Learning Never Stops: How New Perspectives Can Help Improve Patient Care

Sara Ali, MD

Pride month allows us as a country to celebrate the many accomplishments LGBTQ+ folks have made and to continue honoring those accomplishments. However, although we have made vast progress over the years, LGBTQ+ health disparities continue to persist. For example, in a national survey, about 50% of respondents reported having to teach their own health care professionals about LGBTQ+ health. In another survey, one out of three respondents have at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. LGBTQ+ youth are 120% more likely to experience homelessness, which directly relates to health disparities they face later down the line. Health care professionals are given the privilege and responsibility of upholding equity in practice, and this includes advocating for the safety and inclusion of LGBTQ+ patients.

During my very first clinical rotation, I had no idea what the etiquette of a third-year medical student was supposed to be. As a result, I often chose to be more conservative with my behavior—especially with my attending physicians. Pediatrics is a field some would say is most adjacent to obstetrics and gynecology, and naturally I wanted to make a good impression. During a physical exam appointment with an adolescent, medical students are required to perform the Home and Environment, Education and Employment, Activities, Drugs, Sexuality, and Suicide/Depression (or HEADSS) assessment. If the adolescent is accompanied by a parent, they are kindly asked to leave so the assessment may be conducted in private. Both students and physicians conduct the assessment in private to not only honor the patient–physician relationship but also to provide a feeling of safety for the adolescent. After developing rapport with a particular patient, my attending physician and I began the HEADSS assessment with her.

The patient was a quiet, shy 17-year-old about to start college. During the sexuality part of the assessment, I asked her what her sexual orientation was as a way to initiate a safe sex talk. Initially hesitant, the patient eventually disclosed to me that she was bisexual. The patient had been working with the attending physician since she was born, so the physician was delighted that she felt comfortable enough to share this. After I finished giving the appropriate guidance talk to her, the attending had mentioned to the patient that whenever she was ready to come out, her family would accept her and love her. The attending even guaranteed it. My mind instantly flashed back to the many youth I personally knew who were displaced to the street after coming out to their families. I felt internal conflict arise, but did not want to seem confrontational to my preceptor and risk leaving a poor impression. However, I also didn't want my attending to continue guaranteeing such a fate to unassuming youth. I knew I wouldn't be able to reconcile myself if I didn't speak up. After all, it is a privilege to have such vulnerable conversations with youth; we owe it to them to guide them well.

After the visit concluded, I gently inquired with my preceptor if she had made this same guarantee to all of her LGBTQ+ adolescent patients. The attending looked at me curiously for a few minutes, and finally replied that if she knew the patient and their families well, she did. Gathering my courage, I mentioned the homeless LGBTQ+ youth I knew and how their families in fact did not accept them. Our conversation led to an enlightening discourse on generational differences of taking words literally, and how even though my attending's intent was to reassure love and warmth, the way to do that had to adapt with those generational differences. After our conversation, my preceptor changed the way she spoke to LGBTQ+ adolescents, such that she assured warmth and love without guaranteeing absolute acceptance from their parents. The success of this initiative would not be possible without my attending's ability to learn and listen, even from those who are below her hierarchically. This quality not only enriched my learning experience with her but also enriched her own practice.

I have been devoted to advocating for LGBTQ+ folks since my first year as a medical student. After beginning medical school, I created an advocacy website, queerhealthnarratives.com, which serves as a forum to help amplify the voices of LGBTQ+ patients. My website is featured in my medical school's sex and gender curriculum and serves as a resource for medical students to learn what it is like being a queer patient and what quality health care looks like for queer patients.