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Lesbian, gay, bisexual, transgender, and queer health curriculum in medical education: a gap analysis
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Lesbian, gay, bisexual, transgender, and queer health curriculum in medical education: a gap analysis
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Content
Lesbian, Gay, Bisexual, Transgender, and Queer Health Curriculum in Medical
Education: A Gap Analysis
by
Kathryn Schaivone
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2022
© Copyright by Kathryn Schaivone, 2022
All Rights Reserved.
.
The Committee for Kathryn Schaivone certifies the approval of this Dissertation
Ronan Hallowell
Jennifer Phillips
Patricia Tobey, Committee Chair
Rossier School of Education
University of Southern California
2022
iv
Abstract
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience health
disparities and unequal access to medical care at higher rates than the general population.
Inclusive care provided by physicians equipped to work with the LGBTQ population has been
noted as essential to reducing the health disparities these patients face. Despite calls to action and
recommendations from academic leadership organizations, medical students do not receive
adequate education and training to care for this population. This study assessed the extent and
underlying influences of the curriculum gap on LGBTQ health at Univ-Med, a large urban
medical school. Clark and Estes’s gap analysis model was applied to understand the knowledge,
motivation, and organizational influences resulting in the shortfall in the curriculum. The study’s
stakeholders are medical students enrolled at Univ-Med, 147 completed the online survey, and
nine participated in the focus groups. Key findings from the study identified gaps in the
curriculum on sexual history taking, identifying, and addressing healthcare disparities, a lack of
opportunities to acquire mastery in LGTBQ health, and faculty knowledge of LGBTQ health,
including cultural humility. This descriptive study identified knowledge and organizational
influences that resulted in recommendations focused on curriculum development with the
participation of medical students to ensure a sense of ownership in their education.
Keywords: curriculum, medical, education, LGBTQ, healthcare disparities
v
Table of Contents
Abstract .......................................................................................................................................... iv
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................. x
Chapter One: Introduction to the Study .......................................................................................... 1
Context and Background of the Problem ............................................................................ 2
Description of Stakeholder Groups ..................................................................................... 3
Stakeholder Group for the Study ........................................................................................ 4
Stakeholder Performance Goals .......................................................................................... 4
Purpose of the Project and Research Questions .................................................................. 5
Importance of the Study ...................................................................................................... 6
Overview of Theoretical Framework and Methodology .................................................... 7
Research Design.................................................................................................................. 8
Definition of Terms............................................................................................................. 9
Organization of the Dissertation ....................................................................................... 11
Chapter Two: Review of the Literature ........................................................................................ 12
Medical Education in the United States ............................................................................ 12
LGBTQ Standards in Medical Education ......................................................................... 14
Gaps in LGBTQ Health Education Standards .................................................................. 16
Bias and Discrimination: Cultural Taxation as Bias ......................................................... 19
Current Trends in Medical Education ............................................................................... 20
Gaps in the Literature........................................................................................................ 22
Gap Analysis Framework ................................................................................................. 22
vi
Stakeholder Knowledge, Motivation, and Organizational Influences .............................. 23
Knowledge Influences ...................................................................................................... 24
Motivational Influences .................................................................................................... 28
Organizational Influences ................................................................................................. 32
Conceptual Framework ..................................................................................................... 37
Conclusion ........................................................................................................................ 39
Chapter Three: Methodology ........................................................................................................ 41
Research Questions ........................................................................................................... 41
Overview of Design .......................................................................................................... 41
Participating Stakeholders ................................................................................................ 43
Data Collection and Instrumentation ................................................................................ 44
Alignment of the KMO Influences and Data Collection .................................................. 48
Data Analysis .................................................................................................................... 50
Validity and Reliability ..................................................................................................... 50
Credibility and Trustworthiness ........................................................................................ 51
Limitations and Delimitations ........................................................................................... 52
Chapter Four: Results and Findings .............................................................................................. 54
Methodological Approach and Rationale ......................................................................... 54
Stakeholders ...................................................................................................................... 55
Results and Finding........................................................................................................... 57
Knowledge Results and Findings...................................................................................... 58
Knowledge Summary and Determination of Asset or Need ............................................. 66
Motivation Results and Findings ...................................................................................... 68
vii
Motivation Summary and Determination of Asset or Need ............................................. 71
Students Desire More Knowledge of Health Care for Transgender Persons .................... 72
Organizational Influence Findings .................................................................................... 73
Summary of Organizational Influences Findings ............................................................. 83
Summary ........................................................................................................................... 84
Chapter Five: Recommendations .................................................................................................. 85
Recommendations for Practice to Address KMO Influences ........................................... 85
Integrated Implementation and Evaluation Plan ............................................................... 98
The Role of Institutional Leadership .............................................................................. 108
Recommendations for Future Research .......................................................................... 109
Conclusion ...................................................................................................................... 109
References ................................................................................................................................... 111
Appendix A. IRB Study Information .......................................................................................... 125
Appendix B. Focus Group Information Sheet for Exempt Research.......................................... 127
Appendix C: Focus Group Questions ......................................................................................... 129
Appendix D: Survey ................................................................................................................... 130
Appendix E: Theoretical Alignment Matrix ............................................................................... 133
Appendix F: Focus Group Code Book........................................................................................ 134
viii
List of Tables
Table 1: Organizational Mission, Performance Goal, and Stakeholder Goal 4
Table 2: AAMC and AMA Domains 16
Table 3: Knowledge Influences Summary 27
Table 4: Motivation Influences 32
Table 5: Organizational Influences 35
Table 6: KMO, Survey, and Focus Group Alignment 49
Table 7: Focus Group Participants 57
Table 8: Medical School Year and Frequency of Inquiry About Gender Identity 63
Table 9: Medical School Year and Frequency of Inquiry About Sexual Orientation 63
Table 10: Open-Ended Knowledge Themes 64
Table 11: Knowledge Asset or Need 67
Table 12: Motivation Asset or Need 72
Table 13: Number of Hours of LGBTQ Health Education 80
Table 14: Organizational Influences Asset or Need 83
Table 15: Knowledge Recommendations 87
Table 16: Motivation Recommendations 91
Table 17: Organizational Recommendations 94
Table 18: Outcomes, Metrics, and Methods for External and Internal Outcomes 103
Table 19: Behavior Level 104
Table 20: Required Drivers to Support Critical Behaviors and KMO 105
Appendix C: Focus Group Questions 129
Appendix E: Theoretical Alignment Matrix 133
ix
Appendix G: Focus Group Code Book 134
x
List of Figures
Figure 1: Conceptual Framework 39
Figure 2: Parity in Access to Healthcare for LGBTQ Patients 60
Figure 3: Frequency of Inquiry of Sexual and Gender Identity 62
Figure 4: Observation of Faculty Setting a Positive Example 70
Figure 5: Request Additional Formalized Education in LGBTQ Health 74
Figure 6: Placement of Additional LGBTQ Health Curriculum 75
Figure 7: Number of Hours of LGBTQ Education Related to Year in Medical School 80
Figure 8: Evaluation Levels 101
Figure 9: Solutions, Plan, and Evaluation 107
1
Chapter One: Introduction to the Study
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience health
disparities and unequal access to medical care at higher rates than the general population. The
numerous obstacles facing this community while seeking medical care include physician lack of
knowledge, poor clinical outcomes, and less than optimal health and wellness (Institute of
Medicine Board of Population Health, 2011). Patients in this population frequently receive care
from a provider without the training to understand their comprehensive medical needs (Khalili et
al., 2015). Moreover, an absence of understanding of sexual and gender identity and its
importance to overall health leaves these patients with deficiencies in their care (Parameshwaran
et al., 2017).
This study addressed the curriculum and training gap in LGBTQ health in medical school
education. The absence of an LGBTQ health curriculum results in inadequate physician
knowledge and compromised medical care for this population. Medical schools need to bolster
this essential preparation with the infusion of time and resources (Hollenbach et al., 2014;
Sawning et al., 2017). In a pivotal study on the topic, Obedian-Maliver et al. (2011) surveyed
medical school deans regarding the scope of LGBTQ health content in their curriculum. On
average, the research team found fewer than 5 hours in a 4-year curriculum on all aspects of
LGBTQ health. Furthermore, when asked about the quality of the education, 70% of the deans
rated the content as fair, poor, or very poor. In a survey of academic medical institutions, only
32% indicated some training, and 52% had none (Khalili et al., 2015).
Additionally, clinical experiences are insufficient to ensure that every medical student
graduates with a baseline competence to care for the needs of LGBTQ patients (Bonvicini, 2017;
Zelin et al., 2018). The research shows that training is most effective when it begins early in
2
medical education and becomes part of physicians’ professional development (Kaufman &
Mann, 2010; Lomis et al., 2017). Empowering future physicians to identify and change barriers
contributing to health inequities can result in a desirable transformation in care (Zelin et al.,
2018).
Context and Background of the Problem
Founded over 100 years ago, the University School of Medicine (Univ-Med, a
pseudonym) is a well-established medical school with a long history of community service.
1
Annually, it admits 186 medical students. The institution has over 3,500 full and part-time
faculty physicians. Univ-Med maintains close ties with its alumni, and thousands of graduates
stay in the local area to practice medicine. The institution is committed to advancing biomedical
research and has numerous federally funded programs. Univ-Med’s mission is to improve
individuals’ and society’s quality of life by fostering health, preventing disease, and promoting
well-being in the community and society. Univ-Med is an affiliated three-hospital system with
specialty and primary care provider clinics. Demonstrating academic excellence and state-of-the-
art clinical care, faculty are experts who teach and practice at the Univ-Med and provide patient
care in the affiliated hospital system. The Univ-Med curriculum integrates clinical and basic
science; students are immersed in clinical environments early in their training to learn from
seeing patients at affiliated hospitals. In addition, Univ-Med’s students rotate through clinical
placements to care for disadvantaged and underserved populations in the surrounding
communities. An overarching goal of Univ-Med is to recruit, retain, and increase minority
1
Information derived from organizational documents and websites not cited to protect
anonymity.
3
student enrollment recognizing the importance of diversity in their education and public presence
in the patient care settings.
In August 2021, Univ-Med launched a phased-in new medical school curriculum
emphasizing clinical excellence, patient advocacy, health justice, and systems of care. The goal
is to provide medical students with immersive educational experiences in health justice to
understand the historical and systemic social forces contributing to a wide range of health
disparities. Students will graduate with the requisite medical knowledge and clinical skills to
guide holistic, competent, compassionate care. Health policy and population health will be
integrated throughout medical education to help students develop the skills to advocate for
vulnerable populations. Univ-Med’s lack of LGBTQ health education in the current curriculum
and the deficiency of initiatives proposed in the new curriculum are organizational influences.
Description of Stakeholder Groups
Multiple primary stakeholder groups share a common goal at Univ-Med to ensure
medically competent and socially aware physicians graduate from the program. These
stakeholders include medical school leadership, faculty, medical students, and patients. Univ-
Med has additional layers of complexity as it is a school within a university and is accountable to
the university’s board of Trustees, administration, and leadership. While Univ-Med has over
3,000 full and part-time faculty, the number of those who directly educate the medical students is
one-third. These faculty hold a Doctor of Medicine (MD) or other terminal degrees and are
typically responsible for education and patient care. Students as the primary stakeholders have
the most significant bi-directional accountability relationship with the Univ-Med. The program is
4 years long, and each class has 186 students. At any given time, these medical students
participate in education, training, research, and the delivery of patient care
4
Stakeholder Group for the Study
This study explored the knowledge, motivation, and organizational influences impacting
students who currently face this need for LGBTQ health in the current and new curriculum. The
key stakeholder group for this study was medical students in Years 1–4 at Univ-Med. They enter
medical school after completing a bachelor’s degree. The gender breakdown is about equal, with
48% male and 52% female. Most students are California natives and received their
undergraduate degrees in the state. As future medical care providers, the students have the most
at stake with their personal and professional identities on the line. The outcome is in the
organization’s hands. The gap analysis comprehensively focused on all stakeholder concerns and
goals.
Stakeholder Performance Goals
Table 1 lists the organizational mission and goals for the key stakeholders of this study.
Table 1
Organizational Mission, Performance Goal, and Stakeholder Goal
Organizational mission
Educate future physicians to improve their patients and the community’s quality of life by
promoting optimal health, advocacy, and social justice.
Organizational performance goal
In August 2021, Univ-Med developed and began implementing a new phased-in curriculum.
Medical student stakeholders’ goal
By the end of their medical school education, students will achieve competency in medical
care and have increased knowledge, confidence, and humility for their patients.
5
Purpose of the Project and Research Questions
Establishing the purpose of any study is the first step in the research process and leads to
the long-term goal or aim (Newman et al., 2003; Onwuegbuzie & Leech, 2015). The purpose of
this research was two-fold: (a) to determine how and why a gap exists in learner knowledge and
motivation related to the absence of an LGBTQ curriculum and (b) to examine the role of the
organization and the impact on student knowledge and motivation on this topic. This study had
the following goals: (a) add to the knowledge base, (b) have a social and or organizational
influence, (c) generate new ideas, and (d) inform stakeholders. The knowledge obtained is
expressed and illustrated in the data to understand gaps in student education. The concomitant
social and organizational influences shed additional light on disparities in the curriculum.
Through this research, students, faculty, and leadership will understand the implications of the
gap and contribute to generating solutions and ideas. This work contributes valuable information
to Univ-Med toward its mission of educating and graduating clinically and culturally competent
medical students.
The study used Clark and Estes’s (2008) model to discover and describe the
organizational factors and the key stakeholders’ knowledge and motivational influences. The
research objectives and purpose established the study’s foundation. The research questions (RQs)
helped organize the study to provide relevance and direction while setting study boundaries
(Christensen & Johnson, 2016). The RQs provided the broader concepts that led to data
collection in this mixed-methods study. They are
1. What are the medical students’ knowledge and motivation related to learning LGBTQ
health in their education?
6
2. What do students want in their education on LGBTQ health that can guide Univ-Med
with curriculum integration of this topic?
3. How do culture, context, and organizational priorities at Univ-Med either support or
hinder the inclusion of an LGBTQ curriculum?
4. What are the recommendations for Univ-Med in the areas of knowledge, motivation,
and organizational resources?
Importance of the Study
To combat health disparities for the LGBTQ population, the U.S. Department of Health
and Human Services (HHS) released Advancing LGBTQ Health and Well-Being (Institute of
Medicine Board of Population Health, 2011). The HHS outlines resources and services to assist
healthcare providers in enhancing cultural humility and improving care for the LGBTQ
community. The publication also outlines strategies to reduce barriers to care, highlighting
physicians’ education to improve their knowledge and capability. Access to inclusive and
comprehensive care provided by well-educated physicians competent to work with the
population can go a long way to mitigating health disparities (Lim et al., 2014). Becoming a
capable physician who can safely care for patients is a function of increased self-efficacy formed
during medical education (Bandura, 1986).
A shortfall in acquiring knowledge and clinical experiences can leave students with low
self-efficacy and undeveloped advocacy skills to care for LGBTQ patients (White et al., 2015).
Medical students have doubts about their ability to provide care to LGBTQ patients, having not
received the content they need to feel fully prepared (Sawning et al., 2017). As noted in the
introduction, research findings highlight the absence of training opportunities for students
throughout their educational experiences. In their mission and vision, Univ-Med stated they
7
strive for excellence in educating the next generation of physicians with a diverse curriculum and
ethical foundations of medical practice. Univ-Med leadership acknowledges this lack of LGBTQ
health as a curricular problem. It supports mechanisms to educate the students consistent with
their mission.
Overview of Theoretical Framework and Methodology
A theoretical framework utilizes identifiable theories and grounds the research. The
variables and factors viewed through the theoretical framework’s lens provided meaning and
contribution to the outcomes. Therefore, the framework's rationale should center on how the
study contributes to knowledge of the problem.
Clark and Estes’s (2008) gap analysis model combines conceptual and theoretical
frameworks for this study. A theoretical framework enables a researcher to look at variables such
as knowledge and, in part, informs other aspects of the research, such as the interrelations among
constructs (Crawford, 2020; Creswell & Creswell, 2018). Bandura’s (1986) social cognitive
theory is the primary influence of the theoretical framework. Social cognitive theory enabled
analysis of the role of human agency, capability, modeling, and self-efficacy in medical
education (Bandura, 1986). The gap analysis framework draws upon Bandura’s social cognitive
theory concepts to aid in studying motivation. The convergence of student knowledge and
motivation with organizational conditions and processes offers the optimal approach to
identifying intended and actual outcomes (Clark & Estes, 2008). This methodology enables
looking beyond the surface markers and into the multiple facets of the problem.
Clark and Estes’s (2008) model can provide guidance and structure to Univ-Med to
assess stakeholder performance levels and goals. These stakeholders are sources and provide the
data and information needed to analyze the knowledge, motivation, and organizational factors.
8
Clark and Estes (2008) outlined evaluation levels and stressed the importance of looking at
performance solutions to maximize outcomes and integrate solutions to manage change.
Univ-Med is an educational and research institution that values aligning performance
solutions to the organizational mission and culture. The data and recommendations, including
examining cultural models and settings, will allow Univ-Med to look at leadership, change
behavior, goal definition, and communication (Clark & Estes, 2008). A greater understanding of
differences in knowledge and skills, including factual, conceptual, procedural, and
metacognitive, can illuminate the underlying problem (Krathwohl, 2002). Faculty and student
interaction, goal achievement, self-efficacy, and academic and professional performance are all
formed within the context and culture of an organization (Bandura, 1995). These factors are
critical elements that can provide the story and solution to set Univ-Med up for future success.
This research used a hybrid of theories that make up each element of knowledge, motivation, and
organizational influences.
Research Design
The research design process is the overall strategy and procedures applied to collect,
analyze, and interpret data and create the blueprint (Christensen & Johnson, 2016; Creswell &
Creswell, 2018). One such design has a foundation in the participatory-social justice theory in
mixed-methods research. Creswell and Creswell (2018) provided an overview of using a
participatory-social justice theory in mixed-methods research. They refer to it as transformative
mixed methods, developed by Mertens (2007), and components of this study mirror
transformative mixed methods. While this study is not explicitly transformative, the impetus
comes from recognizing the need for culturally competent physicians to care for LGBTQ
patients. This study combined quantitative and qualitative tools to draw on both data sets for
9
interpretation (Merriam & Tisdell, 2016). This concurrent design began with the quantitative
approach to collect and analyze the factors affecting the medical students’ knowledge,
motivation, and organizational influences. The qualitative results expanded and provided insight
from the quantitative data.
The problem of practice is the lack of an LGBTQ health curriculum at Univ-Med.
Medical students as stakeholders are the keys to uncovering the knowledge and motivation
related to this problem. The quantitative data determined the gaps between the organization and
medical student performance goals. There are subsets of factors within each knowledge,
motivation, and organizational (KMO) influence, each deserving investigation through this
study. By centering on the research problem and questions, many approaches are utilized for
collecting and analyzing data (Creswell & Creswell, 2018).
Definition of Terms
Terminology, definitions, and vernacular are often problematic in writing or oral
communication when discussing the LGBTQ community.
Bisexual person: A sexual orientation that describes a person who is emotionally and
sexually attracted to people of their own gender and people of other genders (Beemyn, 2018).
Cultural humility: Acquiring cultural knowledge about groups and individuals and
incorporating that cultural understanding to enact personal, professional, systemic, and
environmental changes (Lambda Legal, 2010).
Differences in sex development (DSD): A DSD is a mismatch between a child's
chromosomes or genetic material and the appearance of the child's genitals. A child may present
with a DSD in infancy, childhood, or adolescence. Previously, DSDs were called "intersex"
conditions (Beemyn, 2018).
10
Gay: A sexual orientation that describes a person who is emotionally and sexually
attracted to people of their own gender. It can be used regardless of gender identity but more
commonly describes men (Beemyn, 2018).
Gender identity: A person’s inner sense of being a boy/man/male, girl/woman/female,
another gender or no gender (Beemyn, 2018).
