Standardized Patient Encounter to Enhance Care to LGBTQIA+ Patients

• Athletic training educators can use a standardized patient experience to provide care for a gay patient. This should help the learners provide better patient-centered care as clinicians.

• The standardized patient case can be used to examine and assess psychomotor skills, affective skills, or both.

• Debriefing is a critical component of any SP encounter to help the learner reflect and receive feedback to improve future performance and enforce transferable skills.

Patients who identify as lesbian, gay, bisexual, transgender, queer, intersex, other diverse sexualities, other gender identities, or other gender expressions (LGBTQIA+) tend to have poor experiences with the health care system compared to their heterosexual and cisgender counterparts.^1–3  Providers frequently lack knowledge or understanding of these patients’ particular needs and experiences and may deny a patient’s identity or even blatantly mistreat patients.¹  Members of this population may delay or neglect treatment when an acute injury or illness arises if related fears may make them wary of seeking care.²  In a recent survey of people who identified as gay, bisexual, or men who have sex with men, nearly 30% reported experiencing anticipated health care stigma (feeling afraid of or avoiding health care services due to a fear of discrimination).⁴  This can exacerbate existing health disparities and contribute to poor outcomes and may lead to mental health problems, like depression and anxiety.⁵  In the traditional athletic training setting, LGBTQIA+ patients report similar concerns with their clinicians, including perceptions of a lack of support and a lack of education on their needs.^6,7 

Nearly all health professions’ ethical standards require them to provide care in an equitable and nondiscriminatory way; athletic training is no exception.⁸  To provide this care, the educational path must prepare future practitioners to engage positively with patients of diverse cultural and ethnic backgrounds and those representing gender and sexuality minority groups. However, education around issues specific to LGBTQIA+ patient populations is quite limited in the preparation for medical doctors and other health care professionals.^9,10  As a result, health care practitioners are often underprepared to interact with these patients and report a desire for more training and education in this area.³ 

The Commission on Accreditation of Athletic Training Education (CAATE) standard on diversity, equity, and inclusion (DEI) 2 states that learners must “practice cultural competency, foster cultural humility, and demonstrate respect in client/patient care.”¹¹  However, data from surveys of professional athletic training learners and program directors as well as interviews with current athletic trainers indicate that education in this area may fall short.^3,12,13  In 2019, results from a study completed by Nye et al indicated that, while athletic training clinicians generally held a positive view of patients who identify as LGBTQIA+, they felt that they lacked knowledge related to how to best treat these individuals.³  This finding was supported by Madrak et al, who found that athletic trainers had less cultural competence when caring for lesbian or gay patients than other health care providers such as nurses and mental health counselors.¹⁴ 

The purpose of this article is to present an educational technique that can be used with professional or postprofessional athletic training learners to prepare clinicians to work with patients who may be members of gender or sexuality minority groups. Specifically, we describe a standardized patient (SP) experience for a patient who is gay and concerned about a sexually transmitted infection (STI) after a conversation with a previous partner.

Before professional practice, athletic training learners must exhibit competence in a series of proficiencies that integrate knowledge and clinical decision-making skills.^15,16  It is impossible to ensure that athletic training learners will experience all of the real patient encounters that are necessary to be competent in professional practice.^16–18  Due to barriers in didactic and clinical education, simulation-based learning involving SPs are being integrated into athletic training education.^16,18  Standardized patients have been evidenced to provide learners the opportunity to practice communication and interpersonal skills to enhance patient care as a part of professional training.^17,19  Standardized patient cases are a realistic and valuable teaching method that not only allow learners to gain practical knowledge and increase confidence in their clinical skills but also provide educators with the opportunity to evaluate learner progress and clinical competence.^15,20,21  Additionally, using SPs increases patient safety while simultaneously providing a nonthreatening atmosphere for learning and assessment.²¹ 

A SP is a trained individual who portrays a condition, injury, or illness of a real-life patient for teaching and evaluation purposes.^15–19  Local actors or students in drama programs are commonly retained as SPs. Using these individuals has several advantages over using other athletic training students or program faculty: the learner is likely to be unfamiliar with the person, and the SP typically does not have the medical knowledge to provide leading responses to the learner, while they do have the background necessary to portray an actual patient consistently and realistically. It is imperative that the SP receives extensive training to ensure they act and answer questions in particular ways as well as present appropriate physical signs and symptoms, behaviors, and emotions to imitate a real-life scenario.^18,19  The use of SPs consists of a more realistic, consistent, and detailed process than simply role-playing or simulation.¹⁶ 

An intervention using an SP has many benefits, including providing a clinical case that a learner may not see in their educational experience and a consistent patient experience with the opportunity for immediate discussion and debriefing.²⁰  Of particular relevance for this type of case is the ability to provide an opportunity that allows learners to practice their skills without the potential to cause unintended harm in the form of stigmatization of an actual patient.²² 

One of the benefits of this case is that the patient, presented as a gay male, can be adapted to portray any LGBTQIA+ patient. The name and characteristics of Lane can be adapted to meet the specific learning needs of the students within your program (eg, changing Lane to a transgender individual). This SP case may be used to achieve several desired learning outcomes, and each educator can modify the scenario and assess based on their goals of the case.  Appendix 1 describes potential learning objectives that can be taught and assessed with this SP case. One goal could be focused on patient-centered care for patients who identify as gay and used after related material is presented and discussed didactically. This case may also be used as part of a pathophysiology and pharmacology class in which learners have been taught about STIs and pharmacological agents. Finally, the case could be used to practice patient interactions in which the athletic trainer needs to refer for services and potentially find a provider who is not the team physician or patient interactions in which the learner may not have the background experiences to answer all the patient’s questions.

