Use of Standardized Patients in Endocrinology Fellowship Programs to Teach Competent Transgender Care.

PURPOSE: Transgender and gender-nonconforming individuals have unique health care needs and have difficulty accessing health care services because of a lack of qualified health care providers, insurance coverage, mistreatment, and bias by the medical community. Medical trainees and physicians report a lack of education in, and exposure to, the clinical care and unique aspects of this field. We assessed the use of a standardized patient as a tool to evaluate 4 core medical competencies (patient care, medical knowledge, professionalism, and interpersonal communication) of endocrinology fellows at a single training program.
METHODS: Endocrine fellows were evaluated by faculty in different aspects of transgender care and completed a self-assessment before and after the exercise. Faculty viewed the fellows during the Objective Clinical Structured Examination. Fellows were provided feedback by a faculty member and the standardized patient after the exercise.
RESULTS: Deficits were found in patient care and professionalism. Fellows scored well in medical knowledge. Fellows did not report an improvement in comfort and communication skills after the exercise. Interestingly, fellows' self-assessment scores in several domains declined after the standardized patient encounter, highlighting an occasion for self-reflection and growth within the realms of cultural competency and medical knowledge. MAIN
CONCLUSIONS: We conclude that use of standardized patients to teach medical competencies in transgender medicine may be one approach to improve exposure to, and training in, transgender medicine. Endocrine fellows still had discomfort treating transgender individuals after the standardized patient encounter and require other training activities that may include didactics and clinical case discussions. © Endocrine Society 2019.

Over the past decade, there has been an increasing awareness within the medical community regarding the need to provide and improve education in transgender health care within all levels of training [1, 2]. Medical students as well as internal, family and emergency medicine, plastic surgery, urology, and otolaryngology residents have all reported a lack of structured curriculum and knowledge in transgender-related content [3-6]. Endocrinology fellows also describe inadequate educational guidance and training in this field [7]. In a 2017 survey of 198 second-year endocrinology fellows, 58.9% reported that their training program provided dedicated content in transgender care [7]. Of those who reported dedicated teaching, 40% had received less than 2 hours of content per year, and those who had received education or seen more transgender patients in their training were, not surprisingly, more likely to be confident in treating patients with hormone therapy [7]. Barriers to implementing transgender-specific education interventions include limited curricular time, lack of competency among faculty, and poor institutional support [5].

To address the need for improved training in transgender-related health care topics, many endocrinology fellowship programs are implementing formal education strategies. In a web-based survey of endocrinology program directors done in 2016, there were 54 responses from 104 programs [1]. Of those who responded, 35 of the 54 programs (72.2%) provide dedicated teaching on transgender health topics [1]. These teaching methods include direct patient care, lectures, small group discussions, online modules/webinars, and elective rotations [1]. None of the 54 program directors reported use of patient simulation as a means of teaching transgender care [1].

The Objective Structured Clinical Examination (OSCE) is a teaching tool that was introduced in 1975 and consists of various stations in which a learner or trainee is asked to interact with a standardized patient (SP, or actor) for a specified amount of time within the context of a given medical scenario [8]. The OSCE has been used in more than 50 countries across 5 continents, within various health professional settings (medicine, dentistry, pharmacy, nursing) and in varying phases of education (undergraduate, postgraduate, and continuing professional development) [9]. It has been found to be a reliable and valid tool in assessing skills through varying fields and levels of training [10-13]. There has only been one published case demonstrating the use of OSCE as a tool for training internal medicine/primary care residents in transgender health care [14]. The use of the OSCE and SP in teaching transgender-competent care therefore represents an untapped educational tool and requires further evaluation. In this paper, we provide data on the effectiveness of using the OSCE and SP in teaching transgender competency for endocrinology fellows, specifically.