Health disparity: A particular type of health difference closely linked with social,
economic, and/or environmental disadvantage. Health disparities adversely affect groups of
people who have systematically experienced more significant obstacles to health based on their
racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive,
sensory, or physical disability; sexual orientation, or gender identity; geographic location; or
other characteristics historically linked to discrimination or exclusion (Beemyn, 2018).
Healthcare disparity: Differential treatment between groups within the healthcare system
process, for example, fear of identifying specific aspects of self, denial of care, inadequate care,
and sometimes avoidance of healthcare systems (Beemyn, 2018).
Heteronormativity: The assumption that everyone is heterosexual and that
heterosexuality is superior to all other sexualities (Beemyn, 2018).
Heterosexual: A sexual orientation that describes a woman who is emotionally and
sexually attracted to men and men who are emotionally and sexually attracted to women
(Beeyman, 2018).
Lesbian: A sexual orientation that describes a woman who is emotionally and sexually
attracted to other women (Lambda Legal, 2010).
Queer: An inclusive and shared adjective that consolidates the terminology gay, lesbian,
bisexual, and, at times, transgender people (Lambda Legal, 2010).
11
Sexual orientation: How an individual describes their emotional and sexual attraction
(Beemyn, 2018).
Transgender: Describes a person whose gender identity and sex assigned at birth do not
correspond. An umbrella term includes gender identities outside of male or female (Lambda
Legal, 2010).
Organization of the Dissertation
A five-chapter dissertation provides the organization of the study. Chapter One
introduces and outlines the problem of practice, its scope, and its importance in medical
education. This chapter also presents the organizational context and the stakeholders; Clark and
Estes’s (2008) model offered structure to the study. Chapter Two reviews the literature relevant
to the study organized through the gap analysis model. Chapter Three reviews the mixed-
methods research methodology and describes the selection of stakeholders and participants, data
collection, and statistical methods. Chapter Four presents the study’s findings with detailed
descriptions of the assessment and the rationale. Finally, the study concludes with Chapter Five,
which describes the integration of the literature, findings, and outcomes to provide viable
solutions to achieve desired performance and highlights recommendations and solutions.
12
Chapter Two: Review of the Literature
This chapter provides context on an LGBTQ health curriculum in medical education.
Seminal research highlights the past and current state of instruction and the need to include
LGBTQ health in medical education and provides the groundwork for examining this problem.
Moreover, this chapter reviews the literature on the impact of the deficit in knowledge, cultural
humility, and physician experience, resulting in health disparities for the LGBTQ population.
These training deficiencies are identified, including revising goals for curricula leading to
inclusive and equitable care for all society members.
The review begins with an overview of medical education followed by LGBTQ health
standards and recommendations for integration in medical schools. Next, research on the
LGBTQ population and community health needs are reviewed, including the disparity and
outcome on the health and well-being of LGBTQ patients. Research on the link between
education, training, cultural humility, and clinical competency is part of the literature review.
The review examines current trends in LGBTQ health education at medical schools to elucidate
best practices. Finally, Clark and Estes’s (2008) gap analysis model, specifically KMO
influences on stakeholders, provides the foundation for reviewing social cognitive theory,
cultural models, and settings. The conceptual framework guiding the study closes the chapter.
Medical Education in the United States
Columbia University College of Physicians and Surgeons awarded the first Medical
Doctor degree in 1770 (American Association of Medical Colleges, n.d.). Soon after, the
University of Pennsylvania, Harvard, and the University of Maryland established Schools of
Medicine and conferred the same degree. The American Association of Medical Colleges
(AAMC) was founded in 1876 by deans and faculty to set medical schools’ education standards.
13
Medical schools receive accreditation from the Liaison Committee on Medical Education
(LCME, 2017) for educational programs in the United States. The AAMC sets forth
recommendations and standards for medical education, and the LCME ensures that medical
schools meet these standards.
Accreditation verifies whether an institution meets function, structure, and performance
standards. The process also fosters institutional and program improvement. Standards require
that all teaching faculty know and use the specific competencies in their training and assessment
(Licensing Commission on Medical Education, n.d.). The AAMC developed 13 entrustable
professional activities (EPAs) that medical students must demonstrate before graduation. The
AAMC EPAs include (a) performing general procedures of a physician, (b) identifying system
failures that contribute to a culture of safety, (c) gathering a medical history and conducting a
physical exam, and (d) prioritizing a differential diagnosis following a patient encounter. The
knowledge, skills, and attitude that provide information toward identifying a gap in LGBTQ
health education are as follows:
• Competency in patient care and clinical skills requires students to provide
compassionate, appropriate, and effective care for treating health problems and
promoting health.
• Competency in interpersonal and communication skills states that students must
demonstrate effective interactions with patients, families, and other health
professionals.
In 2019 over 20,000 medical students demonstrated these EPAs and graduated in the United
States (AAMC, n.d.). However, medical school graduation alone does not permit individuals to
perform patient care.
14
To become licensed to practice medicine, graduates must continue into additional
specialized education known as residency programs. Residency programs receive accreditation
from the Accreditation Council for Graduate Medical Education (ACGME, n.d.). In 2019,
ACGME reported over 139,000 residents in training at hospitals and university medical centers
annually. Similar to the professional activities for undergraduate medical education, residents
must demonstrate competency in six domains to become licensed to practice medicine: (a)
patient care, (b) medical knowledge, (c) communication, (d) professionalism, (e) systems-based
care, and (f) practice-based improvement (ACGME, n.d.). Residency programs include post-
graduate training in general medical care, such as family or internal medicine. Additionally,
residency programs offer specialized care training, such as urological surgery and endocrinology.
This advanced education prepares physicians in training to care for a myriad of medical
conditions and patient populations.
LGBTQ Standards in Medical Education
The AAMC provides recommendations and educational resources on diverse topics to
medical schools. In 2014 AAMC released the publication Implementing Curricular and
Institutional Climate Changes to Improve Health Care for Individuals who are LGBT, Gender
Nonconforming, or Born with Differences of Sex Development (DSD). Then organization aims to
provide standards for an LGBTQ health curriculum by which medical schools can implement
programs and evaluate if trainees can provide clinically sound and culturally competent care to
this population (Hollenbach et al., 2014). The AAMC developed the guide to provide a
framework for implementation and assessment. Their overall goals are to support medical
schools by outlining how to integrate LGBTQ health content into medical education, specifically
on the role of institutional climate. In 2019, the American Medical Association (AMA), the
15
professional organization for licensed physicians, issued professional guidelines to strengthen
standards of LGBTQ medical education and to collaborate with medical schools to ensure
LGBTQ health education efforts become implemented nationwide (AMA, 2019). The standards
and recommendations from AMA and AAMC are noted in Table 2 and reinforce the role of
KMO influences in education.
In addition to educational guidelines, many professional organizations and the U.S.
government published specialty-specific reports and statements for the overall advocacy efforts
to improve the health care provided to LGBTQ individuals. Health Professionals Advancing
LGBTQ Equality (GLMA), one of the largest collaborative organizations, complied policy
statements from professional organizations such as the America Academy of Pediatrics, the
American Public Health Association, the American Academy of Nursing, and others. The
GLMA compendium outlines why and how effective health care is vital to the community. The
document reinforces the knowledge and skills that need to be taught in medical school,
residency, and continuing medical education (GLMA, 2013). The federal government has
included the importance of this topic in Healthy People 2020, issued by the Institute of
Medicine in 2011. The institute outlines resources and services to improve care for the LGBTQ
community, notably educational resources for health care providers to enhance cultural humility
(Institute of Medicine Board of Population Health, 2011). Healthy People 2020 also outlines
strategies to reduce disparities, highlighting medical education for students and physicians to
improve their knowledge and capability.
16
Table 2
AAMC and AMA Domains
AAMC competency domains AMA domains
Patient care Enhance ability to render patient care in health
as well as in illness
Knowledge for practice Education efforts to start in medical school
Practice-based practice and improvement Collaborate with LGBTQ communities
Interpersonal and communication skills Non-judgmental recognition of optimal care
Professionalism Oppose reparative or conversion therapy
Systems-based practice Seek out local or national experts.
Interprofessional collaboration and
professional development
Collaborate with partner organizations. Educate
practicing physicians on current research
Note. Adapted from Implementing Curricular and Institutional Climate Changes to Improve
Health Care for Individuals Who Are LGBT, Gender Nonconforming or Born with DSD, by A.
Hollenbeck, 2019, American Association of Medical Colleges.
Gaps in LGBTQ Health Education Standards
In medical education, as elsewhere, accreditation influences curriculum design. The
accreditation process mandates curricular content medical schools need to implement and
sustain. The AAMC publishes recommendations, and the LCME accredits medical schools. In
2000, the LCME introduced the following standard for cultural competence:
The faculty and students must demonstrate an understanding of how people of diverse
cultures and belief systems perceive health and illness and respond to various symptoms,
diseases, and treatments. Medical students should learn to recognize and appropriately
17
address gender and cultural biases in health care delivery while first considering the
patient’s health. (AAMC, 2005, p. 1)
The standard describes topics and content using terms such as diverse manner, health care
disparities, and cultural humility. Consequently, medical schools can define these for themselves;
and choose to exclude aspects of cultural competence, including LGBTQ health.
Specialized Training in Residency Programs
The lack of LGBTQ health education within residency programs is notable as this is the
last stage of training before becoming licensed to practice medicine. In a study of supervising
academic physicians, 52% reported they had not received LGBTQ training in medical school or
residency; these teaching faculty are ill-equipped to train others on health matters in the LGBTQ
community (Johnston & Shearer, 2017; Khalili et al., 2015). In 2017, Davidge-Pitts et al.
reported on residency programs in endocrinology, a specialty that frequently provides care for
people seeking gender-affirming care and surgery, and found only 2–5 hours of education
annually.
Research reveals the paucity of instruction and clinical knowledge provided to residents
in their training. Nowhere is this more significant than in specialty training such as urology, and
plastic surgery, which typically cares for higher numbers of transgender patients (Davidge-Pitts
et al., 2017; Dubin et al., 2018). In their review of 131 medical education publications on
transgender health, Dubin et al. (2018) team found that transgender education is typically a few
hours of awareness and information about the population’s health issues. Moreover, inadequate
knowledge, experience, and low self-efficacy among residents and supervising academic
physicians place additional risk on the community (Dubin et al., 2018; Rhodes et al., 2018).
18
Population and Community Health
Inclusive care provided by physicians equipped to work with the LGBTQ population has
been noted as essential to reducing the health disparities these patients face (HHS, 2016).
Without the knowledge and confidence to care for LGBTQ patients, many providers do not take
a sexual history, collect gender identity data, or ask about health issues specific to sexual
orientation (Khalili et al., 2015; Quinn et al., 2015). This critical data collection provides much-
needed information used to make appropriate care decisions. Failure to elicit sexual orientation
and gender identity from patients can, in many ways, be considered a medical error (Noonan et
al., 2018; Sabin et al., 2015). This failure to sufficiently interview and discuss gender identity
and sexual orientation has been compared to failure to screen and diagnose disease (Hana et al.,
2021; Quinn et al., 2015).
The health needs of the LGBTQ community mirror the general population in many
aspects. These patients also have unique requirements and wishes that make the provision of
medical care challenging to this population. GLMA (2013) has published the top issues
impacting the health and well-being that LGBTQ people should discuss with their health care
provider. These health issues include (a) population-specific for gay men and bisexuals,
including hepatitis immunization and screening, human papillomavirus, HIV-AIDS, and (b) for
lesbians, breast health, and intimate partner violence. GLMA also recommends that transgender
people discuss hormones, access to health care, and past health history.
In publications, popular media, and routine use, the singular term LGBTQ is frequently
used to define an entire population. A review of best practices on health disparities (Lim et al.,
2014) emphasized that providers must recognize that all LGBTQ people are not alike and need
individualized care. To further illustrate the need to understand the similarities and uniqueness of
19
the LGBTQ population in 2018, estimates indicated that 12.1% of adults have heart disease,
totaling 30 million people (Hoffman et al., 2018). If 5.6% of the population are LGBTQ, it
stands to reason that, for the average physician who sees 30 patients per day, at least 1 or 2 of
their patients will be LGBTQ (Caceres et al., 2017; Hoffman et al., 2018). For the LGBTQ
population, evidence points to worse cardiovascular health than the straight population (Caceres
et al., 2017; Hoffman et al., 2018). The difference in adverse heart disease outcomes, morbidity,
and mortality may be attributable to LGBTQ overall life stressors specific to sexual orientation
discrimination (Caceres et al., 2017; Hana et al., 2021).
Bias and Discrimination: Cultural Taxation as Bias
In 1973, the American Psychiatric Association removed gay from its diagnostic and
statistical manual of disease; nevertheless, a change in attitude has been slow. In many
communities, this population must keep their sexuality private for safety and security reasons
affecting their health status. Sue (2010) contended that social differentiation and categorization,
such as perceived deviant behavior, perpetuates stigma and marginalizes this community.
Inadequate physicians’ knowledge and experience mean that these patients may not receive the
care needed due to implicit bias and marginalization on the part of the health care team
(Bonvicini, 2017). Implicit bias is attitudes or stereotypes that unconsciously affect
understanding, actions, and decisions (Lambda Legal, 2010). Studies have determined that
implicit bias and preferences such as heteronormativity may contribute to inequalities in the
medical care provided to the LGBTQ population (Bonvicini, 2017; Sabin et al., 2015).
Moreover, LGBTQ persons may be reluctant to seek care and often forgo preventive and
routine medical care (Dubin et al., 2018; Khalili et al., 2015). Inadequate training materializes
with the demonstration of microaggressions, such as verbal abuse or microinvalidation in health
20
settings (Lambda Legal, 2010; Sue, 2010). Limited resources and negative experiences with
health care staff are challenges faced by LGBTQ individuals while accessing health care (Dean
et al., 2016; Johnston & Shearer, 2017). LGBTQ persons, more frequently than the general
population, lack health insurance, financial resources, and employment, placing a barrier
between their need and their ability to receive care (GLMA, 2013; Institute of Medicine Board of
Population Health, 2011).
The LGBTQ community, much like communities of color, face cultural taxation in the
form of the summation of additional expectations to help educate others about improving the
lives of the LGBTQ community. Cultural taxation is a term used to describe the unique burden
placed on ethnic minor faculty in academia when they undertake diversity-related problems
within their institution (Padilla, 1994). In academic environments, LGBTQ faculty express the
onus they face to educate peers, students, and administrators on discrimination (Bosch, 2019).
LGBTQ individuals in academic environments and many other fields face a similar pressure that
their non-minorities peers do not face (Khalili et al., 2015).
Current Trends in Medical Education
Armed with the data and knowledge of health disparities, many medical schools
implement education on implicit and diagnostic bias, microaggression, and stigma to ensure
students understand the link between attitudes, behavior, and patient outcomes. Coursework on
implicit and explicit attitudes provides additional information to enable students to recognize the
role mindset plays in their decision-making (Morris et al., 2019; Sabin et al., 2015). The
coursework allows students to look at behaviors, attitudes, influences, and pathways of thought
that block effective medical care delivery. An additional curricular building block currently
implemented in some schools focuses on the nature of physician diagnostic evaluation, such as
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fundamental attribution error and biases, also known as a cognitive disposition (Croskerry, 2002;
Quinn et al., 2015). Clinicians’ and medical educators’ awareness and acceptance of bias and
decision-making can lead to training and educational modalities, forming strategies to ensure
equitable care (Khalili et al., 2015; Sarkin, 2019).
Emerging curriculum and education in LGBTQ health implemented in medical school
and residency programs demonstrate efficacy. In a systematic review, Morris et al. (2019) and
his interprofessional team found 13 health professional education programs in medical schools
that have developed and implemented curricular interventions to ensure students receive
comprehensive information on bias reduction strategies. Many schools implement introductory
programs centered around definitions, terminology, and the prevalence of health inequalities
(Dubin et al., 2018; Noonan et al., 2018). Curricular integration of LGBTQ health is a starting
point for developing proficient physicians.
The comprehensive and innovative programs implemented at the University of Louisville
are noteworthy. In 2015 Louisville conducted a community engagement forum to understand this
population better and enabled participants to develop recommendations to improve teaching and
access to care (Holthouser et al., 2017; Noonan et al., 2018). As a result of this collaborative
work with the community, the education team implemented a comprehensive and integrated
curriculum for LGBTQ health to understand how provider actions and systemic issues impede
care (Khalili et al., 2015; Sawning et al., 2017).
The AAMC publication on curricular integration to improve the health of LGBTQ
individuals is the standard and guide by which medical schools are encouraged to develop
curricula specific to this topic (Hollenbach et al., 2014). The authors cite schools with exemplar
curricula, including the University of Louisville. The curriculum is primarily for beginning
22
medical students to ensure they receive this knowledge and training early in their education. In
addition, the university conducts annual cultural humility workshops campus-wide to expose
students to diverse people and their beliefs. The key elements of the Louisville curriculum noted
include history taking, physical examination, ethics, evidence-based medicine, and issues of
culture and diversity in medicine. These elements are standards published by AAMC as
competency domains of patient care, knowledge for practice, professionalism, and practice-based
learning and improvement.
Gaps in the Literature
The shortfall in clinical experiences for medical students with LGBTQ patients is one
area lacking research. Most universities implementing LGBTQ health curricula have utilized
lectures, reading, group discussions, and case studies (Morris et al., 2019). Clinical experiences
are essential because students who lack practice, experiential learning, and procedural
knowledge in LGBTQ health struggle with these skills after graduation (O’Leary & Kunkel,
2021; Swanwick et al., 2018). Moreover, research teams stress the value of these patient care
experiences to enhance knowledge and motivation. For example, in the 3rd and 4th years, which
are considered the clinical clerkships, medical students begin demonstrating the knowledge they
have previously obtained. Clinical experiences allow them to demonstrate advanced skills such
as counseling a patient on gender-affirming surgery (Hollenbach et al., 2014; Korpaisarn &
Safer, 2018). Well-structured clinical experiences benefit students in their development as
healthcare providers.
Gap Analysis Framework
According to Clark and Estes (2008), organizations achieve success through a system of
interacting people and processes that contribute to organizational goals. This achievement
23
depends on iterative gap identification followed by mitigation using well-designed research to
make informed decisions (Clark & Estes, 2008). Clark and Estes set forth a structural and
functional model with a pre-existing set of categories of KMO.
Identifying performance and overall organizational goals in KMO is a process of
understanding and classifying influences to develop methods to improve these factors. Studying
assumed influences of knowledge, motivation, and organization can provide the information to
determine the possible solutions (Clark & Estes, 2008). The outcomes data takes on meaning for
the organization when combined with the stakeholders’ understanding of KMO (Newman et al.,
2003). The gap analysis model is specific to a context-based problem that affects an organization.
The overall problem aligns with a stakeholder goal and critically analyzes unmet goals’ status,
gap, and cause (Clark & Estes, 2008). Research questions address what is causing the gap in a
particular setting, relying on evidence-based research to support the determination of causes and
solutions (Newman et al., 2003).
Stakeholder Knowledge, Motivation, and Organizational Influences
Clark and Estes (2008) laid out steps and processes to identify causes and underlying
factors contributing to the problem to analyze the problem and potentially close the gap
effectively. Clark and Estes’s process model recommends defining and analyzing performance to
identify potential causes. Discovering the attainment level of knowledge and skills combined
with motivational influences can lay the groundwork to identify and implement solutions. For
example, unclear performance goals for students on LGBTQ health impedes the development of
the skills to become a culturally competent physician (Khalili et al., 2015; Tamas et al., 2010).
This study explored the knowledge types in medical education, including content (facts,
24
procedures, and concepts) and strategic knowledge (heuristic, generalizable, and context-
dependent), as a basis for skill acquisition (Kaufman & Mann, 2014; Medina et al., 2017).
