%) as "good," and two (13%) as "poor," with one respondent (7%) describing the coverage as "very poor." None of the respondents described the coverage as "very good." CONCLUSIONS: Currently, medical schools include limited content on LGBTQI health, most of which focuses on sexuality. There is a need for further inclusion of curriculum related to transgender, gender diverse, and intersex people.

Training a medical workforce to meet the needs of diverse minority communities.

BACKGROUND: The growing demand for a competent health workforce to meet the needs of increasingly diverse societies has been widely acknowledged. One medical school in New Zealand explored the integration of the commonly used patient-centred model approach, with an intersectional framework in the development of a cultural competency training programme. In the Pacific Immersion Programme, medical students in their fourth year of training are given the opportunity to learn about different factors that influence the health and health care of a minority community through immersion in that community. The programme objectives include enabling students to learn through experience living within the local community context, and supporting them to re-evaluate their own personal beliefs, assumptions and/or prior prejudices. This study evaluates the usefulness of this programme in the training of medical students to work in diverse communities. METHODS: Two analytical approaches were used for evaluation. Deductive and inductive analyses were conducted on 235 reflective essays completed by three cohorts of students from 2011 to 2013 to ascertain the value of the programme for student learning. In addition, one cohort was invited to complete a pre and post-programme questionnaire. RESULTS: Overall, the students found the programme to be a valued learning environment. They found living within a Pacific family environment to be an eye opening experience. It increased students comfort level in cross cultural engagement and emphasised the importance of patient's perspectives in health care provision. Students' self-reported knowledge about Pacific cultural values, protocols, traditional beliefs and the main health challenges increased significantly after the programme. They appreciated learning directly from community members, and through observations about how culture, beliefs and the socio-economic environment influence peoples' health and wellbeing. CONCLUSIONS: Medical schools are required to train a competent health workforce to meet the needs of diverse communities. The Pacific Immersion Programme provides a unique learning environment which can improve the training of doctors to work in diverse communities. The key to its success is enabling students to be engaged learners from "the inside" rather than an "outsider looking in". The Programme enables experiential learning in a sensitive and meaningful way and can be useful for training in other institutions.

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials.

AIMS: To give an updated perspective of interventions from additional data collected since our first review, conducted in 2008. BACKGROUND: This updated Cochrane Review incorporates new information from recent randomized controlled trials on culturally appropriate diabetes health education interventions. METHODS: An electronic literature search of six databases was repeated, with databases of ongoing trials checked and three journals hand-searched. Meta-analysis was carried out for sufficiently homogeneous outcomes, and common themes among trials were highlighted. RESULTS: A total of 22 new trials were added to the original 11. Meta-analysis of 28 trials containing suitable data showed significant improvements in glycaemic control (HbA1c ) and diabetes knowledge over a period of 24 months, after the delivery of culturally appropriate education to participants, compared with those receiving 'conventional' care. There were no consistent benefits over the control group in other selected outcome measures, and lack of data continued to make analysis of several outcome measures difficult. CONCLUSIONS: Research activity in this field has increased considerably over the past 6 years, with culturally appropriate diabetes education showing consistent benefits over conventional care in terms of glycaemic control and diabetes knowledge, sustained in the short- to mid-term. Further research is needed to determine the clinical significance of these improvements and their cost-effectiveness.

Thirty-four Years Working Hand in Hand With Community Health Workers: A Doctor's Perspective.

The author, a physician, describes her long history of working with community health workers (CHWs), as well as her admiration for her colleagues in CHW programs and for the late Dr Eva Salber. CHWs have a unique capability not only to serve their communities but also to transform American health care and public health. It is in society's interest to utilize many more CHWs in diverse roles and settings. This requires thoughtful program design, recruitment, trust, support, and full integration of CHWs into professional teams.

Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial.

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.

Colorado Immersion Training in Community Engagement: Because You Can't Study What You Don't Know.

BACKGROUND: Community engagement (CE)has become a major element in medical research. In alliance with the goals of the Clinical and Translational Sciences Award program, Colorado Immersion Training in Community Engagement (CIT) is a community-campus partnership that aims to introduce an expanded pool of researchers to community-based participatory research (CBPR) and CE. OBJECTIVES: To describe CIT components and preliminary results. METHODS: CIT attempts to support a change in the research trajectory of academic health researchers, program developers, and graduate students toward CE. The program occurs on campus and in six community settings: Urban African American, urban Asian and refugee, urban Latino, urban American Indian/Alaska Native, rural northeast Colorado, and rural San Luis Valley. Components include a 4-week Directed Reading, a seminar on CBPR, 4-day community immersion, reflection, and 6-month support. Evaluation describes recruitment, implementation, and participants' understanding of CBPR and skills post-training. RESULTS: Fifty-eight people have participated. A comprehensive curriculum was developed to address (1) principals of CBPR, (2) health disparities, (3) listening to community, (4) self-reflection, and (5) engagement tools. Community immersions expose participants to a community's culture and opportunities to discuss health issues with a range of community members. Local "community guides" enhance participants' experience. Of the first two cohorts, 90% changed the way they plan to approach their research, 94% changed how they viewed community involvement in research, and 77% learned new skills to help engage communities in research. CONCLUSIONS: CIT applies to and positively impacts researchers from a variety of disciplines. CIT creates opportunities for long lasting partnerships between researchers and communities.

Responding to a changing nation: are faculty prepared for cross-cultural conversations and care?