The purpose of this study was to evaluate the acceptability and effectiveness of an OSCE in providing training and feedback in the delivery of endocrine care for transgender individuals. A single case vignette of a transfeminine patient seeking hormone therapy was used to test 4 of the 6 core medical competencies established by the Accreditation Council for Graduate Medical Education: medical knowledge, patient care, professionalism, and interpersonal and communication skills [15]. Faculty and the SP provided immediate feedback in these competencies following the exercise. Endocrinology fellows provided data regarding their medical knowledge of transgender medicine before and after the exercise.

1. Methods

A. Subjects

A yearly OSCE program using SPs is completed by each clinical endocrinology fellow-in-training at Emory University School of Medicine. During the 2016–2017 academic year, 6 fellows (in both first and second years of training) were remotely observed by video by 2 separate faculty members during a standardized patient encounter of a transfeminine patient seeking hormone therapy. Both faculty members were members of the World Professional Association for Transgender Health and one served on the Endocrine Society guidelines for Transgender and Gender Incongruence. Both faculty members, collectively, had more than 20 years of experience in providing care for transgender individuals. The 2 faculty members viewed the OSCE and discussed feedback for the fellow in the same room. One of the 2 faculty members, on a rotating basis, entered the room where the fellow and SP were located to provide feedback on the exercise. All fellows that participated gave consent to release data on assessment and feedback.

B. Intervention

The clinical case of a transgender female seeking initial hormone therapy was presented to each of the 6 fellows who participated in the OSCE (Figs. 1–2). The SP was provided with a script and information to volunteer to each fellow as well as information to share if the fellow inquired about a particular topic/subject. Information provided to the SP included gender history, medications, social history (including employment, education, and sexual history), family history, interest in fertility, and a review of systems-pertinent positives (Fig. 3). For the physical examination portion, the SP had 3 cards to provide to each fellow: one general examination card (stating “well appearing person dressed in feminine clothes”) to present at the onset of examination and 2 additional cards to provide if prompted by the fellow, one for breast examination (stating “normal male breasts with no masses”) and one for genitalia examination (stating “penis and scrotum present”) (Fig. 4). After completing a full history and physical examination, each fellow stepped out of the room to order laboratory tests he or she believed were indicated and retrieved the results from the requested laboratory tests (Fig. 5). Finally, the fellow reentered the room and completed the visit by discussing his or her assessment and plan.

Figure 1.

Instructions and description of the Objective Structured Clinical Examination on transgender medicine provided to each fellow.

Figure 3.

Additional information to be provided upon interview by the endocrine follow on the topic of transgender medicine. The additional information is available only upon questioning of the standardized patient.

Figure 4.

Additional information on the examination of the standardized patient on the topic of transgender medicine. The physical findings of the standardized patient upon the fellow performing examinations of these organs.

Figure 5.

Results of requested laboratory testing upon ordering by the endocrinology fellow for the Objective Structured Clinical Examination on the topic of transgender medicine. The results of laboratory tests if ordered.

Instructions provided to the standardized patient. The background information for the standardized patient for the case of the new patient who identifies as transgender

Assessment of each of the 6 fellows by 2 separate faculty members was done in predefined metrics in areas including taking a relevant medical history, physical examination, laboratory orders and interpretation, discussion of hormone therapy, and the overall care for a transfeminine patient. Of note, a score of “completed correctly” was only awarded if both faculty members assessed the task to be done correctly. Case-specific feedback points were provided to the faculty members to assess and discuss with the fellows (Fig. 6). Feedback provided to the fellows were mapped to 4 of the 6 Accreditation Council for Graduate Medical Education Core Competencies: patient care, medical knowledge, professionalism, and interpersonal communication [15]. Two core competencies were not evaluated: practice-based learning and improvement and systems-based practice. Because of the longitudinal nature of these 2 competencies required for assessment. The standardized patient also provided feedback on communication skills and professionalism during the encounter.

Figure 6.

Case-specific feedback provided by faculty to endocrinology fellow on the topic of transgender medicine. Key feedback areas for faculty to discuss with fellows.