Knowledge Influences
Competency-based education designed through evidence-based medicine is one of the
foundational elements of a medical school curriculum. Physicians acquire broad knowledge,
skills, theories, and medical concepts to become practitioners. Their education includes task-
oriented skill training and other theoretical and conceptual subjects. This distinction between
skill acquisition and the overall gestalt of medical education is significant when determining
outcomes and potential gaps (Dweck, 2008; Kaufman & Mann, 2010). Knowledge operates on
multiple levels in medical education, starting with declarative or explicit (Swanwick et al.,
2018). It progresses to procedural or psychomotor gained through experience and moves to
learning in the environment (de Bruin et al., 2018; Kaufman & Mann, 2010). The final stage
conceptualizes relationships from different perspectives for clinical care application (Ambrose et
al., 2010; Kaufman & Mann, 2014). Educational achievement in medicine has multiple
interconnected causal pathways, and at each phase, understanding knowledge influence can help
identify successful outcomes.
Knowledge Influence 1: Factual
The practice of medicine is continually evolving, and with it, the knowledge, skills, and
attitudes necessary to provide patient care. The AAMC domain of knowledge for practice in
LGBTQ health includes applying scientific principles fundamental to health, such as defining
and describing the differences among gender expression, sex and gender, and sexual orientation
(Hollenbach et al., 2014). Before seeing patients, this domain concentrates on a medical
student’s knowledge and abilities. The domain also includes how it is to be evaluated, including
25
demonstrating an investigatory and analytic approach by stating and recalling, for example, the
efficacy of various interventions for gender dysphoria (Parker et al., 2011). This set of
knowledge for practice is an illustration of factual knowledge. To be conversant or solve
problems, learners need to know facts and to demonstrate they have achieved educational goals
(Ambrose et al., 2010; Krathwohl, 2002).
The lack of factual knowledge of LGBTQ health among medical students, either self-
reported or demonstrated, is well documented. As evident in numerous medical education
publications, this is a skill deficit they often carry into their professional careers and has
significant consequences for the students and the patients they serve (Loeb et al., 2017; Noonan
et al., 2018; Parameshwaran et al., 2017; Sawning et al., 2017). Attitudes, comfort, confidence,
skill-building, and clinical proficiency builds upon the knowledge, and if the structural
foundation is missing, it becomes difficult for the student to acquire additional skills (Hollenbach
et al., 2014). At the most basic level, knowing sexual development, the components of a sexual
history for LGBTQ patients, and the risk factors for sexually active LGBTQ patients are
essential for medical students to succeed in their clinical rotations (Bonvicini, 2017; White et al.,
2015).
Knowledge Influence 2: Conceptual
Health disparities, marginalization, social stress, and cultural humility are concepts
medical students need to learn to care for a diverse population. These concepts are present in the
health disparities education and recommendations from AAMC. The ability to gain conceptual
knowledge requires the learner to understand the interrelationships of elements, patterns, and
topics and how they function together (Krathwohl, 2002; Medina et al., 2017).
26
Students understand that sex is an anatomical construct at the most basic conceptual level. In
contrast, gender reflects a social construct of what it means to be masculine or feminine,
allowing a student to describe the difference between specific aspects of gender identity
(Dallaghan et al., 2018; Hollenbach et al., 2014). Courses such as reproductive medicine provide
a platform for students to integrate and reinforce concepts related to LGBTQ health. Students
benefit from learning not to attach concepts of sexual orientation to pathology (Bonvicini, 2017;
Sarkin, 2019). In medical education, success in clinical care is often independent of domain-
specific conceptual knowledge built upon what, how, and why, with the latter fostered by clinical
experience.
Conceptual knowledge enables a physician to look at a pre-existing set of categories and
collect meaningful data in an iterative process of gathering information, interpreting results, and
proposing and implementing solutions (Kaufman & Mann, 2010). The medical problem, be it
from an underlying condition or a gap in care, requires an information-gathering approach using
these pre-existing categories to allow the provider to determine causes and solutions (Hollenbach
et al., 2014). The how, which includes procedural knowledge, is the third influence.
Knowledge Influence 3: Procedural
Learning procedures or knowing how is accomplished by understanding subject-specific
techniques through repeated practice of that skill (de Bruin et al., 2018; Kaufman & Mann,
2014). In the learning domain of patient care, the AAMC defines competency as performing a
complete and accurate history and physical exam with sensitivity to patients who are LGBTQ.
The skill needed is not just examining a patient; for example, it ensures using the patient’s
correct pronouns. The lack of training in clinical skills needed for effective patient outcomes in
27
the population is not addressed sufficiently in education, and these skills are foundational
elements of competency (Dubin et al., 2018; Tamas et al., 2010).
Multiple studies at medical schools have found that students feel unprepared to attain a
sexual history with a culturally competent approach for LGBTQ patients (O’Leary & Kunkel,
2021; Parameshwaran et al., 2017). Frequently, physicians do not take a sexual history from
patients due to a concern of offending patients and do not ask questions about gender identity
and sexual orientation (Khalili et al., 2015; Korpaisarn & Safer, 2018). Table 3 outlines the
stakeholder assumed knowledge influences and types.
Table 3
Knowledge Influences Summary
Assumed knowledge influence Knowledge type
Medical students need to acquire factual knowledge
of LGBTQ health, including population-specific
medical needs, the impact of health disparities,
and effective provider-patient interaction skills.
Factual and declarative knowledge
Medical students need conceptual knowledge of
LGBTQ health through understanding the
interrelationships of fundamental theories,
elements, patterns, classifications, and how they
function together.
Conceptual knowledge
Medical students need to acquire knowledge of
procedures and tasks relevant to LGBTQ health
by attaining medical skill competence.
Procedural
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Motivational Influences
Medical education has evolved to be competency-based, focused on students’ ability to
demonstrate skills essential to safe patient-centered care. In an ongoing and sustainable way,
medical competency becomes evident through effective communication, technical skills,
knowledge, and clinical reasoning, which benefit patients and the community (Lomis et al.,
2017). Competency-based medical education is grounded in educational theories and principles
such as adult learning theory, self-directed learning, and self-efficacy (Hollenbach et al., 2014;
Lomis et al., 2017). The goal is for students to demonstrate proficiency in knowledge, skills, and
attitude through deliberate practice, enhancing self-efficacy in various domains.
Medical students at Univ-Med do not lack motivation. On the contrary, they are highly
motivated and have invested time and energy in preparation for acceptance to the program.
Situational experiences, exposure, and opportunity to learn LGBTQ health have been absent in
their curriculum; therefore, building intrinsic motivation has been interrupted (Dweck & Elliot,
2005). Vicarious experiences, faculty observation, actual performance, social persuasion, and
psychological factors provide learners with the determination and belief of self-efficacy
(Bandura, 1991; Dweck, 2008). New experiences, opportunities, and learning in the motivational
process are critical components of skill acquisition. Ensuring competency necessitates
identifying strengths, needs, and opportunities for more effective and supportive education
(Hollenbach et al., 2014). Motivation through deliberate practice to become a reflective
practitioner is the goal of medical education.
Motivational Influence 1: Self-Efficacy
One of social cognitive theory’s five constructs is self-efficacy (Bandura, 1982). Self-
efficacy is central to transferring knowledge and training. Influenced by a person’s specific
29
capabilities, competency development relies on self-efficacy formed during medical education.
Confidence helps form a student’s perception of their ability to carry out a specific task by
attaining the skill to accomplish a goal (Bandura, 1986). Self-efficacy develops within specific
domains or tasks rather than a global assessment of ability (Bandura, 1982; Kaufman & Mann,
2010). Mastery experiences and deliberate practice can improve a learner’s ability to work
through actions to manage prospective situations (Bandura, 1982; Kaufman & Mann, 2014).
Perception plays a significant role in one’s ability to perform specific skills and can influence
acquiring competency (Nama et al., 2017).
Medical students throughout the United States report low rates of self-confidence and
preparedness to care for LGBTQ patients and consistently request additional opportunities for
learning on this topic (Dallaghan et al., 2018; White et al., 2015). In a nationwide survey of over
4,000 medical students, 64% evaluated their LGBTQ health curriculum as poor or very poor
(White et al., 2015). Students also stated that they have substantial reservations about their
ability to provide care to LGBTQ patients due to readiness (Holthouser et al., 2017; Sawning et
al., 2017). The results show that students acknowledge that their medical school curriculum does
not provide the necessary breadth and depth. In addition, medical students’ preparedness and
accuracy of knowledge about LBGTQ health appear inadequate, further demonstrating less than
optimal education offered at medical schools (Bonvicini, 2017; Noonan et al., 2018; Sawning et
al., 2017). Students are voicing their dissatisfaction with the lack of a culturally competent
curriculum in their training and realize this puts them at a disadvantage when delivering care for
LGBTQ patients (Dallaghan et al., 2018; Khalili et al., 2015; Nama et al., 2017).
Opportunities to enhance self-efficacy can be complicated when students learn a subject
matter, such as LGBTQ health, which may intertwine with societal norms and values (Nama et
30
al., 2017; Rhodes et al., 2018; Sawning et al., 2017). Beliefs, attitudes, emotions, and context
influence student learning and limit or enhance a learner’s willingness to take on new challenges
(Bandura, 1986; Dweck, 2008; Kaufman & Mann, 2010). Faculty and student interaction, goal
achievement, self-efficacy, and academic performance can positively or negatively influence
emotions (Bandura, 1986; Kaufman & Mann, 2014). Still, recent research suggests that medical
students have favorable attitudes and emotions toward the LGBTQ population, ranging from
74% to 86% of students stating they are comfortable with LGBTQ patients (Sawning et al.,
2017; White et al., 2015; Zelin et al., 2018). Nevertheless, despite the positive attitude medical
students have toward the LGBTQ population, there persists a lack of confidence in caring for this
population (Greene et al., 2018; Morrison et al., 2017).
Accountability in a relationship is associated with positive cognitive outcomes and
significantly impacts intellectual and behavioral tasks (Bandura, 1989; Dweck & Elliot, 2005).
However, this is true only if the training and evaluation are in a culture or environment that
includes personal orientation, relationships, and contextual norms (Sue, 2010). Therefore, to
better understand poor confidence and low self-efficacy, it was necessary to look at the role of
observation and vicarious experiences in medical education.
Motivational Influence 2: Vicarious Experience
The study assessed the influence of vicarious experiences from role model observation
from two perspectives. First, it explored vicarious experiences as motivation and a key
component and process within social cognitive theory (Bandura, 1986). The second perspective
is discussed in detail in organizational influences with observation and role modeling as a
cultural setting. Observation and role modeling transmits the medical profession’s values and
forms the learner’s core knowledge base (Guralnick & Yedowitz-Freeman, 2017; Kaufman &
31
Mann, 2010). The phrase “see one, do one, teach one” is frequently heard at medical schools
nationwide (Heath, 2020, p. 1820). This phrase has a longstanding history and recognizable
content of observing, supervising, and educating others. Observation of others in medical
education is a significant motivational influence in and of itself. Observing faculty can influence
learning more than formal teaching, with the most significant impression from physicians whom
students view as role models (Glicken & Merenstein, 2007). In medical school, where much
learning is experiential, faculty role modeling is powerful, especially during patient care, where
learners observe faculty behavior and interactions. Observation and modeling others’ behaviors
are essential learning strategies to facilitate knowledge transfer (Kaufman & Mann, 2010).
Additionally, observation can help learners understand performance standards and conceptualize
target behaviors in the social and educational environment (Bandura, 1982; Rios, 2016).
Modeling frames students’ perception of whether an LGBTQ perspective is absent or
welcomed. The absence of an LGBTQ curriculum can be an implicit message in the environment
that the content is unacceptable or not essential (Dean et al., 2016; Lambda Legal, 2010; Sue,
2010). Consequently, a respected faculty member who does not demonstrate patient care with
cultural humility signals to learners that the approach is unimportant (Croskerry, 2002; Nama et
al., 2017). Based on the consistent absence of an LGBTQ perspective, college and medical
students extrapolated an implicit climate of marginalization (Nama et al., 2017; Sarkin, 2019).
LGBTQ health, which may be taught poorly or not taught at all, can hinder performance
attainment and knowledge transfer (Holthouser et al., 2017; Institute of Medicine Board of
Population Health, 2011). Table 4 lists the motivational influences and motivation types relevant
to the stakeholder group of medical students.
32
Table 4
Motivation Influences
Assumed motivation influence Motivation type
Students need to be confident in LGBTQ health to provide
care with cultural humility.
Self-efficacy
Students need to feel capable in their ability to develop
LGBTQ clinical and population-specific competence and
cultural humility.
Self-efficacy
Students need vicarious experiences to observe role models
who demonstrate inclusiveness and set a positive
example.
Vicarious-observation
Organizational Influences
Organizational influence refers to the social and organizational context, including the
characteristics of an organization and its impact on people and outcomes (Schein & Schein,
2017). For example, shared values are an organizational influence and a subset of organizational
culture (Rueda, 2011; Schein & Schein, 2017). Aspects of an organization such as
communications, actions, policies, and conditions are also influencers. Driving elements such as
organizational climate and processes move that institution toward success or failure; these
organizational and driving factors help define the culture and climate (Schein & Schein, 2017).
Gallimore and Goldenberg (2001) stated that an organization’s culture includes cultural settings
and models.
Organizational Influence 1: Cultural Model
The cultural model structures and represents knowledge relevant to that organization.
Cultural models are perceptual structures and behavior patterns based on shared experiences
connected with a system of values (Gallimore & Goldenberg, 2001). Cultural models are
33
traditions and patterns of daily behavior expressed in different formats and circumstances within
an organization (Kezar, 2011; Rueda, 2011). A cultural model explains distinct organizational
phenomena and explores social dynamics and relationships. Social cognition within cultural
models emphasizes everyone’s role in the collective process (Kezar, 2011). Kezar also described
the pivot point individuals hold by understanding their role within the organization’s cultural
identity.
The cultural model for a medical school is accountability to students and society to
ensure that the newly minted physician is skilled and can safely practice medical care by
graduation. Accountability transactions between medical students and the university are process
and outcomes-based and, as such, employ characteristics of cultural agency and answerability
(Avrichir, 2003; Hollenbach et al., 2014). The expectations and responsibility are that medical
students will graduate in 4 years, and mechanisms are in place to ensure they accomplish this
goal. The accountability measurement is that students will meet established standards by the time
they graduate (Guralnick & Yedowitz-Freeman, 2017; Lomis et al., 2017). Moreover, the
benchmark to ensure students’ education portfolio includes demonstrating clinical skills and
progressing to patient care.
Univ-Med provides education, and the students are responsible for engaging in the
process to show outcomes and competency expressed in a grade. The university ensures that
medical students can safely care for patients under supervision. Outcomes-based models provide
stakeholders information about the program’s rationale, goal, intended outcomes, and the inputs
and processes required to achieve those goals. Parker et al. (2011) noted that health care and
medical education, which have roots in professional identity formation, often have difficulty
34
defining the attribution of outcomes. The study sought to provide Univ-Med with the tools to
define and assess outcomes.
The organizational model at Univ-Med includes (a) policies and practices, (b) patterns of
implementation, and (c) the social and natural environment within these systems. All three are
contextual factors and flow through the organization (Avrichir, 2003).
Organizational Influence 2: Cultural Setting
The cultural setting, including the climate, can be seen in the routines of life and in
various dynamic situations where behavior occurs (Rueda, 2011). Organizational routines such
as the who, what, and why make up this social or cultural setting. A person’s connection to the
social, interpersonal, and individual system within the atmosphere of an organization’s cultural
setting can be defined (Gallimore & Goldenberg, 2001; Kezar, 2011). Implementing the new
social and health justice curriculum at Univ-Med signals a change. Achievement and successful
integration occur in a dynamic cultural setting that values diversity, community engagement, and
robust infrastructure (Hollenbach et al., 2014; Sawning et al., 2017). The AAMC recommends
that institutional climate receives evaluation before and after the curricular change in several
categories: (a) leadership and commitment, (b) efforts to educate, (c) promotion of equality, and
d) ensuring a welcoming patient care environment. An integrated LGBTQ curriculum can
produce changes in knowledge and motivation, organizational setting, and culture (Holthouser et
al., 2017).
The AAMC strategies for influencing curriculum change and institutional climate include
role modeling (Lomis et al., 2017). The ongoing effects of positive role models provide students
with a visible statement of the institutional commitment to specific efforts. As an organizational
influence, faculty demonstrate the social and professional role, and through observation, students
35
acquire knowledge framing their impression of the organization (Kaufman & Mann, 2014). The
faculty guides the learning in the clinical setting, and students and patients often view them as
leaders and influencers. Univ-Med is going through a significant organizational change by
implementing curriculum renewal. The university hopes to reinforce its identity and image as a
social and health justice leader. Integrating an LGBTQ curriculum can produce a change
associated with a culture clear of bias and open to innovative ideas, such as curriculum renewal
(GLMA, 2013; Holthouser et al., 2017). A climate is absent of educational programs that
demonstrate this new identity contradicts the university’s claims and what it does. Table 5
provides the organizational influences and where they fit in the schema.
Table 5
Organizational Influences
Assumed organization influence Organizational category
The university needs to align its new social and health
justice curriculum with and incorporate LGBTQ
health in that curriculum.
Cultural model
The medical students need to have a sense of ownership
of the LGBTQ curriculum through inclusion in the
development.
Medical students need to observe faculty who
demonstrate cultural humility and LGBTQ
competency.
Cultural setting
Cultural setting
36
Clark and Estes’s (2008) model outlines intended performance outcomes compared to
actual performance, enabling an organization to determine gaps. While knowledge, motivation,
and the organization play a role in this solution, the case is decisive for the influence of
organizational culture and climate. If housed in an organization with an adaptive culture,
motivational and knowledge solutions show a greater likelihood of sustainability (Avrichir,
2003). Outcomes such as increased knowledge and enhanced motivation that stand-alone
typically fail without the factors to support change, such as clear goals and alignment of
processes (Kaufman & Mann, 2014; Lomis et al., 2017). The role of culture and its power in
enabling or hindering performance necessitates a flexible and reciprocal culture (Clark & Estes,
2008).
A critical starting point in this assessment is to look at the factors hindering teaching
LGBTQ health. Clark and Estes (2008) gave the analogy of the organizational factors as the
“conditions that make it easier or more difficult to get to your intended destination” (p. 43). The
medical students’ goal is to become competent, caring, and socially aware physicians. These
organizational barriers may hinder the current state of education at Univ-Med, shaping these
stakeholders and their intent to graduate.
Culture and Change
Adaptive organizational culture is “a pattern of shared beliefs, values, and behaviors that
indicate the organization is aware of and concerned about changes and oriented toward agile and
flexible action to address such changes” (Costanza et al., 2016, p.44). The characteristics of
adaptive culture in organizational change include openness to risk-taking, development of
capabilities, collaborative action planning, executing change, and sustaining change (Costanza et
al., 2016; Lomis et al., 2017). The need for change may be visible at a higher level of the
37
organization, in the trenches, or both. Regardless, communication from leadership should
highlight the need and essential points so everyone feels heard and their perspective integrated.
As the organization is dynamic, the transformation components must have congruence, in this
case, a curriculum that emphasizes social and health justice and an LGBTQ curriculum
Conceptual Framework
A conceptual framework is a researcher-constructed justification of the need for the study
and informs the research question (Crawford, 2020; Varpio et al., 2020). My experience, the
literature, and the theoretical framework contribute to the conceptual framework. It is a tool of
linked concepts to help understand the relationship among concepts or variables. The conceptual
framework falls inside of a larger theoretical framework. It is relevant to note that the conceptual
framework is the justification or argument for the study as it informs and describes all other
aspects of the research (Crawford, 2020). The argumentation of the conceptual framework details
the study's importance and demonstrates the appropriate design and method (Ravitch & Riggan,
2016; Varpio et al., 2020). The argumentation also includes the rationale for the methodology
and how it meets rigorous research standards (Crawford, 2020; Varpio et al., 2020). The
concepts, beliefs, and ideas that guide the research support its meaning and contribution to
society (Kaufman & Mann, 2010; Mertens, 2007).
The argumentation of the conceptual framework for this medical school research has its
foundation in the scope and scale of health disparities in the LGBTQ community due to the lack
of physician knowledge to care for this population effectively (Davidge-Pitts et al., 2017; Quinn
et al., 2015). Inadequate knowledge translates into an insufficient understanding of the
population’s medical needs, including how to provide safe and competent care (Khalili et al.,
2015). The argumentation for this work at Univ-Med is the documented lack of curriculum, as
38
seen in the syllabus and university information. The faculty also acknowledge the shortfall in
patient care experiences available for students and inconsistent role modeling in the patient care
settings.
