Diversity, Equity & Inclusion Trans Patients, Trans Selves

DIVERSITY, EQUITY & INCLUSION

By Lachlan Driver, MD

Treating a queer patient hits a little bit differently when we’re also a queer health care provider. For better or worse we see a little bit of ourselves, our experiences, and the challenges we’ve faced in life in those same patients. I recently had an experience where I was seeing a “John Smith, male, 20s” for chief concern of “sore throat.” As I entered the room, fully expecting a bread-and-butter viral versus streptococcus pharyngitis patient, my clinical brain paused because as I was walking in and saying my usual greeting, “Hello Mr. Smith…” I saw in front of me a transgender woman.

Even as a trans individual, I would be lying if I said walking in and immediately misgendering my patient did not phase me, although it is not uncommon for the electronic health record and a patient’s identity, name, or other aspects relating to their sense of self to be incongruous. In the few seconds that followed I realized that I needed to kick into gear my many years of internal preparation for this moment. I immediately introduced myself, though probably somewhat overzealously, “Hello I’m Dr. Driver! I use he/him or they/ them pronouns, I will be taking care of you today. What name and pronouns do you use?” As she introduced herself, I could see a sigh of relief. She would not be questioned as to why she does not look like the picture painted in her chart; she would be understood.

To save everyone the suspense — I never found the root cause of her sore throat, although we used shared decision making and tested for strep pharyngitis, mononucleosis, COVID-19, and gonorrhea/chlamydia, as she frequently has oral receptive sex with partners who have penises.

However, what I was able to do as her doctor was take two minutes to call registration and make sure that her true gender and her name in the chart are listed correctly. I was able to update my patient that it is now officially changed in our system, so no one would be walking in calling her by the wrong name and/or gender, and subsequently being awkward and confused about why the chart says one thing and the patient another. Although I cannot explain the pharyngitis, somehow what I was able to do for her seemed more significant, both for my sense of well-being as a queer provider and for the patient. Focusing on these seemingly small things allows me to cope with the monumental feeling of otherness as a queer provider and consider my own experiences.

I came away from this early interaction entirely humbled — we all make mistakes, but being an ally to queer and transgender patients, to be that supportive, is more complicated than simply wearing a rainbow pin; we wear the pin as a sign that we are willing to listen, to go that extra mile, to support our patients regardless of their gender or sexual identity.

So many times, as physicians, queer or otherwise, we feel helpless in the larger system, as we try to advocate for our patients and do what we can for whom we can when we can. And many times, small interactions, such as this one, can change an LGBTQ+ patient’s experience in a big way, whether it’s medical or social. I have been asked more times than I can recount on how to support the transgender patient, although gender is a spectrum and the needs of, for instance, a nonbinary person who is just in the process of coming out are vastly different than a transgender man who has been on testosterone for years.

Often cisgender people do not realize that it is not usually a one-off interaction that is toxic or hurtful, it’s the day-afterday coping with the onslaught of the “ma’ams,” “sirs,” or “what does your wife do?” It sometimes feels like waves hitting against a rock, a single wave does nothing, but given time the rock wears down and wears away. Sometimes as physicians the best we think we can do is not worsen that already substantial mental load, but the reality is that we can often do more. We can advocate to adjust our patient’s name in the electronic health record. We can stand up to coworkers who make inappropriate jokes. We can feel empowered to correct people who use incorrect pronouns. We can normalize gender diversity and allow gender diverse physicians to thrive and treat gender diverse patients. Finally, we can amplify the voices of those who have been marginalized without speaking for them. These seemingly small things may allow us to heal the patient even if we cannot treat the disease.

“Focusing on these seemingly small things allows me to cope with the monumental feeling of otherness as a queer provider and consider my own experiences.”

ABOUT THE AUTHOR

Dr. Driver is an emergency medicine resident in the Harvard Affiliated Emergency Medicine Residency (HAEMR) program at Mass General Brigham, as well as a member of the LGBTQ Advisory Committee at Harvard Medical School.

About ADIEM

The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the realization of our common goals of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Joining ADIEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”

“Resident, Know Thyself:” The Challenge of Assessing Self-awareness and Well-being in Milestone 2.0

By Carolyn Commissaris, MD, and Esther H. Chen, MD, on behalf of the SAEM Education Committee

The new milestones for assessing emergency medicine (EM) residents went into effect in July 2021 just as we were getting used to the old ones. Notably, there is a new milestone, PROF3: Self-awareness and Well-being, with anchors ranging from Level 1: “recognizes, with assistance, the status of one’s personal and professional well-being” to Level 5: “coaches others when their emotional responses or level of knowledge/skills fail to meet professional expectations.”

