Evaluating Effectiveness of an Online LGBTQIA+ Health Course for Medical Students

The sexual and gender minority (SGM) community is a growing proportion of the US population, with 7.1% of US adults and one in five Generation Z adults identifying as lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, or other (LGBTQIA+) and 9.2% of high school students identifying as gender diverse. ^{1, 2} Despite this demographic growth, health disparities, such as the number of adverse childhood events, ³ within SGM populations have worsened across generations, suggesting that SGM health may be declining. The urgency of these disparities is supported by the National Institutes of Health’s formal recognition of SGMs as a population with health disparities. ⁴ While the field of SGM health has grown in recent decades, a significant need remains to improve health outcomes in this population.

Of particular concern is the need to improve the quality of health care provided to the SGM community. SGMs often face discrimination and stigma in the health care setting from practitioners and other staff, which creates barriers to receiving quality care. ⁴ Minority stress theory has posited that stressors faced by SGMs, including stigma in health care, contribute to chronic stress and adverse health outcomes. ⁵ Intersectional biopsychosocial frameworks have suggested that overlapping identities can intensify exposure to chronic stress, and individuals who identify both as Black, Indigenous, or People of Color and SGM have been found to have more adverse health outcomes and suboptimal health care access. ^{6, 7}

Health care providers, however, do not currently receive adequate training on how to provide high-quality, comprehensive care for SGMs. ⁴ Despite evidence that medical students with SGM clinical experience (compared to those without) provide higher quality care to SGM patients, students in the United States receive only 5 hours of training specific to SGM health care. ⁸ Evidence has suggested that medical students may require as many as 35 hours of SGM-focused didactic hours to achieve high cultural competency. ⁹ However, many medical schools fall well below this benchmark. ⁸ Some medical schools have implemented a one-time session on SGM health in residency preparation courses or have created a longitudinal track for students focused on SGM health. ¹⁰, ¹¹ While these efforts are valuable, a single session is limited in its ability to be comprehensive, and a longitudinal track targets only students already interested in SGM health. To prepare future physicians, especially primary care providers, to care for a diverse patient population, incorporating more robust and widely accessible SGM content into undergraduate medical education is essential.

To address this need, we created and implemented a novel, comprehensive, 2-week online elective for undergraduate medical students focused on SGM health. The objective of this study was to evaluate how this course impacted the self-perceived confidence and competence of undergraduate medical students regarding the care of SGM patients.

A self-directed, 2-week online elective, Introduction to LGBTQIA+ Health, was developed by students and faculty using Kern’s six-step approach to curriculum development to address the need for SGM health education. ¹² The course was offered to third- and fourth-year undergraduate medical students at the University of Michigan as an elective that counted toward nonclinical graduation requirements, with voluntary enrollment throughout the year. The course contains 10 modules that build from basic foundational concepts to specialty-specific care using a combination of written content, multimedia, and prerecorded expert lectures. Each module concludes with a 10-question quiz requiring a passing grade of 80%. To receive educational credit, all students are required to complete pre-and postsurveys. As part of these surveys, we used the 18-item, 7-point Likert Lesbian, Gay, Bisexual, Transgender Development of Clinical Skills Survey (LGBT-DOCSS; Appendix A) to assess cultural competency with an overall mean score in three specific domains: attitudinal awareness, basic knowledge, and clinical preparedness. ¹³ Higher scores indicate higher levels of knowledge and preparedness in caring for SGM individuals. Scores of 6 and above are defined as high competency, 5 to 6 as moderate competency, and lower than 5 as low competency. ⁹ We also assessed self-perceived confidence in the care of SGM patients via a 5-point Likert retrospective pre–post survey (Appendix B). Paired sample t tests were conducted in R to assess differences in pre- and postscores. This research was granted exemption by the University of Michigan Institutional Review Board (HUM00217485).

Thirty-three students completed the course at the time of analysis. Prior to the course, students on average had high attitudinal awareness (6.89), low clinical preparedness (4.33), moderate basic knowledge (5.68), and moderate overall competency (5.63) on a 7-point Likert scale (Table 1, Figure 1). Improvement in all LGBT-DOCSS items was observed with significant increases in clinical preparedness (from low to moderate, 5.45, P<.001), basic knowledge (from moderate to high, 6.73, P<.001), and overall competency (from moderate to high, 6.31, P<.001; Figure 1, Figure 2). Regarding the 5-point Likert self-perceived confidence scale, students reported low confidence in caring for lesbian, gay, and bisexual (LGB) patients (2.76) as well as transgender and gender diverse patients (2.33) prior to the course (Table 1 ). After completion of the course, students showed significantly improved confidence in caring for LGB patients (3.76, P<.001) and transgender and gender-diverse patients (3.52, P<.001).

This research shows that the Introduction to LGBTQIA+ Health course significantly increased the self-perceived competence and confidence of undergraduate medical students in caring for SGM patients. Students were found to have significant improvement in self-rated clinical preparedness, basic knowledge, overall competency, and confidence in treating SGM patients. These findings indicate that this curriculum has the potential to help prepare future physicians to care for this patient population. As far as we are aware, this is the most comprehensive online, asynchronous course on SGM health designed specifically for undergraduate medical education. Given the current paucity of SGM health in medical education, this course provides an example for other programs looking to similarly expand their own curricula. ^{4, 14} The hope is that increased provider knowledge and competency leads to higher quality care and decreased stigmatization to ultimately improve outcomes. ^{4, 5, 15}

This study had several limitations. Students self-selected to participate in this course, which may indicate prior interest and/or knowledge related to SGM health and may have contributed to the high attitudinal awareness scores in precourse surveys. Additionally, given the small number of students who have taken the course thus far, the limited sample size prevented the use of more complex analyses, such as a fixed-effects model. Also, students included in this analysis were limited to a single institution, and different institutions may have SGM health education already included in their curricula, which may affect outcomes. Another limitation is that, while the LGBT-DOCSS survey tool is a validated instrument, its measures were all self-perceived. Finally, because no simulated clinical practice or longitudinal data exists, we cannot comment on whether the course has changed behaviors or patient outcomes.

Future efforts include transforming this course into a massive online open course (MOOC) available to trainees at other institutions. ¹⁶ Of note, the course is now available to residents and physicians at the University of Michigan due to high levels of interest, and we will continue to collect data from participants. We also are continuously adding modules on additional topics. It is noteworthy that such a significant change was seen with only a 2-week, online course, prompting consideration of whether further improvement could be achieved with more interactive curricular components, such as shadowing clinical providers or standardized patient interactions, which are widely used in medical education. ¹⁷ With the addition of in-person clinical experiences and assessments, we may better achieve and evaluate student growth in clinical skills. We are considering collecting longitudinal, postintervention data to evaluate how the course affects participants’ future clinical practice, as well.

Our hope is that the success of this SGM health curriculum will encourage other undergraduate medical institutions to similarly provide SGM education for their trainees.