The conceptual framework connects theories and constructs. In medical education,
knowledge is a construct upon which everything else develops. The theories mentioned
providing a way to explain and look at the data in context. My experience in education and
seeing LGBTQ health care disparities prompts this conceptual framework. Moreover, it
demonstrates the advancement of knowledge (Crawford, 2020; Grant & Osanloo, 2015). The
design, data collection, analysis, and interpretation elements support the conceptual framework
in descriptive research.
The conceptual framework for this study is illustrated in Figure 1 and guides the work.
The impact of the problem of practice is the health disparities the LGBTQ population faces.
There are many contributing causes, but for this study, the literature supports the lack of LGBTQ
health education in medical school, resulting in physicians’ underperformance in cultural
humility and clinical competence. The lens of KMO allowed for examining the relationships
among the variables. The descriptive variables are the students’ demographics, current
knowledge, and motivation. The final variable is the organization, the role culture and setting
play in the model, and the influence on the students.
39
Figure 1
Conceptual Framework
Conclusion
It is not easy to ensure that physicians are knowledgeable and practice with cultural
humility. The gaps identified in the education offered at medical schools contribute to the
problem, resulting in under-preparedness and accuracy of medical students’ knowledge about
LBGTQ health (Sawning et al., 2017). Clark and Estes’s (2008) model is not a formal theory but
shows the need for support in specific areas of KMO influence. Formal theories of organizational
culture, models, and setting, such as Kezar’s (2011) work on cultural models, contribute to
solidifying the theory in this research. In addition, Bandura’s (1986) social cognitive theory
plays a significant role in the framework of this study by looking at student motivation and self-
40
efficacy. The healthcare system in the United States is rapidly and ever-changing, comprised of
a mix of patients, healthcare providers, hospital systems, and government regulations. As a
result, medical schools and residency programs must balance providing educational content on
this topic and dozens of other population health care issues to prepare students for the future.
While medical education has made strides toward improving educational outcomes, these
conclusions spotlight the need for a significant overhaul in medical education to ensure our most
vulnerable populations receive quality and non-biased care.
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Chapter Three: Methodology
This study focused on the KMO influences affecting the lack of an LGBTQ curriculum at
Univ-Med through gap analysis. By concentrating on the research problem and questions, many
approaches were applied to collecting and analyzing data (Creswell & Creswell, 2018). This
chapter provides information about the methods used to gather and analyze data, their use, and
their overall purpose. The chapter begins with an overview of the research design and setting. It
includes the data sources, data collection methods, and relevant activities, including instruments,
data collection procedures, and analysis. The chapter concludes with a discussion of ethics,
limitations, delimitations, and researcher information to clarify any biases affecting the process
or outcome.
Research Questions
Guiding the study’s design are the following:
1. What are the medical students’ knowledge and motivation related to learning LGBTQ
health in their education?
2. What do students want in their education on LGBTQ health that can guide Univ-Med
with curriculum integration of this topic?
3. How do culture, context, and organizational priorities at Univ-Med either support or
hinder the inclusion of an LGBTQ curriculum?
4. What are the recommendations for Univ-Med in the areas of knowledge, motivation,
and organizational resources?
Overview of Design
The research design process is the strategy and procedures researchers use to collect,
evaluate, and interpret data and create the blueprint (Christensen & Johnson, 2016; Creswell &
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Creswell, 2018). Transformative participatory inquiry is a design approach that focuses on social
change, targeted to the needs of a particular group and context; in this case, the context is
medical education (Mertens, 2007). Mertens describes this type of research which can be either
transformative or practical in the framing and is in keeping with culturally competent
methodologies. A participatory action mixed-methods framework uses qualitative methods to
complement quantitative data, incorporating a transformative lens with a goal of social justice
(Creswell & Creswell, 2018; Mertens, 2007). The impetus for this study grew out of (a) the
recognition of the dearth of culturally competent physicians to care for LGBTQ patients and (b)
the absence of a curriculum on LGBTQ health in medical education. Based on the writings of
Mertens (2007), components of this study that mirror participatory mixed methods include (a)
recognizing diversity among study participants, (b) the reference to a problem in a community of
concern, and (c) participation of groups with an eye toward the facilitation of social change. This
mixed-methods study combined quantitative and qualitative tools to enable the interpretation of
both data sets (Merriam & Tisdell, 2016).
The foundation of human-centered design (HCD) provided the approach to stakeholder
involvement and participation. Design thinking, or HCD, is an approach to program development
that emphasizes the importance of the end-user, the medical students (Gottlieb et al., 2017). The
process approaches a needs assessment utilizing tools and mindsets in an iterative fashion
grounded in the end-user’s needs.
The specific mixed-methods design used was concurrent, also known as convergent
design, to collect data to answer the research questions (Fetters et al., 2013). Collecting
quantitative and qualitative data has two simultaneous approaches: first, data are analyzed
separately and then merged (Christensen & Johnson, 2016). The survey was the method for
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quantitative data collection, focusing on knowledge and motivational influences. The qualitative
data were obtained through focus groups and sought organizational influences, stakeholder
recommendations, and input. This approach facilitated comparing and integrating quantitative
and qualitative data to interpret the results (Creswell & Creswell, 2018; Newman et al., 2003).
The overall problem is multifaceted; therefore, this approach enabled the investigation of
different phenomena in the research questions.
Participating Stakeholders
The population of focus for this study is all Univ-Med medical students in Years 1–4.
These stakeholders are sources and provide the data and information needed to analyze the KMO
factors and influences. At the time of data collection, each class of students had 186 enrollees.
Students received an email invitation to complete the survey. The options provided to them for
participation were (a) to complete an online survey, (b) to complete the survey and participate in
a focus group, or (c) to decline any participation by not responding to requests.
Survey Sampling (Recruitment) Criterion and Rationale
Census surveying was the method used and included all medical students. Recruitment
occurred from all classes with no exclusion criteria. Students from the 1st through the 4th year
made a unique contribution based on the courses and clinical experiences up to the survey
completion. The survey allowed the primary stakeholders, the medical students, to be heard and
contribute information on how this gap affects their education.
The Univ-Med's curriculum and student affairs office supported this research and is
interested in the results and recommendations. Recruitment efforts were formalized through
Univ-Med and informal via other channels to reach students. The associate dean for student
affairs sent the first email recruitment to all medical students. The email encouraged each student
44
to complete the survey and gave a brief overview of the research, survey link, and my contact
information. MedLambda, the student LGBTQ organization, reminded everyone on their email
list. Pride-K, a collaborative hospital and medical school organization included the survey link
and a reminder in a recent email. In January, 2nd-year medical students rotated through the
clinical skills center at Univ-Med for experiential learning. During this event, they were
reminded about the survey and given the Qualtrics link on their computers.
Focus Group Sampling Criteria and Rationale
Medical students in Years 1–4 who completed the online survey and answered the final
item to volunteer for the focus group research participated. The goal of the focus group was to
complement the survey data on student recommendations for the curriculum. The focus group
sought to collect data on the meaning the students give to the problem through a qualitative
process that opened the research to analyze multiple attitudes, knowledge, and feelings (Mertens,
2007). A medical school’s organizational culture strongly influences motivation and knowledge;
therefore, the qualitative methodology of focus group interviews provided a mechanism to obtain
data on organizational context and culture (Rios, 2016).
Data Collection and Instrumentation
Using data for decision-making enables researchers to systematically gather and measure
information on variables of interest (Christensen & Johnson, 2016; Morgan, 2014). In this study,
the selection of the data collection methods and instrumentation enabled all medical students to
have an opportunity to voice opinions and recommendations. The research questions dictated the
sources and types of data required, employing a “descriptive analysis to characterize the world or
a phenomenon in the data to answer questions about who, what, where, when, and to what
extent” (Loeb et al., 2017, p. 39).
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Answering Research Questions 1 and 2 was possible by collecting information on the
state of student behavior, actions, predispositions, and attributes in the problem of practice. The
survey for the quantitative data allowed for measuring a range of behaviors, including attitudes
and attributes. The data sources were obtained directly from the participants without
experimental intervention. These data came from surveys, document reviews, and focus groups.
As a descriptive study, the literature aided in selecting the data sources as the most effective way
to observe the problem of practice (Christensen & Johnson, 2016; Loeb et al., 2017).
Data to answer the third and fourth research questions were obtained from open-ended
questions on the survey and focus group interviews. The essential concepts analyzed included
respondents’ perceived needs and the desire to learn about LGBTQ health. The data helped
explain what they would like included in their education and what would be most valuable to
them as future doctors. Therefore, a qualitative approach was employed to obtain insights within
the specific domain of their educational experience (Merriam & Tisdell, 2016).
Method 1: Survey
An online survey was used to assess the KMO influences through a secure cloud-based
tool, Qualtrics. A quantitative description of knowledge, trends, and opinions by studying a
population sample makes up a survey design (Creswell & Creswell, 2018; Leonard & Robinson,
2018). During the design process, the research question received careful consideration as a guide
for developing the survey questions. The survey evaluated medical students’ knowledge and
motivation related to LGBTQ health in their curriculum. The 18-item questionnaire used a
combination of Likert-scale and open-ended questions. The advantage of the survey was
objectivity, as the respondent never saw me and vice versa. Open-ended questions yielded
detailed and descriptive data (Merriam & Tisdell, 2016). Responses from the open-ended
46
comments were reported with the survey data and qualitative focus group findings to provide
additional depth, detail, and validation.
The medical student population of 744 students received the survey. The descriptive
information of value was the respondents’ abilities (knowledge), thoughts and behavior
(motivation and social cognition), and attributes (demographics). The type of sampling was
census; all relevant individuals received recruitment for participation in the study (Christensen &
Johnson, 2016; Salkind, 2014). The survey distribution was through the associate deans of
student affairs and curriculum. The survey in Qualtrics went to all students’ emails. The survey
asked for demographic data to analyze, combined and separately, the classes of medical students.
The survey also included Likert-scale questions that provided data to establish and examine the
stakeholder KMO influences that created performance gaps (Clark & Estes, 2008).
Method 2: Focus Group Interviews
Focus group interviews are a technique to discuss issues with multiple participants
simultaneously (Krueger & Casey, 2014). In this study, these interviews aimed to obtain detailed
information on more abstract topics to generate educational ideas and concepts. The discussion
delved into participants’ thoughts, feelings, and ideas to gather data on the relevant research
questions (Christensen & Johnson, 2016; Krueger & Casey, 2014). The purpose of this data
collection procedure and connection to KMO was (a) to stimulate new ideas and creative
concepts as it relates to the organizational influences of culture and setting; (b) to interpret
previously obtained quantitative results of knowledge and motivation, specifically bringing a
voice to the responses received electronically in the survey; and (c) to obtain the general
background that provides the comprehensive understanding of organizational setting and
structure.
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Focus Group Instrument
The data collection instrument for the focus group had several elements related to
organizational influences, and the questions were open-ended. It was semi-structured and
provided framing for the conversation. The open-ended questions enabled the respondent to give
breadth and depth to answers. In addition, the ability to be flexible and change the order of the
questions to follow up with topics raised in a previous response allowed for a more natural flow.
Three types of focus group questions were employed: (a) engagement, (b) exploration, and (c)
summary/ending to provide structure (Krueger & Casey, 2014).
Focus Group Procedures
Recruitment for the focus groups occurred via a question in the survey where respondents
indicated a willingness to participate. If a respondent elected to participate, a link sent them to a
registration page separate from the survey. To learn how participants experience the phenomena
of interest, the focus group enabled examining layers of detail (Krueger & Casey, 2014). Each
group had four to six students. The sessions lasted 60 minutes to fit the students’ schedules and
available time blocks. The same criteria and procedures for human subjects and IRB inclusion
set for the survey were applied to the focus group.
The construct of the participants for the focus group received careful consideration with
the advantage in this case of non-probability sampling of convenience and specificity. The type
of non-probability sample method was voluntary sampling. A voluntary sample comprises
people who self-select or choose to participate, typically because they are interested in the topic
(Merriam & Tisdell, 2016). In this case, the participants were students who volunteered through
the survey.
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Students received a choice of two dates from which to choose to attend the focus group.
The communication between us was via university email. Each focus group participant received
an email reminder. The focus group was informal to encourage each student to participate.
Before signing into the Zoom, students were allowed to change their names; none chose to do so.
Method 3 Secondary Data
Secondary data collection occurs by someone other than a researcher for specific
purposes (Merriam & Tisdell, 2016). Secondary data have history and are in a workable format
that is easy to use and evaluate. At an educational institution with a long history, secondary data
was accessible and contained information to aid this study. The secondary data included copies
of the curriculum, course syllabi, and program evaluation. The curriculum information provided
details about the topics in each course and allowed for exploration of any relevant course work in
LGBTQ health. The analysis included a review of material from a Professional Practice of
Medicine course. This course contains the only formal LGBTQ curriculum offered at Univ-Med,
one 3-hour session. The additional secondary data source was pre-workshop survey results from
students in their 3rd and 4th year of medical school during their family medicine clerkship. The
workshop faculty developed a survey to understand students’ attitudes, knowledge better, and
experience before the workshop to tailor the content as needed. The faculty consented to the use
of the secondary data in this study.
Alignment of the KMO Influences and Data Collection
Stakeholder-specific KMO assumed influences relate to the experience of the medical
students in the organization. The lack of education and training in LGBTQ health at Univ-Med
for the student stakeholder group necessitated an in-depth investigation into knowledge, any
obstacles in motivation, and the organization’s role. The survey and focus group questions
49
provided the method to probe into each influence. Table 6 illustrates the KMO, the rationale for
inclusion in the survey and focus group, and how each question aligned with the KMO
principles.
Table 6
KMO, Survey, and Focus Group Alignment
KMO Survey Focus group
Factual (LGBTQ knowledge,
terminology, and facts)
Short answers or multiple choice to
ascertain factual knowledge
Conceptual (principles, theory) Survey questions to interpret, compare
and classify LGBTQ health
concerns
Procedural (techniques, steps) Demonstrate ability/knowledge in
patient care
Describe concerns
Self-efficacy (expectation of
success)
Confidence, comfortable learning
environment
Describe concerns
Affect (emotions, beliefs) Define or categorize their feelings
Organizational (cultural
models and settings)
Access to information, goals,
resources
Describe the impact
Demographic data Descriptive analysis
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Data Analysis
The study provided a better understanding of the state of KMO factors to illuminate
educational gaps. The quantitative portion was designed as a descriptive study and did not test
specific relationships between dependent and independent variables (Christensen & Johnson,
2016; Salkind, 2010). The methods used to analyze descriptive data began when I closed the
survey. The mixed-methods approach of convergent or concurrent conclusions with additional
coverage allowed for a “pragmatic, purpose-driven perspective on combining methods”
(Morgan, 2014, p. 27).
The goal of collecting qualitative data was to identify and describe themes from the
participants’ perspectives. Qualitative data collected from the open-ended survey question and
focus groups followed this purpose-driven perspective to focus on organizational influences
holistically. Focus group data were categorized by themes that emerged during the discussions
and then organized into a format for analysis (Krueger & Casey, 2014). The Zoom focus group
sessions were audio and video-recorded, and the transcript was retained for coding. The data
obtained were coded into categories focused on the students' opinions of the organization and
their recommendations. The structure of the analysis included data comparison and examination
of key concepts.
Validity and Reliability
Seeing an object from multiple perspectives allows a more thorough examination of the
phenomena (Christensen & Johnson, 2016). Creswell and Creswell (2018) also took this view in
developing triangulation for mixed-methods research; if you use different methods and produce
similar observations, convergence increases confidence. In this study, the actual response rate
(i.e., the sample to analyze) was small compared to the overall population. The response rate
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discussion reviews the sampling errors which could arise because the sample differs from the
population (Lavrakas, 2008). In the findings and recommendations, I was mindful of the threats
to validity, including self-selection bias: (a) a student agreed to fill out the survey, or (b) a
student did not want to complete the survey because of the topic/content (Lavrakas, 2008).
Credibility and Trustworthiness
Several strategies were employed to maximize credibility and trustworthiness during the
qualitative data collection and analysis. The participants and their data remained confidential.
The files were maintained in a secure server. The participants knew they were not anonymous as
a recorded Zoom focus group. Determination of the credibility of the data is the ability to show
with transparency the process of data collection and analysis (Merriam & Tisdell, 2016).
Throughout the focus group, I conducted just-in-time member checks by stating “if I heard you
correctly” or “it appears from what I am hearing” or “as I look at my notes, the theme of” with
the use of these statements, ensuring an understanding of the discussion. Two focus groups
occurred, allowing comparison of the participant responses from groups one and two to cross-
reference. For the qualitative data, I tried to achieve, in theory, saturation through the consistency
of questions asked in each focus group.
Ethics in research concerns the relationship between society and science, consisting of
principles to guide research (Christensen & Johnson, 2016; Lavrakas, 2008). The role of any
researcher and their relationship with the participants is an ethical consideration and affects
participants and the trustworthiness or credibility of the data (Merriam & Tisdell, 2016). In
medicine, the familiar statement to first do no harm is ascribed to the oath taken by physicians,
and it is an equally important obligation in research. The University of Southern California
Office for the Protection of Research Subjects approved this study as exempt. The survey and the
52
focus group participants received notification that their participation was their consent. In the
recruitment email, the participants received information that exempt research did not require
informed consent. I stated that a study information sheet was available upon request to all
participants.
The USC Office for the Protection of Research Subjects (OPRS) reviewed each data
collection method in the study. The study complied with institutional and ethical guidelines for
confidentiality, anonymity, protection from harm, and professionalism. This study included a
survey and group interviews, and some ethical considerations applied to both. This study fell
under the category of social-behavioral research. The USC OPRS outlines social and behavioral
research and its application to the study of humans concerning activities, motives, psychological
processes, and interactions. Interviews focus groups, and surveys are standard social-behavioral
research methods involving no physical risk. The information sheet included statements about
potential psychological harm in the information sheet.
In this study, I was the moderator for the focus groups. I have training in group
facilitation and debriefing. The participants understood they might know me from other settings
but that I was a doctoral student conducting research during the focus group. The students were
aware that I had no authority over any educational aspect of the students.
Limitations and Delimitations
Limitations that arose from this study analyzing descriptive statistics are due to the
research methods employed (Merriam & Tisdell, 2016). This study’s limitations include
• Descriptive studies cannot determine cause and effect relationships (Onwuegbuzie &
Leech, 2015). Consequently, the study can report results but cannot correlate or link
the findings to each other.
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• The second limitation is survey fatigue. Univ-Med tries to limit the number of
surveys students receive, but students are nevertheless inundated with requests to
evaluate faculty via a survey. When evaluating methods, the issue of survey fatigue
rises as an important topic (Lavrakas, 2008; Leonard & Robinson, 2018).
• Selection bias is another concern that confounds and limits survey results. The title
and subject matter were evident in the email recruitment. Students interested in the
topic were more likely to fill out the survey or volunteer for the focus group.
• Qualitative research occurs in the natural setting of the participant, and the research
accepted the limitations of this approach (Merriam & Tisdell, 2016).
The literature established this study’s delimitations and intentional decisions.
Delimitations are the boundaries set for the study to make the goals and objectives achievable
(Creswell & Creswell, 2018). The boundaries are exclusion and inclusion criteria, including
research questions, variables, participants, and methodology.
• This problem of practice is specific to one university medical school; therefore, the
participants are from the student population at Univ-Med. As opposed to recruiting
participants from other medical schools.
• The study timeline and availability of medical students limited the number of focus
groups conducted and the number of participants in each group.
To effectively utilize Clark and Estes’s (2008) model to study KMO influences, the theoretical
model for this study provided the guidance and mechanisms to collect the needed data.