BACKGROUND AND OBJECTIVES: The United States is becoming increasingly diverse. Health disparities continue with little improvement despite national policies and standards. Medical institutions are modifying their curricula; however, little is known about faculty attitudes and comfort in addressing cultural issues. The purpose of this study was to determine faculty attitudes, self-perceived levels of comfort and skill, and future knowledge needs pertaining to cultural competence. METHODS: A survey was administered to all clinical faculty at the University of Virginia School of Medicine. Survey questions addressed faculty attitudes and self-perceived levels of comfort and skill in dealing with cultural issues, as well as perceived need and interest in future cultural competence training. RESULTS: When considering each phase of education (medical school, residency, continuing medical education [CME]), fewer than 25% of the respondents reported receiving formal instruction in cultural competency in any given phase, although 93% felt that cultural competency training was important. Fifty-eight percent felt "very comfortable" caring for diverse patients, although this dropped to 30% when specifying limited English proficiency. The situation in which the highest percentage of respondents felt "not particularly comfortable" or "not at all comfortable" was breaking bad news to a patient's family first if this was more culturally appropriate (47%). Respondents felt most skilled in working with medical interpreters, apologizing for cross-cultural misunderstandings, and eliciting the patients' perspectives about their health and illness. Respondents felt the least skilled providing culturally sensitive end-of-life care and dealing with cross-cultural conflicts. CONCLUSIONS: Clinical faculty have received limited instruction on cultural competency, and the reported levels of comfort and skill in many challenging areas of multicultural health leave much room for improvement. Until faculty become more comfortable and are able to model and teach these behaviors to learners, positive responses to national policies in culturally competent care are likely to be limited.

Community experience of a Pacific Immersion Programme for medical students in New Zealand.

AIM: To obtain the views of the Pacific community about their involvement in a Pacific Immersion Programme, to determine the programme's viability as a resource for medical education. METHOD: The Pacific Immersion Programme run by the Dunedin School of Medicine had four attachments (March, April, June and September) with local Pacific communities in 2011. Community focus groups were held the week immediately after each attachment. There were two focus group sessions for each attachment, one obtained the views of adults and the other of young people. Focus groups consisted of eight participants recruited through community coordinators and were facilitated by trained research assistants. Sessions were audio recorded and analysed using a thematic framework. RESULTS: Sixty-four members of the community participated in the focus groups. Eight themes emerged from the discussions. The community agreed the Pacific Immersion Programme strengthened community cohesion through efforts to engage the students. There was shared learning and created opportunities for engagement between medical students and the community's younger generation. The Pacific families shared with the students about their health and context through storytelling, dancing and singing and cultural ceremonies. Participants hoped students achieved what they wanted from the programme and the experience was useful for their work in the future. CONCLUSION: Community based medical education is a unique and useful approach for teaching medical students about the health of a minority community. The purpose of the paper is to highlight the impacts on participating communities. Nurturing established relationships and providing mutual benefits for both partners will ensure this opportunity will be available as a learning resource for future medical students.

Improving capacity in ethnicity and health research: report of a tailored programme for NHS Public Health practitioners.

AIM: To determine whether an intervention designed to enhance research capacity among commissioners in the area of ethnicity and health was feasible and impactful, and to identify programme elements that might usefully be replicated elsewhere. BACKGROUND: How healthcare commissioners should be equipped to understand and address multiethnic needs has received little attention to-date. Being able to mobilise and apply evidence is a central element of the commissioning process that requires development. Researching ethnicity and health is widely recognised as challenging and several prior interventions have aimed to enhance competence in this area. These have, however, predominantly taken place in North America and have not been evaluated in detail. METHODS: An innovative research capacity development programme was delivered to public health staff within a large healthcare commissioning organisation in England. Evaluation methodology drew on 'pluralistic' evaluation principles and included formative and summative elements. Participant evaluation forms gave immediate feedback during the programme. Participants also provided feedback at two weeks and 12 months after the programme ended. In addition, one participant and one facilitator provided reflective accounts of the programme's strengths and weaknesses, and programme impact was traced through ongoing partnership work. FINDINGS: The programme was well received and had a tangible impact on knowledge, confidence and practice for most participants. Factors important to success included: embedding learning within the participants' work context; ensuring a balance between theory and practical tips to enhance confidence; and having sustained interaction between trainers and participants. Despite positive signs, the challenging nature of the topic was highlighted, as were wider structural and cultural factors that impede progress in this area. Although it is unrealistic to expect such programmes to have a major impact on commissioning practices, they may well make an important contribution to raising the confidence and competence of staff to undertake work in this area.

Sexual minorities, human rights and public health strategies in Africa.

Remarkable progress has been made towards the recognition of sexual minority rights in Africa. At the same time, a marked increase in attacks, rhetorical abuse, and restrictive legislation against sexual minorities or 'homosexuality' makes activism for sexual rights a risky endeavour in many African countries. Campaigns for sexual rights and 'coming out' are frequently perceived as a form of Western cultural imperialism, leading to an exportation of Western gay identities and provoking a patriotic defensiveness. Cultures of quiet acceptance of same-sex relationships or secretive bisexuality are meanwhile also problematic given the high rate of HIV prevalence on much of the continent. This article examines specific initiatives that are using subtle, somewhat covert means to negotiate a path between rights activism and secretive bisexuality. It argues that strategies primarily focused on health concerns that simultaneously yet discreetly promote sexual rights are having some success in challenging prevalent homophobic or 'silencing' cultures and discourses.