This scenario is about Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) people, specifically about a transgender woman and her interactions with the health-care system.

Much has improved for LGBTQ people over the past few decades as society, and the laws that govern it, have changed from being discriminatory to recognizing the human rights of LGBTQ people. These changes have been reflected in health care as well:

“Thankfully the situation is improving: medical schools are including more LGBTQ-specific training in their curriculum, and LGBTQ cultural competency training is available to health professionals. Guidelines have been developed to help support family doctors in providing comprehensive care for transgender patients, including hormone therapy.” (Dr. A. Bourns, 2015)

In this scenario we will explore how a physician interrelates with a transgender patient, the issues that arise and the opportunities they present to expand knowledge and understanding.

Collaborator

• Explain how personal values, biases, and professional limitations impact the consultation process. (2.1)
• Recognize that the clinical situation requires expertise beyond one’s own, and determine urgency. (2.2)
• Identify an individual or service with the required skill or expertise. (2.3)
• Communicate well in writing and or orally with the consultant. (2.4)

Manager

• Describe the obligations and responsibilities in the administration and management of an office practice, including finances and human resources. (1.1)
• Communicate to patients and/or families information regarding professional practice, such as contact information, staffing, limitations of service, etc. (1.3)

Professional

• Accept responsibility for continuity of care. (2.2)
• Understand the circumstances in which relief of continuity of care can occur (transfer of care). (2.2.2)
• Be aware of the potential for unconscious bias influencing judgement. (6.2.1)

For a complete list of the CanMEDS roles, visit physiciansapply.ca/orientation/about-the-communication-and-cultural-competence-program/

• Incorporate the patient’s experience and context into problem identification and management.
• Select and attend to the appropriate focus and priority in a situation.
• Manage patients using available best practices.
• Demonstrate respect and/or responsibility.

• Assess, diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)
• Assess, diagnose and manage patients with chronic diseases across multiple care settings (3)
• Recognize and implement appropriate disease-prevention and health-promotion (4)
• Demonstrate habits that support lifelong learning (11)

Critical competencies 

• Establish and maintain proficiency in clinical knowledge, skills and attitudes appropriate to Internal Medicine (2)
• Perform a complete and appropriate assessment of a patient, including a complete history, organized hypothesis-driven physical examination, and the ability to synthesize information to form an appropriate treatment plan and follow up including:
  • Recognize, effectively assess unstable patients and initiate appropriate resuscitation
  • Be able to assess patients with one or more chronic conditions, develop a comprehensive plan of investigation and management (3)
• Seek appropriate consultation from other health professionals, recognizing the limits of one’s own expertise (5)
• Develop rapport, trust and ethical therapeutic relationships with patients and families (8)
• Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals accurately (9)
• Develop a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
• Demonstrate a commitment to patients, the profession and society through ethical practice (19)
• Demonstrate knowledge of and apply the professional, legal and ethical codes for physicians (21)

Being a practicing physician, either in private or group practice, you will employ people to staff your office. In most instances, the receptionist is the first person a patient interacts with in your practice. As with the physician and all staff members, the receptionist’s words, behaviour and attitude influence and reflect the office culture.

• In the scene between Carla and Betty, what do you think might be Carla’s reaction to Betty’s behaviour, and vice versa?
• What tone does this first encounter set for future interactions?
• What conversations are appropriate to have in a reception area?

Receptionists often need to ask patients basic information (date of birth, address, marital status, next of kin, etc.). Depending upon the office layout, their conversation might be overheard by other patients.

In this case, Carla, the patient, starts the conversation. Does this constitute a breach of privacy? What if the receptionist starts the conversation?

What layout changes to the waiting room could be made to improve privacy and patient confidentiality?

What information and directions should the physician give to office staff about patient confidentiality?

Carla is told to go to room two to see the physician. Imagine what it would be like to be in an unfamiliar medical office. Where is room two? Is the door open or closed? If closed, do I knock? Would this situation influence how you feel about seeing the physician?

How should physicians manage the office staff? If you had a staff meeting, what would you say about how they should behave with patients? How would you monitor their behaviours? How would you model the behaviours that you aspire?

Would you:

• Have a patient survey?
• Ask patients directly?
• Ask staff how they feel about the patients?
• With your office door open, listen to the interactions and conversations in the reception area?

Think about the first 30 seconds of the interview between the physician and patient. In the Communication skills module, we emphasized the importance of this first, brief interaction, and the importance of body language to establishing a patient-centred approach to communication.