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Chapter Four: Results and Findings
The purpose of this study was to assess the impact of the LGBTQ curriculum gap on
medical student education and performance at Univ-Med. The outcomes included: (a) adding to
the knowledge base, (b) understanding the social and organizational influences, and (c)
generation of innovative ideas and recommendations. This chapter will provide the results and
findings organized by the categories of assumed KMO needs. The questions that led the study
were
1. What are the medical students’ knowledge and motivation related to learning LGBTQ
health in their education?
2. What do students want in their education on LGBTQ health that can guide Univ-Med
with curriculum integration of this topic?
3. How do culture, context, and organizational priorities at Univ-Med either support or
hinder the inclusion of an LGBTQ curriculum?
4. What are the recommendations for the organizational practice in knowledge,
motivation, and resources to include the LGBTQ curriculum?
Methodological Approach and Rationale
A mixed-methods approach was utilized, including surveys, document reviews, and focus
groups. The survey focused on the first two research questions to determine knowledge and
motivation influences. The survey contained 18 items that used a Likert scale, which is easily
understood, and the responses are quantifiable through statistical analysis. Additionally,
stakeholders participated in Zoom focus group sessions, and digital document evaluation
occurred. The focus group sessions provided a more thorough understanding of the
55
organizational influences and outcomes. University documents were analyzed to determine what
curricula were in place to hinder or support LGBTQ health education.
Stakeholders
The primary stakeholders for this study were medical students enrolled in Years 1–4 at
Univ-Med during the 2021–2022 term. The university department of curriculum supported the
research and distributed the survey. An additional stakeholder group is the department of medical
education, specifically the medical education curriculum committee.
Survey Participants
The Univ-Med medical education curriculum committee supported the study and emailed
the survey to all students from the student affairs office to 744 medical students. Participants
completed an 18-item anonymous survey online. Of these recipients, half are in their 1st and 2nd
year of medical school and are primarily on campus for classes and clinical medicine
experiences. The other half are in clinical and specialty clerkships and participate in patient care
encounters and workshops in hospitals and clinics. Each class has 186 medical students and
includes those on leave of absence. The total number of respondents was 147, comprised of 29
students in their 1st year of medical school, 86 in the 2nd year, 13 in the 3d year, 12 in the 4th
year, and four on leave of absence.
Respondents were asked to state their gender identity with the question, “What is your
gender identity.” I worded the question to understand better the medical students’ internal sense
of self and gender identification. Fifty-one percent of the respondents identified as female, 42%
as male, 4.3% as other, 2% as non-binary/third gender person, 0.7% as agender, and 0 as a
transgender person. The survey asked respondents for their sexual identification; 99 students
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selected straight, 18 selected bisexual, 11 chose gay, five selected lesbian, four chose asexual,
and nine selected queer.
Two of the survey questions were open-ended. These first open-ended asked for opinions,
ideas, and suggestions on the content they would like included in any LGBTQ health curriculum
and had 44 responses. The second open-ended question asked what skills they are most
interested in learning about to care for LGBTQ patients. It is important to note that while an
equal number of medical students (186) from each class received the survey, the breakdown of
who responded is of note. Year 1 medical students comprised 20% of the respondents. The 2nd
year medical students encompass 60% of the respondents. Students in Years 3–4 and those on
LOA made up 20% of the respondents. The students’ educational and clinical experiences in
medical school are a function of their class; accordingly, the number of respondents from each is
identified. Their length of time in medical school typically determines the extent of their
exposure to any LGBTQ curriculum.
Focus Group Participants
Two focus groups had a total of nine participants. All submitted their names and contact
information for scheduling purposes through a link provided in the survey. All students who
volunteered for the focus group participated. Table 7 notes the participants using a pseudonym,
pronouns, and year in medical school. Each focus group lasted 60 minutes, and all participants
stayed for the entire discussion. All participants displayed their full names during the discussion;
no one asked to use a pseudonym. Students introduced themselves and gave their pronouns, with
six identifying as she/her, two identifying as he/him, and one identifying as they/them.
57
Table 7
Focus Group Participants
Pseudonym Pronouns Year
Abby She/her 4th
Andrea She/her 1st
Chris He/him 2nd
Kathy She/her 2nd
Leon He/him 4th
Nick She/her 1st
Randy They/them 3rd
Susan She/her 1st
Tina She/her 3rd
Results and Finding
The results and findings reported through the lens of KMO influences align with the
theoretical and conceptual frameworks and the literature. The data elucidated if a deficit exists in
each core area. Furthermore, the data clarified the underlying factors creating or influencing the
gap. The study used four data sources: (a) a survey instrument with Likert-scale items, (b) a
survey instrument with two open-ended questions, (c) a focus group, and d) secondary data and
document review. These sources determined the impact of the lack of LGBTQ health in medical
education. Review of the influences determined asset or need for each data type of survey, focus
group, and secondary data. For each KMO influence, findings will be presented specifying the
data types collected.
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Knowledge Results and Findings
The focus of Research Question 1 is the assessment of medical students’ knowledge and
motivation related to learning LGBTQ health in their education. A survey collected the
quantitative data that assessed factual, conceptual, and procedural knowledge. The data
contributed to the knowledge of the study theories, principles, and vital processes to generate
innovative ideas and solve future challenges. It was essential in looking at knowledge influences
to be aware of the factors that make up the social cognitive theory used as the theoretical
framework for this study (Bandura, 1986). Cognitive factors that play a role in learning and
motivation include past experiences and education; therefore, the baseline data collection
occurred for students’ overall experience and knowledge of LGBTQ health. A structural
foundation of LGBTQ health knowledge can impact attitudes, comfort, confidence, skill-
building, clinical proficiency, and the ability to acquire additional competency (Hollenbach et al.,
2014). Thus, assessing medical students’ knowledge of LGBTQ health is the starting point
toward understanding the impact of the related influences.
Factual Knowledge
The acquisition of factual knowledge of LGBTQ health, including terminology and
definitions, population-specific medical needs, and health disparities, were assessed in this study
using data collected in the survey. As noted in the survey, the findings show that respondents
have basic knowledge of specific terminology. Respondents are also aware of the lack of parity
in access to health care for the LGBTQ community compared to the general population. It is
concerned an asset that respondents have this baseline knowledge, as supported by the literature
and noted in the survey discussion below.
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Survey
Physician knowledge of basic terminology of the vocabulary used by the LGBTQ
population to self-identify validates individual expression of sex and gender (Parameshwaran et
al., 2017). Participants answered questions about their knowledge and understanding of less
frequently used terms for the LGBTQ community to establish a baseline awareness of the
population. The survey, therefore, asked about the terms asexual, pansexual, and intersex, with
84% of the respondents stating they somewhat agreed or strongly agreed they understood the
terms. Only 11% of respondents stated they did not understand the terms, and 5% responded that
they neither agreed nor disagreed.
The survey included one question to determine respondents’ knowledge of whether
access to health care is the same for LGBTQ individuals and other populations. Knowledge of
LGBTQ health includes clinical and medical information and awareness of health disparities.
Based on the findings for this question, respondents know that access to healthcare is not the
same for the LGBTQ community. The respondents selected from the Likert scale of strongly
disagree to strongly agree. As noted in Figure 2, the most significant percentage of respondents,
51%, disagreed that access to health care for the LGBTQ population is the same as for others,
and 39% somewhat disagreed with the statement.
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Figure 2
Parity in Access to Healthcare for LGBTQ Patients
The survey results show that respondents know that access to healthcare is not the same
for LGBTQ individuals as other population members; nevertheless, they want more information
and in-depth knowledge of the topic.
Focus Group and Secondary Data
Focus group participants discussed their need and desire to learn how to address and
better understand healthcare disparities. A review of focus group data identified addressing the
health disparities and understanding the nuances for queer patients, and practicing cultural
humility with an understanding of health disparities as themes.
Procedural Knowledge
Procedural patient care competency includes performing a complete sexual history and an
accurate physical exam inclusive of LGBTQ patients. The first step in this skill is asking the
patient to state their gender identity and sexual orientation. These two items help the physician
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage of Students
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structure the history to gather data for the best understanding of the health status and needs of the
patient. The survey, open-ended comments, and focus groups provided data to evaluate this
procedural knowledge influence. The following survey findings show that most respondents
know the questions to ask to gain an understanding of a patient’s gender identity and sexual
orientation. Over half the respondents perform this procedure and query their patients about half
the time or more frequently. These findings are considered a strength in respondent knowledge.
Survey Results
Participants were asked how frequently they inquire about a patient’s sexual orientation
and gender identity. They answered on a Likert scale from always to never. Figure 3 illustrates
the responses to these two questions separately and compared to each other. The figure shows the
frequency respondents ask a patient for gender identity and sexual orientation. These two
questions have a strong positive correlation with a p-value of 0.00001. The students on leave of
absence were excluded as they have no patient contact.
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Figure 3
Frequency of Inquiry of Sexual and Gender Identity
The respondents’ year in medical school and the frequency of inquiry was analyzed.
There is a statistically significant relationship between the year of medical school and the
frequency with which the respondent asked about gender identity. As noted in Table 8,
respondents in Years 1 and 2 of medical school asked about gender identity more frequently than
their peers in years 3 and 4, resulting in a p-value of 0.00185 and a Chi-Square of 31.2.
Likewise, in Table 9, the frequency of inquiry about sexual orientation based on the year
of medical school is illustrated. These frequencies are also statistically significant, with a p-value
of 0.0000373 and a chi-square of 23.6.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Never Sometimes About half the
time
Most of the
time
Always
Percent
How frequently do you enquire about a patient's sexual identity?
How frequently do you enquire about a patient's gender identity?
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Table 8
Medical School Year and Frequency of Inquiry About Gender Identity
Year of medical
school Never Sometimes
About half
the time
Most of the
time Always
1st 10% 9% 33% 26% 35%
2nd 40% 59% 61% 71% 61%
3rd 20% 19% 0% 0% 4%
4th 30% 13% 6% 3% 0%
Table 9
Medical School Year and Frequency of Inquiry About Sexual Orientation
Year of
medical
school Never Sometimes
About half
the time
Most of the
time Always
1st 15% 15% 19% 29% 36%
2nd 62% 53% 73% 69% 55%
3rd 0% 18% 4% 3% 9%
4th 23% 15% 4% 0% 0%
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Open-Ended Survey Questions
The survey included two open-ended questions to enable the respondents to provide
contextual insights that underscore the quantitative data. This question was framed to get
additional information on procedural knowledge. Eighty respondents answered the open-ended
question, what skills are you most interested in learning about with LGBTQ patients? The word
skill was explicitly used in the question to prompt the response. The responses were sorted,
categorized, and coded to look for patterns in the skills in which they expressed a deficit. Table
10 lists the themes and the frequency count for each item. The table lists each theme under
knowledge and the number of respondents who wrote that item/topic in their response. The skills
most frequently mentioned were taking a sexual history, asking questions respectfully and
sensitively, and treating medical concerns specific to gender or sexual orientation. Respondents
stated they would like a curriculum on supportive and inclusive language, appropriate
terminology, and vernacular. Several respondents requested more experiential and hands-on
practice in the simulation environment and the patient care settings.
Table 10
Open-Ended Knowledge Themes
Themes Frequency of mention
Taking a sexual history 47
Treating medical concerns specific to gender or sexual orientation 26
How to ask questions in a respectful and sensitive manner 15
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Focus Group
The participants were asked what procedures and skills regarding LGBTQ health they felt
were absent at Univ-Med. All nine participants mentioned the lack of education on how to take a
sexual history from an LGBTQ patient and the need to enhance general sexual history-taking
skills. Participant Kathy expressed it this way, “I think it would be good for everyone to practice
those sorts of things like getting a sexual history. It would be nice to have a session that’s really
dedicated to getting that history in an inclusive way.” Abby, a 4th-year student, commented, “We
need to learn how to take an inclusive sexual history, but it is also important in the clinical aspect
to have education on what to look out for that is specific to LGBTQ patients.”
Secondary Data Curriculum and Syllabus Review
The ICM syllabus for the past 5 years was reviewed. The syllabus showed that the
students did not receive any instruction on taking a sexual history from an LGBTQ patient or
how to ask culturally appropriate questions. The 1st-year medical students participated in a
simulated patient encounter that included interviewing an LGBTQ patient. The sessions were
conducted in small groups; therefore, only about one-fourth of the class interviewed the
simulated patient, and the others observed. These two skills of taking an LGBTQ sexual history
and sensitive communication are curricula absent in courses where they generally learn history-
taking; this is considered a need in student education.
Conceptual Knowledge
In medical education, students need to draw on what they have learned to understand the
principles and relationships within a domain. The conceptual knowledge in LGBTQ health
includes understanding identity salience and the importance of disclosing sexual and gender
identity. As noted in the discussion of population health in Chapter Two, identity salience is
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prominent and essential to oneself. The knowledge influence explored in conceptual knowledge
is understanding the interrelationships of patterns, classifications, and elements of LGBTQ
identity and how they function together as part of the patient's health. Most respondents, 46%,
have conceptual knowledge of the importance and value of knowing the sexual orientation of
their patient and how this positively contributes to their care.
Survey
A survey question asked respondents if LGBTQ patients should disclose their sexual
orientation to their physicians to evaluate the participants’ conceptual knowledge of the
importance of disclosure and identity salience. Forty-eight percent of respondents chose
somewhat agree or strongly agree, 38% were neutral, and 14% selected somewhat disagree or
strongly disagree. These percentages illustrate that many respondents understand the conceptual
importance of discussing sexual orientation with patients.
Open-Ended, Focus Group, and Secondary Data Findings
No data were collected using these methods on this topic.
Knowledge Summary and Determination of Asset or Need
The overall knowledge recommendations in Chapter Five are based on the information
and findings from the survey, open-ended questions, focus group data, and secondary data
analysis. The factors considered were the current state of respondent knowledge and the depth of
that knowledge related to basic LGBTQ health information competence. Clark and Estes’s
(2008) framework substantiated the classification of the findings as a need or asset. The specific
classification of asset or need was based on the guidelines and recommendations from the
American Medical Association (2019), the U.S. Department of Health and Human Services
(2016), and the Association of American Medical Colleges (2014). These organizations list
67
recommendations and guidelines for the inclusion of LGBTQ health curricula in medical
education. The knowledge influences in Table 11 and the findings were compared to the
recommendations and guidelines from the three national organizations listed above. Based on the
data analysis, it was noted if respondents have this knowledge and if it meets the national
recommendations. The knowledge gaps outlined in the data analysis are considered a need in the
curriculum and will be addressed in Chapter Five.
Table 11
Knowledge Asset or Need
Knowledge type Asset or Need
Factual
LGBTQ terminology on the understanding of
different vernacular
Asset
Access to health care parity for LGBTQ
patients
Asset
Understanding and addressing health care
disparities
Need
Procedural
Inquiry of sexual orientation Asset
Inquiry of gender identity Asset
Ability to take a sexual history, determined by
open-ended questions, focus group
discussion, and secondary data review
Need
Conceptual
Importance of disclosure of sexual orientation Asset
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Motivation Results and Findings
The motivation findings will address Research Question 1 to determine the medical
students’ motivation to learn about LGBTQ health. The gap analysis framework draws upon
Bandura’s social cognitive theory (1991) concepts to aid in studying motivation. The
convergence of student knowledge and motivation offers the optimal approach to identifying
intended and actual outcomes (Clark & Estes, 2008).
Self-Efficacy
Competency development relies on self-efficacy formed during social learning with
cognitive, environmental, and behavioral elements (Bandura, 1986). Their self-efficacy develops
through many distinct aspects of the environment. For this study, the multiple facets of LGBTQ
health and the role of self-efficacy were investigated.
Participants answered a survey question to evaluate their confidence level in taking a
sexual history from an LGBTQ patient. They answered on a Likert scale ranging from 1 (not at
all confident) to 5 (completely confident). Regarding confidence in self-efficacy, 17% reported
completely confident, 38% fairly confident, 19% somewhat confident, 18% slightly confident,
and 8% not at all confident.
Comfort
A potential effect of low self-efficacy is discomfort with the needed task or goal. Lower
comfort levels can impede performance on academic tasks (Ambrose et al., 2010). To gain
additional insight, respondents answered whether, overall, they feel comfortable addressing
LGBTQ patients’ health care needs. Ten percent responded completely comfortable, 23% fairly
comfortable, 29% somewhat comfortable, 26% slightly comfortable, and 12% not at all
comfortable.
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Self-Efficacy and Task Difficulty
As noted in the procedural and conceptual knowledge findings, students understand the
goal attainment of discussing sexual behavior with all patients. Their willingness and ability to
engage in these discussions necessitates managing their actions and emotions. Causal factors of
effort, ability, task difficulty, and change provide enactive efficacy information (Bandura, 1982).
Perceptions of task difficulty and positive or negative biases also affect self-efficacy judgments.
A survey question asked participants if they felt it was more challenging to discuss sexual
behavior with LGBTQ patients than with straight patients. Most respondents did not feel it was
more challenging, with 40% selecting strongly disagree, 24% somewhat disagree, 13% neither
agree nor disagree, 22% somewhat agree, and 1% strongly agree. When asked if they believed it
was more challenging to conduct a physical exam on an LGBTQ patient than a straight patient,
56% selected strongly disagree, 24% somewhat disagree, 13% neither agree nor disagree, 7%
somewhat agree, and less than 1% agree. Overall, the results show that participants can respond
to the demands of this experience and monitor and manage their thoughts and behaviors. These
methods collected no data on confidence, comfort, or self-regulation.
Observation and Vicarious Experience
The medical field has a strong tradition of observation, role modeling, precepting, and
oversight of junior doctors by more senior individuals. Professional identification, values,
interactions with patients, and procedural skills are all learned through observation. Observation
and role models will be addressed in two KMO areas starting with elements of self-efficacy and
motivation. Role models will be addressed again in organizational influences as cultural settings
include observable rituals and behaviors.
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Survey
One survey question asked participants about their observation of the faculty to
understand the role of observation and vicarious experiences in student self-efficacy
development. Participants were asked if, overall, they see faculty and preceptors set a positive
example by displaying cultural humility with patients. Figure 4 illustrates students’ responses on
a Likert scale of strongly disagree to strongly agree, with most students answering strongly
agree or somewhat agree. Respondents’ opinions were set independent of their year in medical
school.
Figure 4
Observation of Faculty Setting a Positive Example
5.59%
12.59%
11.19%
48.95%
21.68%
Percent
Strongly disgree Somewhat disagree Neither agree or disagree
Somewhat agree Strongly agree
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Open-Ended Questions
Respondents in the open-ended questions provided additional information toward
understanding some of the reasons 30% of the participants did not agree that the faculty provided
a positive example. Fifteen participants stated the need to teach the faculty about LGBTQ health.
One student stated, “There have been many times there has been recognition of LGBTQ patients;
however, there is still this pervasive view of gender binary in medicine.”
Motivation Summary and Determination of Asset or Need
Social cognitive theory, self-efficacy, and vicarious experience were analyzed through
survey data to determine medical students’ motivation to learn LGBTQ health in their
curriculum. The specific classification of asset or need was based on the guidelines and
recommendations from the American Medical Association (2019), the U.S. Department of
Health and Human Services (2016), and the Association of American Medical Colleges (2014).
These organizations list recommendations and guidelines for the inclusion of LGBTQ health
curricula in medical education. The motivation influences in Table 12 and the findings were
compared to the recommendations and guidelines from the three national organizations listed
above. Based on the data analysis, it was noted if respondents have this motivation and if it
meets the national recommendations. The gaps highlighted in the data analysis are considered a
need in the curriculum and will be addressed in Chapter Five.
