Editorial / Éditorial

Gay, lesbian and bisexual health care issues and medical curricula

Gregory Robinson, MD, MHSc, CCFP, FRCPC; May Cohen, MD, CCFP, FCCFP

Canadian Medical Association Journal 1996; 155: 709-711

Dr. Robinson is director of the HIV Ontario Observational Database Project and is with the Department of Preventive Medicine and Biostatistics, University of Toronto, Toronto, Ont. Dr. Cohen is a professor in the Department of Family Medicine, McMaster University, Hamilton, Ont.

Paper reprints may be obtained from: Dr. Gregory A. Robinson, HIV Ontario Observational Database Project, Sunnybrook Health Science Centre, Rm. G314A, 2075 Bayview Ave., North York ON M4N 3M5; fax 416 480-5881

See also

Readers' Forum: Gay blade refuses to hang up his sword

Abstract

The authors respond to Nancy Robb's account of the inadequacy of medical school curricula in addressing health care issues relevant to gay, lesbian and bisexual people (see page 765 of this issue [full text / en bref]) by proposing a framework for curriculum reform. This framework supports the development of knowledge, attitudes and skills necessary to the provision of sensitive and comprehensive care for these patient groups through four types of learning experiences: didactic instruction, small-group discussions, simulated patient encounters, and supervised encounters with real patients. Equally important is the attitudinal context in which learning takes place. Without fostering a supportive and accepting environment for education about gay, lesbian and bisexual health care issues, medical schools cannot ensure that future physicians will be equipped to provide appropriate care for all members of society.

Résumé

Les auteurs répondent au compte rendu de Nancy Robb au sujet des lacunes des programmes d'études des facultés de médecine en ce qui a trait aux enjeux des soins de santé des personnes gaies, lesbiennes et bisexuelles (voir page 765 du présent numéro [full text / en bref]) en proposant un cadre de réforme des programmes d'études. Ce cadre appuie l'acquisition des connaissances, des aptitudes et des compétences nécessaires pour fournir des soins adaptés et complets à ces groupes de patients grâce à quatre types d'expériences d'acquisition du savoir : enseignement magistral, discussions en petits groupes, rencontres simulées avec des patients et rencontres supervisées avec des patients réels. Le contexte des attitudes d'acquisition du savoir est tout aussi important. Si elles ne favorisent pas un environnement d'appui et d'acceptation en ce qui a trait à l'éducation relative aux soins de santé des personnes gaies, lesbiennes et bisexuelles, les facultés de médecine ne peuvent assurer que les médecins de demain auront les moyens nécessaires pour fournir des soins appropriés à tous les membres de la société.

In this issue (see pages 765 to 770 [full text / en bref]) Nancy Robb highlights the lack of attention given to lesbian, gay and bisexual health care issues in medical curricula. The "invisibility" of these issues in medical education does little to ensure that future physicians will be equipped to provide comprehensive, high-quality care to gay, lesbian and bisexual patients, whose encounters with health care professionals are frequently negative. Of approximately 1000 respondents to a recent survey of gay, lesbian and bisexual Ontarians, 87% said that they had been discriminated against within the health care system, and 70% reported that they had been insulted on the basis of their sexual orientation (Project Affirmation, Coalition for Lesbian and Gay Rights in Ontario, Toronto: unpublished data, 1995). Other research has drawn attention to the fact that medical curricula inadequately address health care issues relevant to gay, lesbian and bisexual people and that the overall response of the health care system to the needs of these patient groups has been minimal.[14]

Although the recent inclusion of HIV infection and AIDS in most medical school curricula is sometimes assumed to address these needs, in fact it has led to a focus on some aspects of gay male sexual behaviour (almost invariably the potentially "unsafe" aspects of sexual activity) while many other significant health care issues are ignored. As is the case with heterosexual people, gay, lesbian and bisexual people have health care needs that for the most part relate not to sexual activity but to overall health and well-being. For example, some patients may present to a physician with an array of emotional or physical symptoms during the time that they first tell others about their sexual orientation.

Health professionals are becoming more aware of the importance of social, behavioural, emotional, spiritual and cultural factors to health and well-being. The health care system itself also influences the health and well-being of patients. Yet the importance of these determinants in the lives of gay, lesbian and bisexual patients has yet to be integrated in a balanced way into medical curricula. Action is needed to develop and implement curricula that effectively incorporate health care issues of importance to these groups and to create learning environments that build knowledge and understanding, establish professional skills and support positive attitudes toward gay, lesbian and bisexual patients and colleagues.

We propose here a framework that we hope will encourage medical schools across Canada to re-examine their undergraduate and postgraduate medical curricula, the learning opportunities and experiences they offer to students, and the context in which learning occurs -- with the aim of incorporating gay, lesbian and bisexual health care issues within these curricula. This framework can be applied in all phases of the development, implementation and evaluation of medical curricula.

The context of learning

Medical curricula must be examined within the context in which learning occurs (Fig. 1). The content of medical curricula -- knowledge, attitudes and skills -- is conveyed through a variety of learning experiences in the form of didactic instruction, discussion involving small groups, simulated patient encounters and supervised patient encounters. The context of learning encompasses the spectrum of responses and attitudes -- ranging from condemnation and denial to understanding and acceptance -- that influence learners and that gay, lesbian and bisexual patients experience in their encounters with health care professionals.

