Pride in care delivery: Bridging equity gaps for LGBTQ patients

Jesse Ehrenfeld, MD, MPH, FAMIA, FASA, director, Vanderbilt Program for LGBTQ Health, Vanderbilt University Medical Center, may not have a traditional physician’s background.

A veteran, Ehrenfeld was deployed for about seven months in Kandahar, Afghanistan, staffing a NATO trauma hospital for the U.S. Navy as part of his duties. The hospital was the primary receiving facility for not just wounded U.S. soldiers and allies, but also enemy combatants in the southern part of the country.

“Our job was to treat, stabilize and then move the patients back home as quickly as we could,” Ehrenfeld said, noting that he had ancestors on his mother’s side of the family who served in the military for each generation going back to the American Revolutionary War. “I always felt this sort of obligation to do as much as I could” with the opportunities afforded by others’ service “and to give back” likewise, he said.

That discipline carried over from his military experience to his role as a practicing physician in the civilian world. “In the Navy, I was taught early on that the priorities are pretty simple: It’s ship, shipmate and yourself — the mission always comes first,” Ehrenfeld said. “When I’m taking care of patients … you have to put your own priorities aside to make sure the patients get what they need. I think that translates well in the field of medicine.”

His experiences deployed in austere environments also speak to factors he sees facing the healthcare industry today. “There’s so much pressure and tension on the cost side of things in healthcare today that we’re constantly being asked to do more with less,” he said. “That’s the everyday life of a deployed military physician. Certainly, that has been helpful, as I think about how we can be creative in our daily practice of medicine to be more efficient, more effective and give patients the care that they need.”

Ehrenfeld has focused on better serving LGBTQ patients since his residency training in Boston, where he helped create an LGBTQ employee resource group at Massachusetts General Hospital.

When he went to work at Vanderbilt, he helped set up a program specific to LGBTQ health, which he sees as “an evolving space.

“The healthcare workforce today that is in practice received zero to little education when they were going through their training programs — whether they are doctors, nurses or technicians — about the specific needs of LGBTQ patients,” Ehrenfeld said. “There is a gap in terms of what people know about how to take care of LGBTQ people, as well as from an organizational standpoint and understanding of what the rights and responsibilities to this often underserved, unrecognized population have been.”

Some providers seem to be aware of this gap: A survey of more than 400 oncologists in cancer centers nationwide found that 40% said they were not properly informed on how to treat an LGBTQ+ patient.1 A recent study from the Boston University School of Public Health also points to the intersectional concerns for lesbian, gay and bisexual women receiving less post-cancer treatment than other segments of the patient population.2

Understanding your patients is a simple and crucial element for physicians, “but it requires a recognition of the need to do it,” Ehrenfeld said, such as knowing what kind of support system a patient has during recovery from a complex surgery. The starting point “involves understanding their family, their living situation, who’s a part of their life. If I can’t have an open, honest conversation with my patients about their sexual orientation, their gender identity, who their partners are, etc., that’s going to impede” a clinician’s ability to get into “nuanced issues around specific care recommendations that are different for LGBTQ people.”

At the same time, the regulatory landscape has shifted in recent years, which could undermine quality of care for LGBTQ patients. In May, the Department of Health & Human Services (HHS) issued a rule allowing healthcare workers to refuse to provide services if they can cite religious or conscientious objection exemption.3 HHS also proposed in June to revise Section 1557 of the Affordable Care Act to strip out non-discrimination rules for the gender identity of patients.4

Such a change seemingly runs counter to an acknowledgment in the healthcare industry that discrimination can have sizable influence on care outcomes. A 2017 study found that about 18% of LGBTQ people avoided medical care for concerns about discrimination because of sexual orientation or gender identity.5 For the transgender community, the concern is heightened further: A 2015 survey found 23% of transgender people avoided seeking needed care in the previous year for fear of discrimination or mistreatment because of gender identity.6

A growing number of provider organizations are making inroads in acknowledging the need to educate providers and staff on LGBTQ patient issues, Ehrenfeld noted. “Organizations across the country are recognizing that they need to really understand how they can best serve all patients, including LGBTQ patients, in ways that heretofore weren’t happening,” he said.

To assist that work, Ehrenfeld’s program at Vanderbilt partners with organizations on education and training, as well as performs research to produce evidence-based best practices on care delivery for LGBTQ patients. That begins with understanding barriers and priorities for reducing disparities in insurance coverage, life expectancy and social determinants of health.

Awareness is one of those priorities for the Vanderbilt program, such as helping clinicians understand what it means to be a transgender patient. Whether it’s a unit secretary, a new resident or a senior physician, “all of those individuals really need to understand what this means and what the implications are, and how they can provide high-quality, affirming care for all patients when it comes down to somebody walking in our door,” Ehrenfeld said.

The macro issue of EHR development and limitations in data sharing is one barrier to spreading specific patient awareness. “Challenges with how our healthcare system is constructed, the unfortunate way that incentive systems have developed with third-party payers and some of the challenges around just tracking information due to the lack of [EHR] interoperability, lead to people not getting what we know is the right thing all of the time,” Ehrenfeld noted. “It starts by having an understanding of what that right thing is and then creating systems that can unfailingly execute to give every patient the right thing all of the time.”

As for the in-person conversations between physician and patient, that’s a simple matter if a provider isn’t glued to the EHR and can instead devote attention to the patient to ask questions about sexual orientation or gender identity. “People want to be asked these questions. … They understand that in a healthcare context, they’re being asked these questions for legitimate important reasons, to take care of them — not because of anybody’s personal curiosity,” Ehrenfeld said.

As a physician, Ehrenfeld admits that he and other clinicians are often “swimming” in patient data but not necessarily the right data about a specific person, such as preferred names for trans patients. “Knowing a patient’s preferred name is critically important for a transgender person,” Ehrenfeld said, yet preferred name fields in EHRs today may not appear in a patient’s header or a fact sheet at check-in.

“It’s such a simple thing, but I think a telling example of how the information may be somewhere, but it’s not being used or leveraged in a way to help us to help our patients,” Ehrenfeld said. 

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In comments to HHS on potential revision to Section 1557 of the ACA, MGMA wrote: “We strongly support physicians and medical group practice leaders conducting themselves with appropriate respect for patients’ social and cultural beliefs and furnishing care without regard to race, religion, gender, sexual orientation, gender identity, ethnic affiliation, health, age, disability or economic status.” Read the full letter.

Notes:

1. Schabath M, et al. “National survey of oncologists at National Cancer Institute-designated comprehensive cancer centers: Attitudes, knowledge and practice behaviors about LGBTQ patients with cancer.” Journal of Clinical Oncology. 2019; 37:7, 547-558.
2. Boehmer U, Gereige J, Winter M, Ozonoff A. “Cancer survivors’ access to care and quality of life: Do sexual minorities fare worse than heterosexuals?” Cancer. 2019 Sep 1; 125(17), 3,079-3,085.
3. HHS. “Protecting statutory conscience rights in health care; delegations of authority.” May 2, 2019. Available from: bit.ly/2YMqa0A.
4. HHS. “Nondiscrimination in health and health education programs or activities.” June 14, 2019. Available from: bit.ly/3001Wwo.
5. “Discrimination in America: Experiences and views of LGBTQ Americans.” NPR, Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health. November 2017. Available from: rwjf.ws/33xMb1R.
6. National Center for Transgender Equality. “The Report of the 2015 U.S. Transgender Survey.” December 2016. Available from: bit.ly/2MgOKzW.