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Table 12
Motivation Asset or Need
Comfort
Overall comfort addressing the healthcare needs of LGBTQ
patients
Need
Self-efficacy
Challenge they may face discussing sexual behavior with
LGBTQ patients
Asset
Challenge they may face conducting a physical exam with
LGBTQ patients
Asset
Observation and vicarious experience
Respondents observe faculty through vicarious experience
displaying cultural humility with patients
Asset
Self-efficacy
Confidence in taking a sexual history from an LGBTQ
patient
Need
Students Desire More Knowledge of Health Care for Transgender Persons
The significance of the finding on transgender health necessitated a separate discussion on
the categories of knowledge and motivation. The subject most frequently mentioned in the open-
ended comments and the focus group was transgender patients. In the open-ended questions,
there were 18 comments on the care of transgender patients. During the focus group sessions,
discussion of transgender patients occurred 15 times. The respondents’ emphasis on this topic
highlights their recognition of its importance and the need for education on transgender patient
care. A focus group member, Randy, stated a common theme of the groups:
I think there is still a lot of stigma around the LGBTQ community. Because of that, kind
of like in the health care setting, we all hear medical people inappropriately commenting
on how well this Transwoman was passing. I don’t think that, as providers and as doctors,
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we want to be left behind in the dust. We need to make sure that we’re keeping up right
now, and medical school is where we learn this content. We need to know important
things like caring for trans patients. Everyone should be able to know how to manage a
patient.
In a comprehensive curriculum on LGBTQ health, participants want transgender health placed
high on the priority list.
Organizational Influence Findings
Organizational effectiveness aligns with four key traits linked to deeply held aspects of
an organization’s identity. The four key traits include mission, adaptability, involvement, and
consistency (Denison, 1996). Understanding an organization’s influence necessitates awareness
of the cultural context of the behavior.
Cultural Model
The cultural models at Univ-Med impact the student population in the values, patterns of
behavior, and mental structures that influence their education and lives. The lack of an LGBTQ
health curriculum at Univ-Med is a cultural model. It determines priorities and decision-making
and influences how the students and faculty think about this topic. Findings from the open-ended
survey comments and the focus group reinforce the concept that cultural models are durable.
Although Univ-Med is implementing a new phased-in curriculum rooted in social and health
justice, most respondents have not had any content of the new curricula. The only respondents
exposed to the new content are in their 1st year of medical school and makeup 30% of
respondents. Therefore, this university educational change is not viewed as an organizational
influence.
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Survey
Participants were asked in Survey Question 8 (Q8) if they would like additional
formalized education in LGBTQ health in the curriculum. This question gave respondents a
voice on the value of this curriculum in their education. Figure 5 illustrates respondents’
selection, with 76% answering yes, 16% maybe, and 8% responding no.
Figure 5
Request Additional Formalized Education in LGBTQ Health
76%
16%
8%
Additional LGBTQ education
yes maybe no
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Survey Questions 8 and 9 provided respondents an opportunity to contribute their
thoughts and opinions on the topic. In Q9, participants were asked (if they said yes or maybe to
Q8) to state where they would like to see the content added to the curriculum. Figure 6 illustrates
the respondents’ selections for placement in the curriculum. Over 50% of respondents want
curricula embedded throughout all 4 years of medical school. Respondents see the importance of
learning this early in their education, with over 25% selecting during Year 1.
Figure 6
Placement of Additional LGBTQ Health Curriculum
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%
%
All 4 years of medical school Post Clerkship (Elective)
Clerkship Years Year II
Year I
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Open-ended questions provided the forum for the respondents to evaluate the research
question regarding what students want in the curriculum that can guide Univ-Med in integrating
LGBTQ health. Specifically, the respondents contributed their ideas and suggestions for the
content they would like included in their education. The topics raised in the open-ended
comments and again in the focus group reinforce the understanding students share resulting from
persistent exposure to everyday experiences over time.
The data from the open-ended comments, validated by the focus group, was a burden on
the student LGBTQ groups and queer faculty to present this information to the greater
community. Comments include, “Teaching how to take a comprehensive queer history should be
a mandatory requirement; it should not be the duty of MedLamba to do this.” Respondents were
appreciative of the efforts of the student groups but, as expressed by one respondent, realized it
was the responsibility of the university to provide this content; Nick stated,
I am thankful that some student groups put on a sexual medicine awareness series; they
were all super interesting. I wish it were emphasized more in the curriculum how we as
future physicians can support all of our patients, especially those who hold marginalized
identities.
This cultural model at Univ-Med is a pattern of explicit and implicit behavior that has relied on
the affected group to train others, specifically the student LGBTQ groups.
Secondary Data Curriculum and Syllabus Review
The syllabi were reviewed to determine the content and number of hours of any LGBTQ
health education in medical school. The courses that contribute to medical students’ factual,
conceptual, and procedural knowledge were viewed to determine the number of hours of
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LGBTQ health in the courses. The syllabus review provided additional data on knowledge
acquisition.
Course: Introduction to Clinical Medicine. Introduction to Clinical Medicine (ICM) is
an 18-month course in which Years 1–2 medical students learn history taking, physical exam
skills, and communication skills. They shadow a physician faculty member in the hospital and
have the opportunity to interact with patients. This course draws upon lectures and didactic
content in anatomy and physiology to help beginning medical students tie theory into practice. A
review of the syllabus and course materials for 5 years found one LGBTQ health learning
experience in the course. The syllabus listed one experiential session where students interviewed
a simulated patient. Document review reinforced and validated the survey of the number of
formalized hours in the curriculum. Prior to 2021–2022, the simulated patient session of a
practice interview with a gay teenager occurred. This session only occurred once as it did not
meet the Univ-Med medical education guidelines on using bias-free clinical cases.
As noted in the ICM syllabus in the current academic cycle, students had the opportunity
to practice an interview with two simulated patients who portrayed members of the LGBTQ
population. The students, in small groups, practiced general communication skills and took a
sexual history. However, students received no preparation besides their textbook reading of how
to take a general sexual history, nothing specific to the LGBTQ population.
Course: Professional Practice of Medicine. A course called Professional Practice of
Medicine for 2nd-year medical students provides the opportunity to learn about professionalism,
social topics in medicine, and the breadth of physician practices. A review of syllabi for 5 years
showed one workshop conducted for 3 hours in which students presented on LGBTQ health and
had the opportunity to hear from LGBTQ patients. The material presented was researched by
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students and not validated by faculty. Consequently, the soundness and reliability of the
presentations were not determined.
Clinical and Specialty Clerkships. A syllabus review of clerkship courses for medical
students found no formalized curriculum on LGBTQ health in any specialty topic.
Secondary Data Review
The reliance on student groups to educate others was validated in secondary data by
reviewing events sponsored by the student group, MedLambda, and the campus community
group Pride-K. One or both groups conducted all campus activities on any topic related to
LGBTQ issues. A review spanning 3 years of university events showed that any presentations on
LGBTQ matters, including healthcare, were given by student organizations or campus
community groups. As mentioned in the general knowledge findings, Univ-Med formal
curriculum was limited to a workshop in Year 2 of medical school.
Focus Group
During both focus group sessions, all nine participants expressed the concern that it was
always student LGBTQ groups or unofficial organizations such as Pride-K that conducted
lectures and workshops on LGBTQ health. The following quote from Leon, a 4th-year student,
summarizes comments made by all nine focus group participants:
I just really wanted to emphasize how I think it’s kind of inappropriate that currently, the
burden of education on queer topics really is falling on queer medical students. In the
preclinical in MedLambda, we hosted a lot of these workshops. And to be honest, I’m
somewhat disappointed to hear that’s still the primary way people are getting their
education on these topics because it’s definitely feedback that we, as MedLambda, gave
to the administration. You know we are happy to do this. We’re obviously really
79
passionate about these topics, but it really shouldn’t be our job, and the emotional and
academic labor of explaining these topics to our classmates should not fall on us; I just
wanted to emphasize that point.
The findings from the open-ended comments and focus groups reinforce the durability of cultural
models.
Cultural Setting
Cultural setting is the “who, what, when, why, and how of the routines which constitute
everyday life- in essence, a more concrete version of what we commonly call a social context”
(Rueda, 2011, p. 57). It is the visible manifestation of the cultural model. Students at Univ-Med
connect to the social system within the institution’s cultural setting. The tangible nature of the
cultural setting makes it easier for students to identify flaws or discrepancies between message
and method.
Curriculum
Survey
The data collection on general knowledge acquisition asked the survey participants the
number of hours of formalized LGBTQ health education they received in medical school up to
when they completed the survey. Table 13 provides an overview of all respondents. The largest
percentage of students, 64%, had 1 to 4 hours of formalized instruction. To provide additional
detail and a breakdown of the data, Figure 7 shows the number of hours related to the
respondents’ year in medical school. As the respondents progressed through medical school, the
proportion of hours did not necessarily increase.
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Table 13
Number of Hours of LGBTQ Health Education
Hours %
0 hrs 20
1–4 hrs 64
5–8 hrs 13
More than 8 hrs 3
Figure 7
Number of Hours of LGBTQ Education Related to Year in Medical School
0
10
20
30
40
50
60
70
1st 2nd 3rd 4th Leave of absence
Number of Repondents
Year in Medical School
0 hrs. 1-4 hrs. 5-8 hrs. More than 8 hrs.
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Open-Ended Question and Focus Group Findings
No data were collected using these methods on this topic.
Role Models in an Organization
Survey
Because role models play an essential part in determining how students develop
professionally, demonstrating skills in the clinical (cultural) setting is the most distinctive
characteristic of an effective role model. Role modeling and institutional culture occur in clinical
teaching environments observed by students who seek to learn from faculty and preceptors
(Benbassat, 2014). As noted in the survey data, students stated that the faculty generally set a
positive example. Students’ observations impact their opinions of faculty behavior and
competency on LGBTQ health.
A review of the open-ended questions about LGBTQ health content revealed the extent to
which respondents felt the importance of making the coursework a requirement. Twenty of the
open-ended comments included a statement of the necessity of making it a requirement. One
respondent stated, “It should be as intellectually serious as any other lecture. When it’s presented
as some side thing, it sends the unconscious message that LGBT health is not serious.” Another
participant stated, “I think it is important to learn. It should be taught and required at all levels of
medical education.”
Focus Group
Cultural Setting Theme: Faculty Development. The focus group data were reviewed
iteratively to identify key and sub-themes. The findings include a discussion of culture, context,
and organizational priorities that support or hinder the inclusion of an LGBTQ health curriculum.
Speaking with the participants uncovered and created new knowledge of cultural settings (Fetters
82
et al., 2013). The focus groups discussed the topic of role modeling as an organizational
influence. Although the discussion centered around administration, Susan commented,
Administration can provide that training for the lecturers and faculty themselves to get
caught up to be able to make sure they’re teaching these topics to the best of their
knowledge they can. The responsibility is still for the people who are the most trained to
give lectures but to do so, they need additional education. Whatever they need to be
comfortable teaching these issues in a culturally competent way.
Participants Andrea and Leon agreed with Susan and echoed her sentiment. This discussion
highlighted the finding that Administration plays a significant role in the ability of faculty to set
a positive example.
Participants believe faculty development is needed to teach accurate and culturally
competent LGBTQ health. The group cited the importance of ensuring instructors have up-to-
date knowledge and the ability to teach with cultural humility. Respondents commented on the
need for an LGBTQ health curriculum, yet they raised concerns about preparing the faculty who
would teach. While they feel the faculty set a positive example, they are aware of the need for
faculty training on this topic. The respondents commented on the role of the University in
educating faculty. One respondent commented, “To me, it seems like the dominant narrative of
LGBTQ health in what we have learned is about STI prevention. I would like to know more
about LGBTQ health that isn’t always the statistics of HIV infection.” An additional comment
noted, “We have instructors who straight up say that we won’t be seeing many gay patients as if
they know or believe that to be true.”
Cultural Setting Theme: Required Education. The value placed on content learned in
medical school can be viewed as both a cultural model and a cultural setting. Because it is the
83
practice of testing and grades, the focus group’s topic is framed as a cultural setting. The
message from the open-ended comments echoed in the focus groups was the need to make
LGBTQ health content a requirement and attach testing to it to reinforce it as a priority. All nine
focus group members reinforced the sentiment expressed by Nick: “If we have it everywhere in
the curriculum and it’s mandatory, then I think people would take it more seriously.” Tina
continued, “if the university makes it a requirement, it tells the students it’s important to pass.
Students need to take it seriously unless we get tested, it’s a low priority, but it deserves to be a
high priority.”
Summary of Organizational Influences Findings
Table 14 displays the organizational findings as a need or asset. The same procedure was
used for organizational influences as was used for knowledge and motivation to identify gaps
and determine asset or need in the curriculum.
Table 14
Organizational Influences Asset or Need
Cultural model Asset or need
University to provide more LGBTQ health education to relieve the
onus on student organizations
Need
Inclusion of LGBTQ health in all 4 years Need
Cultural setting
Faculty set a positive example by displaying cultural humility and
competency with patients.
Asset
Faculty development to ensure their competency with LGBTQ health Need
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Summary
This chapter presents the results and findings of the quantitative survey, open-ended
comments, qualitative focus group, and secondary data review. The conclusions offer a
perspective on the gap analysis in each influence area of KMO. The results in the knowledge
section revealed needs in the following areas: (a) understanding and addressing health care
disparities, (b) gender and sexual orientation data collection during history taking, (c) taking an
LGBTQ sexual history, and (d) transgender patients and health. These skills are competencies
recommended by the AAMC in medical education to care for LGBTQ patients effectively.
The motivation findings show that respondents have positive self-efficacy and self-
regulation. Respondents need to develop and enhance comfort and confidence in addressing the
healthcare needs of LGBTQ patients. Transgender patient health is an area respondents want
additional education and curriculum. They seek to develop confidence and competence in caring
for these patients and observe faculty interaction with transgender patients. These needs
identified are higher-level skills but were emphasized by respondents in all years of medical
school.
Respondents stated that an LGBTQ education is essential to their future competency as
physicians and believe it is the responsibility of Univ-Med to provide this curriculum in a
formalized and rigorous manner. While faculty set a positive example, the need was established
in faculty development to ensure their competency with LGBTQ patients. The most significant
need noted was for organizational influences. Chapter Five will provide recommendations to
address identified influences affecting respondents.
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Chapter Five: Recommendations
The purpose of this project was to determine if and why a gap exists in learner knowledge
and motivation related to the absence of an LGBTQ curriculum and to examine the
organization’s role and the impact on student knowledge and motivation on this topic. A gap
analysis that examined the KMO impacts systematically categorized a list of assumed influences
as a need or asset. While a complete needs assessment would focus on all stakeholders, for
practical purposes, the stakeholder of focus in this analysis is medical students. This chapter will
discuss stakeholder experiences, challenges, and the subsequent recommendations. The research
questions that guided the study were
1. What are the medical students’ knowledge and motivation related to learning LGBTQ
health in their education?
2. What do students want in their education on LGBTQ health that can guide Univ-Med
with curriculum integration of this topic?
3. How do culture, context, and organizational priorities at Univ-Med either support or
hinder the inclusion of an LGBTQ curriculum?
4. What are the recommendations for Univ-Med in the areas of knowledge, motivation,
and organizational resources?
This chapter will address Research Question 4, what are the recommendations to address
the KMO influences. An integrated implementation and evaluation plan is summarized based on
the recommendations.
Recommendations for Practice to Address KMO Influences
Clark and Estes’s (2008) gap analysis model provided the structure for the study and,
accordingly, the recommendation structure. Throughout this chapter, the AAMC resource book
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on curricular and climate changes Implementing Curricular and Institutional Climate Changes to
Improve Health Care for Individuals who are LGBT, Gender Nonconforming, or Born with DSD
(Hollenbach et al., 2014) will be used to highlight national competencies and their alignment
with the recommendations. When looking at shortfalls in the curriculum in a university
environment, it is essential to view it in the context of the stakeholder and how the deficit
impacts their education. The research finding for each KMO and supporting principles from the
literature support the recommended course of action.
Knowledge Recommendations
The proposed solutions center on the models and theories of competency-based medical
education (CBME; Kaufman & Mann, 2010). The focus of CBME is on teaching the skills
needed by looking at outcomes and performance based on patient and societal needs, as opposed
to imparting a compendium of knowledge and hoping students learn its application. Students
demonstrate competency in knowledge, patient care, and communication through various classes
and experiences. The recommendations in the knowledge category are based on the data analysis
and empirical findings in Chapter Four and the association with the research questions. Table 15
lists the data findings, content-specific recommendations, the need validated through the study
findings, relevant models and theories, and evaluation type.
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Table 15
Knowledge Recommendations
Data findings
Educational
model or theory
and citation
LGBTQ
health and
citation
Content-specific
recommendation Evaluation
Respondents
report a lack
of knowledge
on how to take
a sexual
history of an
LGBTQ
patient,
including
asking about
sexual
orientation
and gender
identity.
Knowledge is
created from
perceptions of
tangible things
and used as a
basis for
decision-
making
processes
(Krathwohl,
2002).
At the most
basic level,
knowing the
components
of the
sexual
history of
LGBTQ
patients is
essential for
medical
students to
succeed in
the clinical
environment
(Nama et
al., 2017).
Integrate
LGBTQ
sexual
history-taking
curriculum,
course work,
and simulated
patient
experiences to
ICM with a
refresher in
each specialty
clerkship.
Formative:
Review, data
collection,
and analysis
from student
surveys,
course syllabi,
and faculty
integration
surveys.
Summative:
Percent of
curriculum
integrated by
review of the
syllabus and
other
materials
Respondents
report a lack
of knowledge,
understanding,
and insight
into
addressing
healthcare
disparities in
the LGBTQ
population.
Thematic
relations aid
memory and
affect
categorization,
including the
structure,
acquisition,
and recall
(Kaufman &
Mann, 2010).
Enhancing
medical
student
knowledge
of this
population's
barriers can
lead to
physicians
who can
alleviate the
problem by
providing
equitable
care for
their
patients
(Rhodes et
al., 2018).
Univ-Med
curriculum
team on
health justice
and systems
of the care
team to
integrate
content to
provide
additional
learnings on
addressing
health
disparities in
LGBTQ
patients
beyond the
current
offering.
Summative:
LGBTQ
health is
acknowledged
and validated
as part of the
new health
justice and
systems of
care
curriculum.
Analysis of
curriculum
documents
and LCME
reports.
88
Recommendation 1 Factual and Procedural: Integrate Sexual History-Taking
The first recommendation is to integrate LGBTQ-specific coursework and simulated
patient experiences into Year 1 with additional enhancement in each specialty clerkship in Years
3 and 4. The survey data, comments, and focus group findings demonstrate that respondents state
the need for this curriculum to be integrated throughout medical school. Demonstrating
competency in sexual history from a patient requires the initial knowledge of the components of
this task, including what questions to ask that will elicit the information needed to care for the
patient effectively. However, more than just what to ask, it requires how to ask and the
demonstration of this competency through patient care experiences. It is only through the
practice of this skill students can effectively memorize each element and garner the finesse of
asking sensitive questions. Adult learning principles of (a) relevance of knowledge acquisition
for current and future experiences, (b) experiential opportunities, and (c) orientation to learning
are built into this recommendation (Kaufman & Mann, 2014).
Integration in beginning education provides the foundational elements through didactic,
case discussion, and experiential simulated opportunities. Supervised patient care experiences in
the clerkship enable students to directly relate the sexual history-taking to the specific patient
care setting, such as OBGYN or surgery. The AAMC (Hollenbach et al., 2014) competency
domains on knowledge of LGBTQ health included in the recommendations have a basis in the
following principles:
• application of established and emerging biophysical scientific principles fundamental
to LGBTQ patients
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• gather essential and accurate information through history, taking eliciting information
sexual behavior, sexual history, and sexual and gender identity from patients in a
developmentally appropriate manner
• demonstrate compassion and understanding to a diverse patient population
The demonstrated breadth of LGBTQ health concerns illustrates the importance of wide-
spectrum curriculum offerings beyond merely asking a patient if they have sex with men,
women, or both (Gonzales et al., 2016). Guided practice allows students to develop goals for
their learning.
Recommendation 2 Factual and Conceptual: Univ-Med to Integrate Didactic Content and
Patient-Student Sessions
Univ-Med must provide additional learnings on addressing health disparities in LGBTQ
patients beyond current health justice and systems of care offerings. Univ-Med began
implementation of the new curriculum in August 2021. Students in the class of 2025 have had
one semester of lectures and workshops covering topics on health justice and systems of care;
one lecture was on the LGBTQ population. A common theme in the focus groups was the need
to improve the content presentation by moving away from the standard lecture format. Focus
group participants reflected on a session many had in their 2nd year when they had the
opportunity to hear from LGBTQ community members/patients. When asked for suggestions if
they had the power to design their education, they requested more time with LGBTQ community
members to learn from their experiences.