Before and immediately following the OSCE transgender patient case, fellows were asked to fill out a 5-question survey about transgender health care regarding topics such as comfort level, medical knowledge, and awareness of guidelines (Fig. 7). Institutional review board approval was not required for this study because this was a simulated patient encounter.

Figure 7.

Fellows self-assessment questionnaire on their comfort in caring for patients who identify as transgender. Fellows completed a self-assessment questionnaire before and after the Objective Structured Clinical Examination with a patient that identifies as transgender.

2. Results

A. Patient care

In taking a relevant medical history, the majority of fellows correctly asked about smoking (6/6), family and social situation (5/6), a personal history of deep vein thrombosis/pulmonary embolism (4/6), mental health and/or history of depression/suicide (4/6), and past use of hormones (4/6). Four of 6 fellows correctly confirmed a diagnosis of gender dysphoria. Areas of deficits in taking a medical history included correctly asking about plans for future fertility (3/6) and inquiring about sexual history/HIV risk (2/6) (Table 1).

Table 1.

Number of Fellows Who Correctly Completed Tasks for Categories in Patient Care (Medical History and Diagnosis)

	Number Completed Correctlya
Medical History
Smoking	6/6
Family and social circumstances	5/6
History of deep vein thrombosis/pulmonary embolism	4/6
Mental health/suicide	4/6
Past use of hormones	4/6
Plans for future fertility	3/6
Sexual history/HIV risks	2/6
Diagnosis
Confirmed diagnosis of gender dysphoria	4/6

A score of completed correctly was awarded only if both faculty members assessed the task to be done correctly.

Of the key physical examination components, only one-third of fellows (2/6) examined breast tissue and only one fellow examined genitalia (1/6). All fellows ordered a testosterone level, complete blood count and comprehensive metabolic panel (CMP) (6/6, respectively). Most fellows correctly ordered a serum estradiol level (5/6). Fewer fellows ordered a prolactin level (2/6) (Table 2).

Table 2.

Number of Fellows Who Correctly Completed Tasks for Categories in Patient Care (Physical Examination and Laboratory Orders)

	Number Completed Correctlya
Physical Examination
Examines breasts	2/6
Examines genitalia	1/6
Laboratory
Testosterone	6/6
Complete blood count	6/6
Comprehensive metabolic panel	6/6
Estradiol	5/6
Prolactin	2/6

A score of completed correctly was awarded only if both faculty members assessed the task to be done correctly.

In discussing hormone therapy, most fellows correctly discussed treatment options (e.g., estrogen, anti-androgen) (5/6), time course of physical changes expected on hormone therapy (4/6), and option for sperm banking (4/6). A lesser percentage correctly discussed the effect of hormone treatment on fertility (3/6) and only one fellow correctly discussed surgical options for transgender women (Table 3).

Table 3.

Number of Fellows Who Correctly Completed Tasks for Categories in Patient Care (Hormone Therapy and Treatment Discussion)

	Number Completed Correctlya
Hormone Therapy
Estrogen formulations, antiandrogen use	5/6
Time course of changes on hormones	4/6
Treatment
Sperm banking	4/6
Effect of treatment on fertility	3/6
Surgical options	1/6

A score of completed correctly was awarded only if both faculty members assessed the task to be done correctly.

B. Medical knowledge

Almost all fellows correctly discussed the risks and benefits of hormone therapy (5/6), whereas only one-half correctly asked about readiness/eligibility for hormone therapy (3/6) (Table 4).

Table 4.

Number of Fellows Who Correctly Completed Tasks for Categories in Medical Knowledge, Professionalism, and Interpersonal Communication Skills

	Number Completed Correctlya
Medical Knowledge
Risks/benefits of hormone therapy	5/6
Readiness/eligibility for hormone therapy	3/6
Professionalism
Use of preferred name and pronouns	2/6
Interpersonal Communication Skills
Introduced self by name	6/6
Elicited an open-ended chief complaint	6/6

A score of completed correctly was awarded only if both faculty members assessed the task to be done correctly.

