LGBTQ Interactive for Residents and Medical Students

Howa Yeung, MD, MSc, is an assistant professor in the department of dermatology at Emory University School of Medicine in Atlanta, GA. A board-certified dermatologist, Dr Yeung’s clinical and research expertise is on skin diseases that disproportionately affect sexual and gender minority (SGM) patients. He met with The Dermatologist to discuss his study, “Interactive Session for Residents and Medical Students on Dermatologic Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients.”

In your words, how can a designed interactive online didactic session help medical students and dermatology residents improve lesbian, gay, bisexual, transgender, and queer (LGBTQ) medical care and practices?
There is a dearth of educational material that targets dermatology trainees that prepare folks to really care for diverse populations, especially people who identify as LGBTQ. There is increasing recognition that this is a gap in our curriculum and that we need to do more to prepare our trainees, but there isn't a gold-standard tool out there that allow us to do so—certainly not a tool that has been evaluated to show that it works for rising dermatologists.

We saw that gap and hoped that we could create a brief interactive session tailored to residents and medical students who will become dermatologists, specifically focusing on dermatologic care for LGBTQ patients so that they can prepare themselves to serve that role in the future.

The study noted that “participants acted as observer, patient, or provider in three distinct clinical scenarios pertaining to dermatologic care of LGBTQ patients.” What were the reasons for implementing three different perspectives within the scenarios?
First, I will credit Dr Patrick McCluskey, one of our coauthors, who came up with this exercise and piloted it during one of our American Academy of Dermatology (AAD) meetings. He was very kind in providing us these scenarios that we have adopted into the session. We had several scenarios where one person is asked to take a sexual history as the provider. Another person served as the patient, with very detailed scenario about one’s sexual history that is relevant to their dermatological complaints. The third person served as an observer who provides feedback on the clinical encounter. When we split up into small groups, the trainees can decide who played which role.

There are strengths of having three different perspectives. First, people come from different level of comfort regarding taking sexual history. We wanted to create a safe space where those who may not be comfortable can serve as an observer and use that as an opportunity to see how others will approach the scenarios. Second, it can be hard to evaluate yourself when you're a part of the role play scenario. It's easier to have a third person to provide constructive feedback—about what we did well and how can we improve in history taking in a manner that is normalizing, affirming, and inclusive. For those who have multiple people who want to serve as an observer, we had our medical student facilitators fill in so that we can have participants in each group.

Can you share what LGBTQ care disparities in the dermatologic field are frequent in the practice?
I would highlight a couple disparities. First, we have to do better in screening and prevention for HIV and sexually transmitted infections (STI) for men who have sex with men. Oftentimes when patients are referred to a dermatologist's office, they are referred for one very specific thing—say warts, for example. Dermatologists, often when we're in a very busy clinic, we focus on that one very particular thing. That one specific problem can be an opportunity to provide more comprehensive care. For example, if you newly diagnosed a patient, who is a man who has sex with another man who has genital warts—that is an opportunity to also discuss safer sex practices, discuss HIV and STI screening, and to talk about HPV vaccination for the patient and their partners. If we diagnose a patient with secondary syphilis, for example, talking to patients about HIV pre-exposure prophylaxis (PrEP) and referring that patient to start PrEP, you can actually prevent HIV infection. If we only focused on treating that wart or that rash, we miss opportunities to provide comprehensive care that ultimately serves the patient's best interests. By knowing some of these health care disparities that disproportionately affect LGBTQ populations, we are really engaging healthcare as a whole, rather than just focusing on the skin itself.

I also see many transgender and gender diverse patients in my practice, For example, treating acne in trans patients who have acne from their hormone therapy, and discussing contraception when offering acne treatments that are teratogenic, such as tetracycline antibiotics and isotretinoin. There are many missed opportunities to collaborate care with trans patients’ hormone provider and mental health providers to optimize their skin outcomes. Being aware of the complexity, but also the opportunities that dermatologists can play in providing care for these patients is really important. I hope that this session at least starts the conversation for our trainees.

What tips or suggestions would you like to offer current dermatologic physicians for treating LGBTQ patients since they have no opportunity to utilize the interactive online didactic session?
We published this paper on MedEd Portal. The entire curriculum, including the case scenario plus the presentation, can be downloaded. I encourage other training programs to download it and adopt it for their learning. The AAD also has an LGBTQ/SGM Expert Resource Group, which consists of expert dermatologists who are committed to help our peers and patients to navigate some complex skin issues that come up in clinical practice. The AAD VMX virtual meeting also had an hour-long session on LGBTQ health, which is more targeted to practicing dermatologists.

Any other pearls of wisdom you’d like to share with your colleagues regarding LGBTQ issues in dermatology?
We must respect that the patients are the experts in themselves, their identity, and their symptoms. It is important for us to ask our patients how their identities and respect how would like to be addressed to develop an effective communication and therapeutic rapport. It remains our responsibility as dermatologists to learn how to provide optimal medical care for LGBTQ patients. I encourage all of us to continue to learn more in this field by partnering with patients.

Reference
Barrett DL, Supapannachart KJ, Caleon RL, Ragmanauskaite L, McCleskey P, Yeung H. Interactive session for residents and medical students on dermatologic care for lesbian, gay, bisexual, transgender, and queer patients. MedEdPORTAL. 2021;17:11148. doi:10.15766/mep_2374-8265.1114