Recommendation 2 is multifaceted to include workshops where groups of students hear
from LGBTQ patients about their experience navigating the challenges they face receiving care,
followed by group discussions on healthcare system changes. Participants’ knowledge of the
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disparity in access to healthcare for the LGBTQ population is an asset. They thoroughly
understand the existence of barriers and less than optimal medical outcomes for these patients.
The open-ended comments and focus group findings indicate the need for the respondents to
learn about the diversity of LGBTQ experience with healthcare and how they can address
disparities in the medical and political environments. Empowering future physicians to identify
and change barriers contributing to health inequities can result in a desirable transformation in
care (Obedin-Maliver et al., 2011).
Students along the continuum in medical education use experiential learning approaches
such as practicums, clerkships, research opportunities, and case discussions. In these
environments, the student views theories and relationships from different perspectives and can
conceptualize retained knowledge (Kaufman & Mann, 2010). This content will empower
students to explore the changes needed in healthcare to overcome these barriers.
Motivation Recommendations
The lack of self-efficacy in the respondents to address the healthcare needs of the
LGBTQ population was validated through the survey, comments, and focus group findings. Self-
efficacy theory posits that essential sources of efficacy information, such as actual behavior
performance, will improve students’ confidence to perform specific behaviors (Bandura, 1986).
A student’s individual’s confidence level in their ability fundamentally affects their decisions on
whether to perform behaviors. Motivation and goal orientation are essential factors in learning.
Feedback is essential to enhancing self-efficacy and should include how skills improve through
practice and understanding that mistakes are part of acquiring skills. Table 16 provides the
outline of the recommendations to enhance self-efficacy in students.
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Table 16
Motivation Recommendations
Data findings
Educational
model or theory
and citation
Subject-matter
citation
Content-specific
recommendation
Evaluation
Respondents
report a lack
of comfort
and
confidence in
addressing
the
healthcare
needs of
LGBTQ
patients.
Settings where
learners are
more apt to
use critical
thinking,
creative
problem
solving, and
intrinsic
motivation to
transfer
learning from
one topic to
another
(Clark, 2005)
Coursework,
patient care
experiences,
and the
socio-cultural
context for
specific
health care
needs
increase self-
efficacy in
medical
students
(Hollenbach
et al., 2014).
Faculty and
leadership
create
opportunities
to acquire
mastery
through
experiential
cooperative
learning.
Formative: Self
and peer
assessment
opportunities
in small
group
discussion
and patient
care
experiences
Recommendation 1 Motivation: Faculty and Leadership to Create Opportunities to Acquire
Mastery in LGBTQ Health
Through experiential and cooperative learning in specialty clerkships, students will have
the opportunity to gain mastery skills. The survey questions, open-ended comments, and focus
group discussion looked at several aspects of motivation. Respondents answered survey
questions on their confidence in taking a sexual history from an LGBTQ patient. They were also
asked a much broader question about their comfort in addressing the overall healthcare needs of
LGBTQ patients. While 55% of respondents stated they felt completely confident or fairly
confident addressing these needs, it was the most frequently stated skill they wished to learn.
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Respondents were much less comfortable when asked about comfort in caring for the overall
health needs of LGBTQ patients, which appeared in both the survey and open-ended comments.
As previously noted in Chapter Two, medical students’ low rates of self-confidence in
caring for LGBTQ patients have been reported in numerous studies (Dallaghan et al., 2018). The
supporting evidence for the respondents’ lack of confidence in taking a sexual history from an
LGBTQ patient is seen in the secondary data review noting the lack of this specific teaching in
all curricula. The supporting evidence for the lack of comfort is more diffuse but seen in the high
percentage of respondents who commented in the open-ended item about wanting to learn how to
treat medical concerns specific to gender or sexual orientation and address healthcare disparities.
Clark and Estes (2008) discuss the value of motivation to keep people interested in a goal and
their effort to accomplish it. The authors contend that motivation is one of the essential
facilitators of performance goals. By implementing innovative learning experiences, students can
increase their comfort and confidence as interest rises.
Experiential and cooperative learning provides a setting where learners are more apt to
use critical thinking, creative problem solving, and intrinsic motivation to transfer learning from
one topic to another (Clark, 2005). Students learn about healthcare teams and experience their
role on a team firsthand during the specialty clerkships. Each clerkship offers the opportunity for
students to take foundational knowledge learned about sexual history taking or addressing
healthcare disparities and see the application in that environment. In the hospital environment,
students will observe and function as team members under the guidance of a preceptor and will
engage with nurses, pharmacists, and other health care professionals, acquiring cooperative
learning skills.
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Organizational Recommendations
The organizational recommendations are based on the theory that as members of a
culture, people share implicit mental models of how the world works to filter information,
determine priorities, and guide our decision-making (Gonzalo et al., 2017). An organization can
foster a collaborative culture if education and assessment are in an environment that includes
personal orientation, relationships, and contextual norms. In organizations, factors influence each
other bi-directionally, such as setting, cognitive, and relationship factors. Consequently,
organizations with leadership and practices which promote flexibility, creativity, clear direction,
and are customer focused will be the ones that can sustain change. Table 17 indicates the
organizational recommendations based on these theories and arguments.
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Table 17
Organizational Recommendations
Data Findings Educational
model or theory
and citation
Subject-matter
citation
Content-specific
recommendation
Evaluation
Respondents
want
additional
didactic and
patient care
experiences
in LGBTQ
health
integrated
throughout
their
curriculum.
The organization
drives the
curriculum,
leadership,
and faculty
decisions that
directly
impact what,
when, and
how a medical
student will
become
educated
(Geraghty et
al., 2020)
Integrating an
LGBTQ
curriculum
has produced
a change
associated
with a
culture clear
of bias,
welcoming,
and open to
the latest
ideas, such
as the
curriculum
renewal
(GLMA,
2013).
Utilize the theory of
HCD and include
medical students
in contributing
ideas to integrate
LGBTQ health
into the
curriculum.
Review agendas
and committee
minutes.
Student
participation
and attendance
at meetings
and in
debriefing
sessions.
Preceptors and
faculty do
not have
adequate
knowledge
of LGBTQ
health to
teach
cultural
competency
with patients.
Traditional
educational
strategies may
effectively
convey ideas;
other
approaches
help faculty
become more
aware of their
teaching and
potential for
improvement
(Benbassat,
2014).
Physicians
with
appropriate
training to
address
social
determinants
of health can
help reduce
these
disparities
(Sawning et
al., 2017).
Through faculty
development,
ensure faculty are
well-versed in the
most up-to-date
knowledge of
LGBTQ health.
Obtain
confidential
feedback from
students on
faculty
teaching of
LGBTQ
health. Review
completion of
training
modules by
faculty.
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Cultural Models
A cultural model shapes and constrains how people think about an issue and the solutions
they see as effective; therefore, the forum was provided for focus group participants to discuss
their overall impressions of Univ-Med and their education. This opportunity provided new ways
for students to think about cultural-education issues. A cultural model that has succeeded at
many institutions is empowering medical students as agents of curricular change (Geraghty et al.,
2020). In this study, 76% of respondents stated they wanted additional LGBTQ health in the
curriculum as representatives of the study body. Students proposed changes at Univ-Med and
offered practical solutions in the open-ended comments and focus group findings. The research
citing the value medical students place on the involvement of curriculum development supports a
collaborative cultural model (Geraghty et al., 2020).
The organizational recommendation is to utilize the theory of HCD to collaborate with
medical students to seek their contribution of ideas to integrate LGBTQ health into the
curriculum. Human-centered design is the process of establishing an interprofessional team
(students, faculty, staff) to put the people (students) and their needs at the center of the solution.
By fostering student engagement in which learners are motivated, they have ownership of the
learning process (Sawning et al., 2017). A student’s connection to the educational and
interpersonal system occurs within an organization’s cultural atmosphere (Gallimore &
Goldenberg, 2001; Kezar, 2011). In this study, exploring the organization’s influence determined
the effect on students and their knowledge and motivation. A cultural model structures thinking
for the people in it; moreover, it gives rise to multiple perspectives on a particular topic.
Study participants want a role in the decision-making about their education but not the
role of the sole provider of that content. The current model of the burden of LGBTQ health
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education falling on student and ad-hoc groups is a durable model because it has persisted over
time. Participants want to contribute ideas and have a say in their curriculum but believe it is the
university’s responsibility to provide the necessary education. Thus, HCD will enable the
university to address social justice and inclusion issues by encouraging collaborative design.
The AAMC recommendations include
• assessment of institutional culture and climate
• value inclusion: the climate and culture of the institution fostered through
professional development activities, education, policy, and practice
• provide a welcoming patient care environment
Cultural Setting
Rueda (2011) stated, “while cultural settings can impact behavior, these settings are also
shaped by individuals and groups who operate with cultural models that impact their behavior”
(p. 57). Clinical teaching faculty often have little formal training about health concerns in the
LGBTQ population. These physicians have few resources and may ultimately learn from the
LGBTQ patient directly or from other faculty with experience in these populations. The AAMC
recommends
• communicating a vision and education that ensures faculty and student buy-in of the
new educational philosophy
• strong administrative support for the creation of faculty development programs
• understanding the implicit bias and assumptions that may adversely affect the care
provided by teaching faculty in clinical settings
The second organizational recommendation is faculty development to ensure they are
well-versed in the most up-to-date knowledge of LGBTQ health. One of the most powerful
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educational resources in medical education is the teaching faculty and their role in the
professional development of students (Rios, 2016). Studies indicate that those role models who
demonstrate empathy, compassion, and caring can set and reinforce lifelong learning values
(Glicken & Merenstein, 2007). These traits are based partly on representing culturally relevant
knowledge and a shared way of thinking and behaving (Schein & Schein, 2017). The cultural
setting in the clinical environment and the role of faculty and preceptors in establishing a
positive example by displaying cultural humility sets the tone of the patient care environment
(Sarkin, 2019).
A curriculum for faculty members and health professions educators entitled Teaching
LGBTQ+ Health is available as an open-source online course from Stanford Medicine. The
faculty development course includes vocabulary, social and behavioral determinants of health,
teaching strategies, and clinical cases. This course has received excellent reviews from other
medical schools, designed by a respected institution. The limited time in the curriculum for
LGBTQ health is a factor that must be understood; however, the importance of this topic
necessitates freeing up faculty time for their professional development. Knowledge and
education have the potential to modify bias and uniform care. Respondents indicate that the
faculty set a positive tone. Adding knowledge and teaching strategies will ensure that students
receive a comprehensive education in the clinical environment. Faculty need to obtain the skills,
resources, and support to understand a new mental education model. The use of change models
can impact long-term sustained change initiatives, such as a curriculum redesign that alters
mental models (Kezar, 2011).
Clark and Estes (2008) stated that organizational performance increases when leaders
identify, articulate, and reinforce the organization’s vision. The sharing of the organization’s
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vision is by proxy from the teaching faculty. In many cases, medical school faculty have not
received formal training as educators but instead teach from a perspective of their clinical
experiences, past training, and their own time as a learner in medical school or residency
(Benbassat, 2014). Curricular change is a complex, multifaceted process; ultimately, the faculty
must implement and sustain these innovations. Faculty development can positively change the
cultural setting in which people experience an issue and can, over time, enact meaningful
changes. AAMC seeks to ensure “a pipeline of physicians better equipped through personal
experiences and diverse learning environments to provide treatment for diseases that
disproportionally impact minority populations” (Hollenbach et al., 2014, p. 190).
Integrated Implementation and Evaluation Plan
A commitment to social justice is essential in the overall mission at Univ-Med.
Physician-Citizen-Scholar is the new foundation of the curriculum, emphasizing citizenship and
patient advocacy. This commitment and agenda are components of the overall mission of Univ-
Med, to improve the quality of life for individuals and society by promoting health, preventing
and curing disease, and educating tomorrow’s physicians. This project examined the underlying
knowledge, motivational and organizational influences of the gap in the LGBTQ health
curriculum. The recommendations address the opportunities to integrate LGBTQ health. The
suggestions are also targeted toward the university as the findings highlight the need for change.
There is a science devoted to sustainability theory. Planning for sustainability should
begin simultaneously as an initial idea and project planning. Sustainability is the act of keeping
the change, process, or business going. It includes articulating the values and beliefs of the
organization’s objectives (Avrichir, 2003). It means understanding that consequences cannot be
anticipated and should not become a barrier to change. To ensure sustainability, the
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implementation and evaluation plan should include communication clear and specific by
leadership, ideally on the value of the change to the organization and its stakeholder with data on
accomplishments (Kirkpatrick, 2001). Organizations cannot remain static; a culture change must
take priority. Ongoing snapshots of sustained change are valuable tools, looking at what changed,
how it continued, and who helped. Acceptance and planning for turnover, personal success, and
failure should be part of the plan and ensure a system is in place to manage this.
Competency-based education informed by evidence-based medicine is one of the
foundational elements of a medical school curriculum. To become a practitioner, students
acquire broad knowledge, skills, theories, and concepts in medicine. These same principles of
competency-based education in knowledge, skills, and motivation are applied when integrating
LGBTQ health. The organization’s role, including culture, context, and priorities, has its own set
of recommendations based on these factors to aid Univ-Med in meeting the organizational
mission of the new physician-citizen-scientist curriculum.
Implementation and Evaluation Framework
The new world Kirkpatrick model (KM) provides a mechanism for creating an effective
implementation and evaluation plan which will demonstrate value to the organization
(Kirkpatrick & Kirkpatrick, 2018). This mechanism and underlying principles promote effective
action by exploring conditions and relationships that align with the stated curriculum goals
(Parker et al., 2011). The KM is used for evaluating training, education, and skill development
embedded within medical education and, as such, must be used in a deliberate and targeted
manner. The KM has four levels of evaluation; however, in these recommendations, the focus
will remain on levels of results and behavior. Evaluation of student performance and the KM
element of reaction and knowledge is conducted at Univ-Med through this established
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mechanism of program review. Student competencies are evaluated through testing, appraisal,
and feedback conducted in each course and clerkship.
In 2001, Kirkpatrick’s theory of change management was published, highlighting how
organizations can successfully manage change by shaping the aim, creating understanding
through effective communication, and participation at all levels of the organization (Kirkpatrick,
2001). This model provides a structure that evaluates change management from a multifaced
perspective. The assessment levels in the KM linked to change theories are illustrated in Figure
8. As an educational organization, the financial results or return on investment emphasized in the
KM are not as critical; however, value appraisal occurs from various perspectives. It is a value-
added to observe how the change affected the organization, its members at all levels, the
learnings, and if it produced the desired outcomes.
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Figure 8
Evaluation Levels
Outcomes
Optimal outcomes assessment necessitates a strategy that looks at the type of evidence
that serves as valid indicators of success and will be helpful for organizational decision-making
processes (Parker et al., 2011). A plan for assessing outcomes ensures that value can be
determined. The goal is aligned to the organizational mission at the highest level to demonstrate
value to the stakeholders. The value to the university outcome is correcting the deficit of
curriculum on LGBTQ health under the spotlight of a new health justice curriculum. The value
of training and return on expectations are accountability features embedded in the assessment.
102
Universities have expertise in evaluation and assessment. Therefore, Univ-Med can use this
expertise to avoid hazards and breakdowns that face many organizations such as determining the
optimal energy and effort to achieve outcomes or using indicators that do not measure the
project’s unique aspects (Parker et al., 2011).
Results and Leading Indicators Level
The external outcomes at the results level are the organization’s public face to
accreditation bodies, medical education leaders, students, and the public. The effect is equally
important to those within the organization who need to establish mechanisms to ensure the
outcome is observable to the stakeholders. The larger goal of implementing LGBTQ health
education and validating this curriculum as integral to the Univ-Med mission begins with
outcomes derived from leading indicators. Leading indicators include the degree to which
targeted results occur due to the learning event and subsequent reinforcement (Johnson et al.,
2007). Leading indicators reassure stakeholders that progress contributes to organizational
outcomes (Kirkpatrick & Kirkpatrick, 2018). Table 18 outlines the leading indicators. For this
study, they are identified as student engagement and satisfaction, increased self-efficacy to
provide patient care, and the organizational priority to implement a new curriculum.
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Table 18
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcomes Metrics Methods
Internal: Implementation of
curriculum on LGBTQ
health in Years 1–2
curricula
Summative: Percent of
curriculum integrated by
review of the syllabus and
other materials
Review, data collection, and
analysis from student
surveys, course syllabi, and
faculty integration surveys
Internal: Implementation of
curriculum on LGBT
health in Years 3–4
Summative: Percent of
curriculum integrated by
review of the syllabus and
other materials
Review, data collection, and
analysis from student
surveys, course syllabi, and
faculty integration surveys
External: Designation and
validation of LGBTQ
health in overall physician-
citizen-scientist (health
justice curriculum)
Summative: LGBTQ health is
acknowledged and
validated as part of the new
social justice curriculum.
Analysis of curriculum
documents and LCME
reports
Behavior and Leading Indicators Level
The behavioral level assessment relies on performance indicators; when achieved, it
emerges in the results. The medical students are the primary stakeholders, and their competence
as future physicians is integral to their professional identity formation. This alignment of critical
behaviors to the student highlights the impact on the program’s progress, as illustrated in Table
19. The needs analysis and root causes established the lack of an LGBTQ curriculum in the
preliminary stages. In implementation and assessment, where much is at stake, it is essential to
look at those earlier identified conclusions and gaps to determine if the organization has achieved
its goals. Implementation of the analysis noting assumed influences of knowledge, motivation,
and organization can provide the information to refine the original solutions (Clark & Estes,
2008). The behaviors, methods, and metrics need to ensure a plan for formative feedback that is
104
timely, topic-specific, and includes a self-assessment component so learners can determine where
they are and where improvements are needed. Feedback should be at the level of the learner at
that moment. Cognitive overload can occur if the feedback is overly complicated and does not
show a path for improvement. Learners need to be the driver of the action plan that comes from
feedback. They should receive guidance on the steps taken, but they should be responsible for
setting goals and deadlines.
Table 19
Behavior Level
Critical behavior Metrics Methods Timing
In at least one
clerkship, student
application of
clinical
competency on
LGBTQ health in
the patient care
setting
Faculty and preceptor
evaluation of
competency-based
behaviors and clinical
skill performance in
the in-patient and out-
patient setting: percent
improvement from
baseline
Qualitative analysis of
students’
performance
reviews
Monthly or on
change of
clinical
clerkship
rotation
Student
demonstration of
effective
communication and
cultural humility
strategies with
simulated LGBTQ
patients
Self, peer, faculty, and
preceptor evaluate
behaviors and
communication with
patients.
Evaluation
Goal-based behaviors
on communication
and interpersonal
skills
Twice during
ICM
Health justice and
systems of care
team assessment of
proposed
curriculum into the
physician-citizen-
scientist mission
The frequency of the
LGBTQ curriculum on
the team agenda for
review and
development of
assessment
The quality of the team
discussion on
curriculum integration
Review agendas and
committee minutes.
Student
participation and
attendance at
meetings and
participation in
debriefing sessions
Twice per year
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Required Drivers
Performance support and other similar activities such as drivers serve as reinforcers or
enablers. Drivers reinforce learning and create a support and accountability package. The
required drivers and methods in Table 20 create the factors that determine the type of evaluation
that is possible and optimal. For example, the mentoring and feedback from faculty support
students’ critical behavior demonstrating clinical competency in LGBTQ health in the patient
care setting. These faculty evaluate the critical behavior. This behavior–reinforcer accountability
system relies on both parties to demonstrate skill. If the preceptors are ineffective at giving
feedback, the student's motivation and self-efficacy may be impacted, and it will be difficult to
observe their clinical competence.
Table 20
Required Drivers to Support Critical Behaviors and KMO
Methods Timing Knowledge, motivation,
organization
Reinforcing: Students acquire
knowledge and motivation
through a curriculum
integrated during ICM and
clerkships.