The fellows listed the Endocrine Society [16], World Professional Association for Transgender Health [17], and University of California San Francisco Center of Excellence for Transgender Health [18] as resources to use for transgender guidelines. The fellows rated their medical knowledge of the endocrine treatment of transgender persons at just below satisfactory (2.8/5); this did not change from pre- to postassessment (Fig. 8, question 2).

Figure 8.

Endocrinology Fellow’s Self-Assessment Score before and after completing an Objective Clinical Structured Examination on the topic of transgender medicine. Fellows were asked to rate their comfort level on a Likert scale (1–5) (1 = poor, 5 = outstanding) on 4 different questions. Q1: Ability to provide compassionate, appropriate, and effective treatment and management of transgender patients; Q2: Medical knowledge regarding the endocrine treatment of transgender patients; Q3: Communication skills with transgender patients in a medical/clinical situation; and Q4: Understanding and sensitivity to the needs of transgender patients.

C. Professionalism

Two of the 6 fellows correctly asked about use of preferred name and/or pronouns (2/6) (Table 4). The fellows’ self-assessment of their understanding and sensitivity to the needs of transgender patients and their ability to provide “compassionate, appropriate, and effective” treatment and management of transgender patients decreased from pre- to postskills assessment surveys [Fig. 8, questions 1 and 4).

D. Interpersonal communication

All fellows correctly introduced themselves by name and elicited an open-ended chief complaint (6/6, respectively) (Table 4). The fellows’ self-assessment of their communication skills with transgender patients decreased from pre- to postskills assessment surveys [Fig. 8, question 3).

3. Discussion

Through the use of a standardized transgender female patient case, we found that clinical endocrinology fellows within our institution during the 2016–2017 academic year demonstrated strong interpersonal communication skills and good proficiency in collecting a medical history and counseling on hormone therapy use. Areas of deficiencies included aspects of professionalism (asking about preferred pronouns), in discussing fertility interest and preservation options, and discussing sexual history/HIV risk factors. As demonstrated in the decline between our pre- and post-OSCE survey, endocrinology fellows (or endocrinologists in general) may not be aware of their knowledge and skills deficits regarding providing competent transgender care.

In regards to physical examination components, the Endocrine Society does not include baseline breast and genitalia examinations in their guidelines [16]. Because many transgender patients find parts of the physical examination uncomfortable or even traumatic, sensitive elements (including breast and genitalia examinations) may be deferred to a later date unless there is a medical need that requires immediate attention [19]. Findings suggestive of an intersex condition should be investigated [19]. Organ-specific screening examinations, such as prostate or cervix, should be addressed in the care of transgender patients [16, 19]; however, this does not need to be done at the initial visit or even by an endocrinologist. We suggest the use of these physical examination maneuvers within the OSCE case to serve as a discussion point for the faculty and trainees.

Briefly, regarding laboratory evaluation, a CMP provides important information about electrolyte function, specifically potassium level, which is necessary for patients starting or continuing on spironolactone therapy [16]. Liver function tests are also included in a CMP; however, severe liver dysfunction was removed from the “moderate to high risk of adverse outcomes” associated with sex hormone therapy for transgender females from the 2009 to the 2017 Endocrine Society Practice guidelines [16] Finally, a complete blood count is not required for transgender female hormone monitoring [16].

For practicing endocrinologists, there are data that demonstrate a lack of training in transgender care. In a 2015 paper survey distributed at an endocrinology-oriented professional conference, two-thirds of respondents had received no training on transgender care during their fellowship (of 80 respondents, 61 were adult endocrinologists, 13 endocrinology fellows, 2 pediatric endocrinologists, and 4 nurse practitioners/physician assistants). In a larger 2017 web-based survey of approximately 400 Endocrine Society clinician members, 80.6% had never received training in the care of transgender patients [1]. Of the approximately 20% who had received training, 58% reported obtaining it during endocrinology fellowship [1].