The introduction of this milestone is timely, as provider well-being has been a central topic of discussion by national organizations for several years. In the last year, 72% of EM providers reported more professional burnout than in the prepandemic period, but nearly 50% were hesitant to seek mental health treatment due to workplace stigma. This startling data led several EM organizations to form the EM Mental Health Collaborative to promote the “Stop the Stigma EM” campaign and attempt to break down barriers to mental health care for EM providers. Within this broader context, the motivation to improve resident wellbeing is laudable, but framing it as an assessment has the potential for negatively impacting resident well-being and discouraging open conversation about burnout and mental health. Furthermore, it’s important to remember that the PROF3 subcompetency is not intended to evaluate a resident’s well-being. Rather, its intent is to ensure that each resident has the fundamental knowledge of factors that affect wellbeing, the mechanisms by which those factors affect well-being, and the tools and resources (personal, programmatic, and institutional) available to improve and maintain their well-being.

Potential Pitfalls Performative Wellness

In framing well-being as an assessed skill, we are concerned that this may create additional barriers to open discussion with residents struggling with burnout, mental health, and wellbeing. Although milestones are not grades, our high-achieving learners may perceive them as such. A resident who fears receiving a “bad grade in wellness” may be more reluctant to disclose mental health challenges they may be facing with program leaders or faculty mentors and less likely to receive the support they need. Moreover, we

“The motivation to improve resident well-being is laudable, but framing it as an assessment has the potential for negatively impacting resident well-being and discouraging open conversation about burnout and mental health.”

should consider how this assessment may encourage “performative wellness,” where the public display of a resident’s well-being is as carefully curated as their Instagram account, highlighting the positives but hiding struggles into an unseen and undiscussed space.

Limitation of Fixed Anchors

Unlike clinical skills which follow a logical progression of skills, the PROF3 rating scale for self-awareness and wellbeing is more complex and may not be as easily measured in a rating scale with fixed anchors. Our residents are highfunctioning individuals who may be perceived as functioning at the “Level 5,” because they are able to coach their peers toward maintaining wellbeing, and yet lack the insight to recognize their own need for help (Level 1).

A Minefield of Bias

There is increasing evidence of bias in assessment in medical education. We caution program leaders and faculty to consider how this milestone may be biased toward or against individuals who talk about their feelings too much or introverted individuals who do not. Additionally, the degree to which learners may want to disclose, discuss, or demonstrate their own personal wellbeing also depends highly on varying cultural expectations and values. It’s critical for programs and residents to understand that residents are not being assessed on their disclosure or management of mental health conditions, but rather their knowledge of factors that affect well-being and the resources they have available to them to maintain wellbeing.

Undefined Accountability and Consequences

Programs are responsible for supporting residents who are not meeting expectations on their milestones. For example, those falling behind in clinical skills may require a remediation strategy that includes additional faculty time for coaching, direct observation, or simulations. Programs typically bear the cost of this additional support. How might a program approach supporting a resident who is consistently not meeting expectations in the PROF3 milestone? Who will bear the cost of mental health interventions? Will individuals who receive a letter of concern be required to seek mental health care? What are the consequences for programs who do not address or provide support for struggling residents? Conversely, as students evaluate programs and institutions with varying levels of mental health resources and support, what might be the impact on resident recruitment?

Practical Approach to the PROF3 Milestone: Dos and Don’ts

Prepare Your Program

• Do have your Clinical Competency

Committee faculty review the Milestone 2.0 supplemental guide for how to assess this milestone. • Do ensure that your residents, faculty, and program leadership understand existing programmatic, institutional, and local mental health resources available to residents. • Do reflect on existing program and institutional resources to support mental health and well-being and advocate for additional resources from the department or institution. • Do collaborate with other residencies and specialties on their approach to and experience with the well-being milestone, as this is not unique to EM.

Evaluate Your Data Sources

• Do use self-assessment and personal goal setting around well-being as a primary source for milestone progression data. • Do use smaller advising group discussions or direct observations of resident wellbeing. During the semi-

annual meeting discussion, discuss well-being in an open and supportive way. • Do internally evaluate programmatic milestone progress for signals of bias in assessment. • Don’t add this milestone to shift-based assessments based on brief clinical encounters.

Stop the Stigma

• Do encourage open discussion of resident well-being in a judgement-free space. • Don’t invoke milestone performance in conversations where residents disclose burnout or other mental health conditions. • Don’t provide metrics on this milestone without providing any additional context. • Don’t provide class averages or other aggregate data for this milestone. • Don’t comment on the presence or treatment of specific mental health disorders in documentation of PROF3 milestone progress.

ABOUT THE AUTHORS

Dr. Commissaris is a medical education fellow and assistant residency program director at the University of Michigan in Ann Arbor, Michigan. She is the 2020-2021 fellow editor-in-training for Academic Emergency Medicine Education & Training journal. Dr. Chen is a professor of emergency medicine and associate residency director at the University of California, San Francisco. She is also the director of graduate medical education at San Francisco General Hospital.