Monthly during ICM and end
of each clerkship
Motivation: Self-efficacy
Encouraging: Mentoring and
feedback from faculty and
preceptor
Monthly during ICM and end
of each clerkship
Motivation: Self-efficacy
Monitoring: Feedback from
simulated patients
Twice during ICM Procedural knowledge
Monitoring: Demonstration
of completion of
curriculum design
benchmarks
Twice per year Organization: Cultural model
and setting, open to
change, demonstration of
trust, and embracing values
and attitudes to foster goals
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Organizational Support
Organizational success is dependent upon the mechanisms established to support new
ventures. Organizations are interdependent systems of support and accountability that span
multiple levels (Schein & Schein, 2017). Each stakeholder and contributor can promote positive
relationships to enhance the new venture (Glicken & Merenstein, 2007). When combined with
the stakeholders’ understanding and actionable knowledge, the data creates meaning for the
organization. Leadership must support stakeholders’ critical behaviors at every level to achieve a
dynamic and comprehensive curriculum fulfilling the University’s mission. The complexity of
the recommended solutions, implementation and evaluation plan in Figure 9 illustrates the
process and outcomes of systems needed to ensure success.
Based on the gap analysis findings, the recommendation is to work with leadership to
develop a several-stage process that includes (a) awareness of the need for change in culture and
organizational priorities during the LGBTQ curriculum preparation; (b) fostering desire during
the design process; (c) ensuring and enhancing knowledge of leadership before and during
implementation; (d) apply the knowledge (ability) and provide opportunities for different levels,
and (e) Reinforce change and performance to sustain the change and ensure support along the
way.
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Figure 9
Solutions, Plan, and Evaluation
Data Analysis and Reporting
The stakes are high with a program that has such prominent visibility. The KM presents a
helpful taxonomy for considering the impact of the development and implementation of LGBTQ
health curricula at different organizational levels. The strategies for reporting listed here provide
approaches to be used throughout the organization:
• Document and disseminate the story
Recommended
Solutions
Continuous Quality
Improvement with Review of
Performance Goals
&
Organizational Support
50 % Implementation of
curriculum on LGBTQ health
in Years 1 and 2
Designation and validation of
LGBTQ health in overall
physician-citizen-scientist
curriculum
Implementation of curriculum
in clerkship
Implementation
Plan
L4 student engagement and
satisfaction, an increase in
students’ self-efficacy to provide
patient care
L3 Student application of clinical
competency on LGBTQ health in the
patient care setting. Demonstration
of effective communication and
cultural humility strategies with
LGBTQ patients (such as the use of
proper pronouns, etc.)
Evaluation Plan
Data Collection
Student surveys
Public and community reaction
Data Analysis
Evaluation team analyze and report
statistical findings from accountability
measures
Data Reporting
LGBTQ community meetings
Summary
Return on Expection we hope will be
a more dynamic and comprehensive
curricullm that meets the University
mission
108
• Report impact
• Applaud successes
• In-depth stories disseminated to other curriculum committees
• Knowledge of factors that enhance or impede the effect of education on results
• Factors that are associated with the successful application of new knowledge, skills,
and attitude
Assessment is significant as it contains diagnostic checkpoints enabling root cause
analysis of any problems identified. The Univ-Med program revolves around the impact of
curriculum change and development on the organization, specifically on the health justice
mission. The program can only be successful if the curriculum aligns closely with its mission. A
well-designed program will facilitate stakeholder involvement, attitudinal changes, and an
opportunity to apply new skills and knowledge in medical care, job commitment, and orientation
to organizational vision and strategies.
The Role of Institutional Leadership
By virtue of their title or by action, deed, or principle, leaders define culture and set the
tone for an organization. Understanding organizational change principles and applications can
guide teams toward effectuating and sustaining change. Managing ethical issues, including
diversity, equity, inclusion, sustainment of partnerships, and change management, are complex
tasks and require an organization and its leaders to focus on their mission, vision, and evidence-
based strategies to accomplish goals. Creativity, leadership, and gaining inspiration from others
help inform a new direction, but only if the challenging work of introspection and reflection
occurs honestly and in a meaningful way.
109
Recommendations for Future Research
In medical education, the challenge is determining the efficacy of any new curriculum or
intervention. The efficacy can be determined through assessment methods to understand if and
how well students have achieved cultural humility and LGBTQ competency. Univ-Med has a
well-established evaluation and assessment program using a variety of modalities. Looking at
established research for guidance, the University of Louisville (Holthouser et al., 2017) utilized
standardized patients to assess the LGBTQ competency of students. Standardized patients are
individuals hired to portray patients to enable students to demonstrate clinical skills. Univ-Med
also has a standardized patient program. The next step would be to establish a research study in a
quasi-experimental design to look at a cohort of students who receive LGBTQ health curricula
prior to a standardized patient program compared to a control group of those who do not. Both
groups would have standardized patient encounters, and their ability to take a sexual history,
communicate effectively and demonstrate cultural humility would be assessed. The AAMC
recommendations to medical students on curricular implementation of LGBTQ health likewise
propose using standardized patient programs for training and assessing medical student
competency (Hollenbach et al., 2014).
Conclusion
Reducing health disparities and removing barriers to care are essential to improving the
quality of life for LGBTQ patients. The lack of LGBTQ health competent physicians contributes
to these health disparities. The purpose of the study was to determine the KMO influences at
work in a gap analysis of the lack of curriculum at Univ-Med. The study results show an
impression on basic student knowledge in factual, conceptual, and procedural areas. The impact
on the students is evident in their lack of ability to take a sexual history, understand the scope of
110
health disparities, care for transgender patients, and trust that the university considers these
competencies a priority. Students have strengths, and the findings show assets in confidence and
knowledge. The institution drives curriculum change, and the data highlight organizational
behavior and priority gaps. The stakeholder of focus for the study was medical students, who
have the most to gain from a change in the curriculum. Determining assets and needs leading to
recommendations will directly benefit the stakeholders.
Clark and Estes’s (2008) gap analysis framework structured the review of the literature,
the data collection, analysis, and recommendations to align with the core mission of Univ-Med,
which is to educate, empower, and develop professionalism in medical students. Knowledge and
motivation are elements in the educational process, and every decision the organization makes
impacts the students. This study will provide Univ-Med leadership with data about how their
stakeholders think and feel about the curriculum gap and their suggestions for the future. The
goal now for Univ-Med is to use this information in a meaningful way to make changes that will
improve their students’ education and the quality of care for the LGBTQ community.
111
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(Eds.), Understanding Medical Education: Evidence, Theory, and Practice (3rd ed.).
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orientation in the undergraduate medical education curriculum. Academic Psychiatry,
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being:2016. Report of the HHS LGBT policy coordinating committee. U.S. Department of
Health and Human Services. https://www.hhs.gov/programs/topic-
sites/lgbt/reports/health-objectives-2016.html
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Theoretical Framework, and Conceptual Framework. Academic Medicine, 95(7), 989–
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L., Tran, E., Wells, M., Chamberlain, L. J., Fetterman, D. M., & Garcia, G. (2015).
Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and
comfort. Teaching and Learning in Medicine, 27(3), 254–263.
https://doi.org/10.1080/10401334.2015.1044656
Zelin, N. S., Hastings, C., Beaulieu-Jones, B. R., Scott, C., Rodriguez-Villa, A., Duarte, C.,
Calahan, C., & Adami, A. J. (2018). Sexual and gender minority health in medical
curricula in new England: A pilot study of medical student comfort, competence and
perception of curricula. Medical Education Online, 23(1), 1461513.
https://doi.org/10.1080/10872981.2018.1461513
125
Appendix A. IRB Study Information
Information Sheet for Exempt Research
Study title: Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) Health Curriculum
in Medical Education: A Gap Analysis
Researcher[s]: Kathryn Schaivone, EdD candidate, Rossier School of Education,
Faculty Advisor: Patricia Tobey, Ph.D., Rossier School of Education
You are invited to participate in a web-based online survey on LGBTQ health curriculum at X. It
should take you approximately 15 minutes to complete.
The purpose of this study
The study aims to gather students’ experiences, opinions, and knowledge, on LGBTQ health
curriculum at X. We will use this information to implement new curriculum and enhance
existing education on this topic.
Participation
Your participation in this survey is voluntary. It should take you approximately 15 minutes to
complete. You may refuse to take part in the research or exit the survey at any time without
penalty. You are free to decline to answer any question for any reason.
Benefits
You will receive no direct benefits from participating in this research study. However, your
responses may help us learn more about any curriculum deficit and your ideas for improvement.
Risk
There is the risk that you may find some of the questions to be sensitive. You may decline to
answer any or all questions, and you may terminate your involvement at any time if you choose.
Confidentiality
Your survey answers will be completed through a link at Qualtrics, where data will be stored in a
password-protected electronic format. Qualtrics does not collect identifying information such as
your name, email address, or IP address. Therefore, your responses will remain anonymous. No
one will be able to identify you or your answers, and no one will know whether or not you
participated in the study.
The University of Southern California Institutional Review Board (IRB) may access the data.
The IRB reviews and monitors research studies to protect the rights and welfare of research
subjects.
At the end of the survey, you will be asked if you are interested in participating in an additional
interview. If you choose to provide contact information of your name and email address, your
survey responses may no longer be anonymous to the researcher. However, no names or
identifying information would be included in any publications or presentations based on these
data, and your responses to this survey will remain confidential.
126
Contact
If you have questions at any time about this study, or you experience adverse effects as a result
of participating in this study, you may contact the researcher whose contact information is
provided on the first page.
If you have questions regarding your rights as a research participant, or if problems arise which
you do not feel you can discuss with the Primary Investigator, please contact the Institutional
Review Board at (323) 442-0114 or email irb@usc.edu.
Electronic Consent: You may print a copy of this consent form for your records.
Completion of all or part of the survey indicates that
• You have read the above information
• You voluntarily agree to participate
• You are 18 years of age or older
127
Appendix B. Focus Group Information Sheet for Exempt Research
Study title: Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) Health Curriculum
in Medical Education: A Gap Analysis
Researcher[s]: Kathryn Schaivone, EdD candidate, Rossier School of Education, University of
Southern California
Faculty Advisor: Patricia Tobey, Ph.D., Rossier School of Education
The purpose of this study
You have been invited to participate in a focus group conducted by X. The purpose of this focus
group is to hear your thoughts, ideas, and suggestions about implementing an LGBTQ
curriculum. The information learned in this focus group will be used to assess any current
educational gaps in the curriculum and make recommendations to Univ-Med leadership.
Procedure
You will be placed in a 5-7 individuals group as part of this study. A moderator will ask you
several questions while facilitating the discussion. This focus group will be Zoom audio/video-
recorded, and the researcher/moderator has approved through the Institutional Review Board.
However, your responses will remain confidential, and no names will be included in the final
report. You can choose whether or not to participate in the focus group, and you may stop at any
time during the study.
Please note that there are no right or wrong answers to focus group questions. The Researcher
wants to hear the many varying viewpoints and would like everyone to contribute their thoughts.
Feel free to be honest even when your responses counter other group members’ opinions.
Participation
Your participation in this survey is voluntary. The group session will be 45-60 minutes. You may
refuse to participate in the research or exit the survey without penalty. You are free to decline to
answer any question for any reason.
Benefits
You will receive no direct benefits from participating in this research study. However, your
responses may help us learn more about any curriculum deficit and your ideas for improvement.
Risk
There is the risk that you may find some of the questions sensitive. You may decline to answer
any or all questions, and you may terminate your involvement at any time if you choose.
Confidentiality
Should you choose to participate, you will be asked to respect the privacy of other focus group
members by not disclosing any content discussed during the study. The researcher will analyze
the data, but your responses will remain confidential, and no names will be included in any
reports.
128
The University of Southern California Institutional Review Board (IRB) may access the data.
The IRB reviews and monitors research studies to protect the rights and welfare of research
subjects.
Contact
If you have questions about this study or experience adverse effects due to participating in this
study, you may contact the researcher whose contact information is provided on the first page.
If you have questions regarding your rights as a research participant, or if problems arise that you
do not feel you can discuss with the Primary Investigator, please contact the Institutional Review
Board at (323) 442-0114 or email irb@usc.edu.
129
Appendix C: Focus Group Questions
Focus group questions Potential probes
Let us start by talking very generally about
the LGBTQ health curriculum in medical
education.
Tell me about your experiences in medical
school, specifically lectures or formal
presentations in Years 1–2 dedicated to the
topic of LGBTQ issues/health.
What did you like about those sessions?
What did you not like?
What did you learn that you might be able
to use in the patient care environment?
Why is it essential to include LGBTQ health
in your medical education?
How will learning this benefit you now and
in the future?
Where in the curriculum do you think these
efforts should be placed?
Can you give me more detail?
What content/topic do you want to be
included in the curriculum?
Can you clarify your opinion or provide
more detail?
How can we get support from other students
for the implementation of a new LGBTQ
curriculum?
Why or why not would support be
beneficial?
How can we involve students in this
curriculum development, and what is the
best way to involve students?
Are there other contributions they can
make?
130
Appendix D: Survey
Assessing Medical Students’ Attitudes, Knowledge and Experience in Treating Lesbian,
Bisexual, Gay, Trans and Queer/Questioning Patients
Demographics
First please provide us with some information about you.
1. What year of medical school are you in?
Options:
1st year
2nd year
3rd year
4th year
Leave of Absence
2. How many hours of formalized LGBTQ health issues education have you received
thus far in medical school?
0 hrs. (1)
1–4 hrs (2)
5–8 hrs (3)
More than 8 hrs (4)
3. These questions are about frequency of actions you might take during an encounter
with a patient.
How frequently do you enquire about a patient’s sexual identity?
How frequently do you enquire about a patient’s gender identity?
Never (1) Sometimes (2)
About half
the time (3)
Most of the
time (4)
Always (5)
131
4. These questions seek to understand your level of comfort and confidence.
How confident are you taking a sexual history from an LGBTQ patient?
Overall I feel comfortable addressing the health care needs of LGBTQ patients.
Not at all
confident (1)
Slightly
confident (2)
Somewhat
confident (3)
Fairly
confident (4)
Completely
confident (5)
5. These questions seek to understand challenges you might experience during patient
encounters
LGBTQ patients should disclose their sexual orientation to their physicians.
It is more challenging to discuss sexual behavior with LGBTQ patients than
heterosexual patients.
It is more challenging to conduct a physical exam on an LGBTQ patient than a
heterosexual patient.
Options:
Strongly
disagree (1)
Somewhat
disagree (2)
Neither agree
nor disagree
(3)
Somewhat
agree (4)
Strongly
agree (5)
6. These questions seek to understand your familiarity with the topic.
Access to health care is the same for LGBTQ individuals as for other members of
the population.
I understand the following terms: asexual, pansexual, intersex.
Strongly
disagree (1)
Somewhat
disagree (2)
Neither agree
nor disagree
(3)
Somewhat
agree (4)
Strongly
agree (5)
7. Overall, Faculty and Preceptors set a positive example by displaying cultural
competency/humility with patients?
Strongly disagree (1) Somewhat disagree (2) Neither agree nor disagree (3)
Somewhat agree (4) Strongly agree (5)
8. Would you like to have additional formalized education in LGBTQ health in your
medical school curriculum?
Yes (1) Maybe (2) No (3)
132
9. If you said yes or maybe to additional LGBTQ health curriculum, where do you think
it should be added?
Year I (1) Year II (2) Clerkship Years (3) Post Clerkship (Elective) (4) All 4
years of medical school (5)
10. What is your gender identity?
Agender (1) Female (2) Male (3) Non-binary / third gender person (4)
Transgender person (5) Other (6)
11. What is your sexual orientation?
Asexual (1) Bisexual (2) Gay (3) Lesbian (4) Straight (5) Other (6)
12. What skills (e.g. taking a sexual history, addressing health disparities, diagnosing and
treating patient medical concerns, etc.) are you most interested in learning about with
LGBTQ patients?
________________________________________________________________
13. Please give us your opinions, ideas and suggestions about the content you would like
included on LGBTQ health.
14. Q14 We are recruiting volunteers to participate in a focus group to discuss the
implementation of LGBTQ curriculum in your education. The focus group will meet
once in February for about 45–60 minutes. If you would be willing to participate or
would like more information, please click on the below and you will be redirected to
a separate sign-up (un-linked to this survey) page. Thank you!
o Yes I want to participate (4)
o No thank you (7)
133
Appendix E: Theoretical Alignment Matrix
Research question Theoretical framework
primary and influences
Data instrument questions
What are the medical
students’ knowledge and
motivation related to
learning LGBTQ health in
their education?
Social cognitive theory
(Bandura, 1982)
Learning Theory (Ambrose,
2010)
Blooms taxonomy revised
(Krathwohl, 2002)
Survey 1, 2, 3, 4, 5, 6, 7,
10, 11
What do students want in
their education on
LGBTQ health that can
guide Univ-Med with
curriculum integration of
this topic?
Social cognitive theory
(Bandura, 1982)
Bloom’s taxonomy revised
(Krathwohl, 2002)
Medical education
(Swanwick, 2018)
Survey 1, 2, 5, 8, 9, 10, 11
Focus group 3, 4
How do culture, context, and
organizational priorities at
Univ-Med either support
or hinder the inclusion of
an LGBTQ curriculum?
Social cognitive theory
(Bandura, 1982)
Organizational change
(Kezar, 2011)
Survey 7, 10, 11
Focus group 1, 2
What are the
recommendations for
Univ-Med in the areas of
knowledge, motivation,
and organizational
resources?
Social cognitive theory
(Bandura, 1982)
Organizational change
(Kezar, 2011)
Medical education
(Swanwick, 2018)
Survey 10, 11
Focus group 2–6
134
Appendix F: Focus Group Code Book
Nodes\coded themes name Description
Clinical skills Skills history and PE. Learned in ICM and
clerkships
Clinical aspect Care of patients in hospital or clinic
Curriculum Current medical education
Core curriculum Add LGBTQ to the core as a requirement
Curriculum change Social and health justice
Medical education Content, discussion of courses
Sex education LGBTQ Knowledge students have upon entry to med
school
Exams Unless required, students don’t take seriously
Faculty member The example set in ICM, and clerkship
Queer faculty Out faculty who provide education
Group work ICM and PPM students lead case discussions
Health care policy talks Content on LGBTQ would be valuable
Health justice Ability to impact change with this knowledge
Patient interview Taking a sexual history LGBTQ
Approaching patients Pronouns asking about sexual history
Patient population Clinic set to see more LGBTQ patients
Real patient stories Value
Standardized patient setting Practice history taking
Trans patients No education on transgender, only in repro or
endo lectures. Information on gender-affirming
care
Queer Queer students educating others
Administration Claim to want student input but don’t take action
Abstract (if available)
Abstract
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience health disparities and unequal access to medical care at higher rates than the general population. Inclusive care provided by physicians equipped to work with the LGBTQ population has been noted as essential to reducing the health disparities these patients face. Despite calls to action and recommendations from academic leadership organizations, medical students do not receive adequate education and training to care for this population. This study assessed the extent and underlying influences of the curriculum gap on LGBTQ health at University-Med, a large urban medical school. Clark and Estes’s gap analysis model was applied to understand the knowledge, motivation, and organizational influences resulting in the shortfall in the curriculum. The study’s stakeholders are medical students enrolled at University-Med, 147 completed the online survey, and nine participated in the focus groups. Key findings from the study identified gaps in the curriculum on sexual history taking, identifying, and addressing healthcare disparities, a lack of opportunities to acquire mastery in LGTBQ health, and faculty knowledge of LGBTQ health, including cultural humility. This descriptive study identified knowledge and organizational influences that resulted in recommendations focused on curriculum development with the participation of medical students to ensure a sense of ownership in their education.
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Asset Metadata
Creator
Schaivone, Kathryn Angela
(author)
Core Title
Lesbian, gay, bisexual, transgender, and queer health curriculum in medical education: a gap analysis
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Degree Conferral Date
2022-08
Publication Date
07/14/2022
Defense Date
04/11/2022
Publisher
University of Southern California
(original),
University of Southern California. Libraries
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Tag
curriculum,education,healthcare disparities,LGBTQ,medical,OAI-PMH Harvest
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Language
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Tobey, Patricia (
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)
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Tags
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