Carla’s non-verbal statement communicates that she is a transgender woman. In this instance, the physician cannot identify her as such so the situation is unclear to him.

What was your initial emotional response to Carla’s information? How did you feel? A person’s reaction to LGBTQ people depends on their familiarity with, in this case, transgender people, their cultural background, their religious background, their own sense of gender identity, and if they are part of the LGBTQ community.

How do you think Dr. Ingram will respond to Carla’s question? As physicians, we are trained to be in control and to know the answers. We feel uncomfortable with uncertainty, ambiguity and lack of knowledge. Perhaps this is why Dr. Ingram focuses on concrete questions e.g., medications, list of surgeries ─ he is comfortable and confident there. Carla has given him lots of information about herself, yet he has avoided pursuing any of it. Have you experienced a similar situation in your practice?

We might not want to admit to it, but physicians have feelings and beliefs that can negatively impact their behaviour with patients. Maybe Dr. Ingram was raised in a homophobic environment. Perhaps he is confused about his own sexuality. We do not know.

Whatever the case, our professional guidelines require us to be aware of our emotions and how they can unconsciously influence or bias the care we provide to a patient.

So, what does Dr. Ingram say? As a professional, a physician must be honest about what they know and what they do not know. Saying otherwise is lying. As well as being unethical, lying destroys trust between a physician and a patient. Patients, for the most part, do not expect physicians to know everything.

So Dr. Ingram says: “No, I haven’t had a transgender patient before.”

Having admitted being unaware of transgender health, how does Dr. Ingram respond to Carla’s request for care?

• “I can’t help you. You need to see someone else.”
• “I don’t know much about this, but I’ll look it up, and talk to some experts.”
• “I would need your complete medical record before doing anything.”

A physician might be uncomfortable with each of these responses. It can happen that a physician feels uncomfortable with a patient. A physician needs to be aware of their discomfort and acknowledge that it could have a negative impact on the decisions they make.

Is it ethical for a physician, having met a patient once, to refuse further care? The physician has a fiduciary responsibility to provide care to the patient and cannot refuse care because of their views.

If the reason for refusal of care is the physician’s lack of experience and expertise, the following options can be considered:

• Self-education. “I’ll look it up”.
• Consultation for help in care. “I’ll talk to some experts.” The “Communicating with adolescents” module discusses this process in considerable detail.
• Consultation with request for transfer of care.
• Asking for previous records is necessary, but should not lead to inappropriate delays in the patient’s care.

There are a number of resources physicians can consult to become educated, informed and able to properly provide healthcare to transgender people. One source is the series on transgender health published in The Lancet. You can also read the following: “Serving transgender people: clinical care considerations and service delivery models in transgender health.”

Some physicians might feel they are unable to provide care for patients in certain situations due to incompatible moral or ethical values. Regulatory authorities and the courts have been clear that refusing to care for patients “based on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status constitutes discrimination.” (Canadian Medical Protection Association, March 2010, revised June 2016.) Physicians are encouraged to review the CMPA policies. In these instances the physician must either provide the needed care or secure transfer to another physician.

There are a limited number of situations, such as abortion and physician-assisted dying, where a physician’s decision to not participate in care of a patient on the basis of their cultural, religious, moral, or personal beliefs might be supported. In such situations, “colleges have adopted guidelines which generally state that physicians are expected to provide sufficient information and resources to enable patients to make their own informed choice and to access options for care, or to provide an effective referral to another physician or resource.” (Canadian Medical Protective Association, March 2010, revised June 2016.)

Bourns, Dr. A. (2015). “For LGBTQ people, finding a family doctor can be tough.” The Star.

Canadian Medical Protective Association (CMPA). (March 2010, revised June 2016). “Treating transgendered individuals.” CMPA.

GLMA: Health Professionals Advancing LGBT Equality. (Accessed 2016). “Cultural competence webinar series.” Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health.

Mount Sinai Hospital (2016). “Are you an ally? videos.” Sinai Health System.

Trans Health Guide. (2016). The content of this guide is based on the “Guidelines and protocols for hormone therapy” and “Primary health care for trans clients.” Rainbow Health Ontario.

Wylie, K., Knudson, G., Khan, S. I. S., Bonierbale, M., Watanyusakul, S., and Baral, S. (2016). “Serving transgender people: clinical care considerations and service delivery models in transgender health.” The Lancet, 388 (10042), 401-411.