Whether overt or covert, condemnation has negative implications. Health care professionals who condemn bisexual, gay and lesbian people may betray their hostility by harassing or discriminating against certain patients and colleagues. Also, health care professionals who deny or fail to address issues of particular relevance to gay, lesbian and bisexual people or assume that everyone is heterosexual cannot meet the needs of all of their patients. Many physicians have an intellectual understanding of the impact of heterosexism and homophobia on the lives of their lesbian, gay and bisexual patients but are unable to provide optimal care because of their inability to accept and support the sexual orientation of these patients. On the other hand, health care professionals who demonstrate an accepting attitude open doors for the sharing of issues that affect the health and well-being of gay, lesbian and bisexual patients. In the context of medical education an attitude of acceptance toward homosexuality and bisexuality provides a supportive context for learning that will ultimately prepare health care professionals to listen to and provide appropriate care for all of their patients.

Learning experiences

Appropriately balanced and comprehensive learning experiences offered in a supportive context will help undergraduate and postgraduate students not only to understand the health care needs of gay, lesbian and bisexual patients but also to move toward an attitude of acceptance. Although particular types of learning experiences are particularly conducive to the development of either knowledge, attitudes or skills, a balance of learning experiences offered in a supportive environment will promote learning across these three areas.

Didactic instruction by means of lectures, tutorials and readings promotes understanding of the factors that influence the health of gay, lesbian and bisexual people. Working in small groups offers an opportunity for learners and faculty members to explore their attitudes toward their own sexuality and that of others. Discussion can be centred on specific case studies involving gay, lesbian or bisexual patients, their families and friends and the specific issues that are unique or important to them. A supportive context is extremely important to facilitate the honest sharing of concerns, experiences and beliefs and can also provide an important and nonthreatening opportunity for gay, lesbian and bisexual students to open up to their peers.

Simulations of patient encounters using trained actors allow students to bring together knowledge and attitudes in a less threatening situation than that of a real patient encounter and to develop skills in history taking and physical examination. They also provide an opportunity for students to learn about gay, lesbian and bisexual issues, the importance of these issues to health, and how best to assist patients directly or in cooperation with other health-related services. Feedback from both the supervising physician and from the "patient" allows the student to explore the often subtle and unrecognized heterosexist or homophobic cues that health professionals frequently convey. Most important, these learning experiences provide an opportunity to develop knowledge and skills and to test attitudes without inflicting harm.

Directly supervised encounters with gay, lesbian and bisexual patients are also extremely important learning experiences that are best pursued after students have acquired the appropriate level of knowledge and skill and have had an opportunity to explore their attitudes and their ability to respond to patient cues. Direct observation and supervision of students need not place patients in a passive role; many patients are willing to provide direct feedback to students and their supervisors. Patients should be encouraged -- without coercion -- to participate directly in the learning experience.

A supportive context

One cannot overemphasize the importance of a supportive context for education about gay, lesbian and bisexual health care issues. Without such a context, the types of learning experiences we have described cannot succeed in training physicians to provide appropriate and sensitive care to gay, lesbian and bisexual people. Faculty members have a crucial role to play in ensuring that the context of learning is a supportive one. This requires that they acquire the knowledge, attitudes and skills that will enable them to be accepting of gay, lesbian and bisexual people, of their lifestyles and of their health concerns.

Using the framework

The framework we propose can be applied to four progressive phases of curriculum change. First, those involved in curriculum development should produce an inventory of the range of learning experiences currently offered that relate to gay, lesbian and bisexual health care issues. Given that role models exert a powerful influence, this inventory should include an examination of the knowledge, skills and attitudes of faculty members. In the second phase, the curriculum should be examined for existing gaps in learning experiences, and such gaps should be addressed to ensure balance. A complete set of learning objectives with respect to expected achievement in knowledge, attitudes and skills should be documented, and programs to address the needs of faculty members in these areas should be developed. In the third phase, changes to faculty training and to curricula that incorporate gay, lesbian and bisexual health care issues should be implemented within a specific time frame. In the final phase the curriculum should be evaluated. The framework can be used to assist in the design of both process and outcome indicators of the effectiveness of the curriculum and its implementation. The evaluation should examine student performance against the learning objectives set during phase two and should include evaluation of the teaching faculty. The context within which these educational activities occur must also be incorporated in the evaluation.

Conclusion

The health care of gay, lesbian and bisexual patients in Canada has been less than stellar. Our framework is intended to assist medical schools in developing curricula that, for both students and faculty members, build knowledge and skills and cultivate accepting attitudes. The adoption or adaptation of our framework in medical education is a good way to begin to ensure that gay, lesbian and bisexual patients receive sensitive and comprehensive care. Medical schools have an obligation to ensure that their students become competent in caring for all members of society.

References

Gibson G. Gay and lesbian patients: teaching our students the realities. Fam Med 1994; 2(3): 4-5.
Henry J. Exploring issues affecting gay and lesbian physicians in Ontario. Ont Med Rev 1995; 62: 25-8.
Wallick MM, Cambre KM, Townsend MH. How the topic of homosexuality is taught at US medical schools. Acad Med 1992; 67: 601-3.
EFPO [Educating Future Physicians of Ontario] Public Expectations Working Group. Some views on lesbians' expectations of physicians: a brief report. Addendum to Some views on women's expectations of physicians (EFPO Working Paper # 9). Toronto: The Working Group, 1993.

| CMAJ September 15, 1996 (vol 155, no 6) / JAMC le 15 septembre 1996 (vol 155, no 6) |