Although the OSCE presents one tool that endocrinology fellowship programs may use to assess a trainee’s various skills in eliciting a history, physical examination, interpreting the results of simulated laboratory or radiology results, medical knowledge, and overall patient interaction [8], we demonstrate that it can also be a powerful tool for teaching cultural competency in the context of transgender care. Cultural competency, broadly speaking, is the recognition and inclusion of cultural variation as it pertains to patient interactions and decision making, which leads to effective cross-cultural care [20, 21] Health care for minority populations, including gender minorities, should incorporate sensitivity to historical stigmatization, awareness of barriers to care, and the prevalence of risk factors and medical conditions in that particular population [22]. The Maimonides Medical Center pediatric residency program has published on the use of OSCE to aid in assessment and feedback of communication and culturally specific skills, such as eliciting patient agenda, acknowledging patients’ perspective on dealing with a given situation, and providing rationale for recommendations through challenging cultural scenarios [21]. These culturally specific skills would be a useful aspect to incorporate in the instruction of care for transgender patients.

There has been one published case demonstrating the use of OSCE as a tool for training internal medicine/primary care residents in transgender health care [14]. Twenty-three residents at New York University (NYU) School of Medicine participated in an OSCE case that involved a transgender woman on spironolactone and estradiol who presented with hypertension and hyperkalemia [14]. The residents at NYU were surveyed on preparedness, perceived performance, and challenges, and were given feedback from a faculty member and the SP in areas such as inquiring about gender identity, pronoun use, name, sexuality and sexual activity, medically relevant transition information, and patient comfort [14]. Less than two-thirds of these residents asked directly about gender identity (61%), made the patient feel comfortable (61%), or effectively asked about medically relevant transition information (58%) [14]. Similar to our OSCE case, overall communication scores were high at 89% [14]. Important areas of feedback to the NYU residents included use of appropriate terminology, how to ask directly about transition, and how to admit to a lack of knowledge to a patient [14]. Of note, the standardized patient used for the NYU OSCE was a transgender actress. The authors advocate for the use of transgender actors to play SP roles whenever possible, and appropriate, to improve insights about patient experience [14].

The decline in the fellows’ self-assessment of their ability to provide “compassionate, appropriate, and effective” treatment, their communication skills with transgender patients, and their understanding and sensitivity to the needs of transgender patients from the pre- to postskills assessment survey is a notable finding in our study. This may suggest that endocrinology fellows were not aware of their knowledge and skills deficits in providing competent transgender care and offers a valuable tool for introspection. Previous studies have found that improving the skills of participants in social and intellectual domains paradoxically helps them recognize the limitations of their abilities [23]. The OSCE provides both a tool for self-assessment, helping medical trainees recognize the deficits that exist, as well as the opportunity to rectify this deficit through immediate feedback and discussion [24].

Finally, using OSCE alone would likely be inadequate in covering the breadth of knowledge and skills necessary for competent transgender care. As previously described, endocrinology fellowship programs are already using direct patient care, lectures, small group discussions, online modules/webinars, and elective rotations as teaching modalities [1]. Potential additional instructional activities could include attendance at regional/national/international conferences, case studies, and multiple-choice questions about transgender care.

4. Conclusion

Using a standardized patient exercise at a single academic training institution uncovered both strengths and deficits within transgender health care knowledge and competency for endocrinology fellows. Furthermore, endocrinology fellows may not be aware of their specific knowledge gaps (although nationally, medical trainees identify an overall lack of structured content in this field). OSCE may be a valuable tool that fellowship programs can use to help elicit knowledge gaps, provide feedback, and increase provider comfort as a means of training trans-competent endocrinologists and other learners such as medical students, residents, advanced practice practitioners, and nurses. Further research is needed to help determine ways of improving transgender health care education within endocrinology fellowship programs in the United States and globally.