Further, the case allows learners to develop interpersonal communication and other soft skills. One of the authors uses the case during the first semester before learners have learned about STIs and related drugs. The learners focused on their communication skills and rapport building with the patient during a visit about a sensitive topic and the importance of patient privacy.

Opportunities to include patient advocacy also exist. Patient advocacy should address the disparities gay men face so that they can receive high-quality inclusive care. Advocates can recognize specific health needs and help patients by promoting regular testing and screenings, providing education on risk factors and prevention strategies, and assisting with access to appropriate medical care. Within this specific case, the patient is a gay male. The patient portrayed can be adapted to meet the learning needs of students within your program (eg, a transgender patient). Patient advocates can also help gay patients navigate the health care system and communicate effectively with other health care providers. This may involve providing support during appointments, helping to explain medical jargon and procedures, and advocating for the patient’s rights to confidentiality and respectful treatment. In addition, patient advocates can help gay patients access resources and services that support their health and well-being, such as LGBTQIA+ support groups, counseling services, and social services. Overall, patient advocacy for a gay patient is about ensuring that all individuals receive equitable and respectful care, regardless of their sexual orientation or gender identity. By supporting the unique needs and concerns of LGBTQIA+ patients, advocates can help to create a more inclusive and just health care system for all.

Training for SPs is an important part of preparing for the experience. Standardized patients need to portray medical scenarios consistently to ensure that learners receive standardized experiences. Proper training ensures SPs adhere to specific case details, behaviors, and responses. Well-trained SPs enhance the realism of simulations, thereby maximizing the learning experience for learners. Realistic interactions with SPs help learners develop clinical skills in a controlled environment. Standardized patients can effectively portray emotions and patient experiences, allowing learners to practice empathy and bedside manner in a realistic context. Proper training helps SPs evoke appropriate emotional responses from learners. Workshops for using SPs in athletic training will ensure that best practices are used.

The patient is based on a fictional patient and currently set up for a 1-on-1 patient-clinician interaction. The Standardized Case Training Information contains the information that is given to the SP during the training ( Appendix 2) and should be used after content related to patient-centered care for patients who identify as LGBTQIA+ has been presented in class. The patient Lane is a 21–22-year-old male collegiate lacrosse player who reports to the Athletic Training Clinic and wishes to talk to the athletic trainer about a sensitive issue. When Lane and the athletic trainer go to a private room, Lane states that his most recent sexual partner was recently diagnosed with chlamydia, and he is not sure what to do.

Lane is prescribed and regularly takes Descovy pre-exposure prophylaxis (PrEP), which is a method of preventing human immunodeficiency virus (HIV) transmission in those at higher risk of contracting HIV. Patients who have had anal or vaginal sex in the last 6 months are considered at higher risk if they meet 1 of the following criteria: have had a sexual partner who has HIV with a detectable viral load or an unknown viral load, do not consistently use condoms during sex, or have contracted a STI in the past 6 months. Patients taking Descovy PrEP are tested for HIV before starting the medication and every 3 months while using the medication.²³  However, patients are not tested for other STIs, like chlamydia. Chlamydia was chosen as the STI for the case because it is the most prevalent STI in the United States.²⁴  Men who have sex with men are more likely to contract chlamydia than women or men who have sex only with women; they are also at a higher risk for reinfection.

After completing a simulation or SP, it is essential for the learner to participate in a facilitated debrief. The purpose of the debrief is to understand participants’ experiences in engaging with the SP and their perceived effect on their athletic training professional practice. This process holds significant importance, as it facilitates reflection on performance using intentionally devised questions to stimulate self-reflection, particularly emphasizing the development of soft skills. The primary objective is to identify any knowledge, skill, attitude, or communication gaps that may have surfaced. The focus varies depending on the specific goals of the simulation, whether it pertains to clinical judgment, critical thinking, problem solving, or behavioral competencies.

Debriefing is specifically tailored to foster critical thinking and refine clinical decision-making abilities. It is crucial that debriefing takes place promptly after the encounter to capture the experience while it remains fresh in memory, including the associated emotional responses. Debriefing sessions are inherently learner centered, providing a secure environment for individuals to explore different perspectives. Facilitators employ a range of open-ended questions designed to stimulate reflection and practical application; examples can be found in the Table.²⁵  These questions may encompass various aspects of critical thinking, with an emphasis on encouraging self-reflection and the transfer of knowledge to real-world clinical settings.

Socratic questioning techniques may be used to prompt deeper introspection, encouraging learners to analyze their thought processes and actions. Effective facilitation involves allowing sufficient time for responses, usually at least 30 seconds. Periodically summarizing key insights and actionable strategies derived from the discussion reinforce how strategies can be applied in clinical practice.²⁶  Facilitators can draw upon a multitude of debriefing assessment tools and methodologies to ensure the effectiveness of the process.^27,28 

The learner may be assessed in a variety of ways depending on the purpose and learning objectives of the SP encounter. If the case is primarily used as a teaching method within the curriculum, the emphasis may be on a formative assessment technique aimed at providing constructive feedback and facilitating the learner’s growth. During the debriefing session after the SP encounter, facilitators can offer timely and targeted formative feedback that aligns with the specific learning objectives of the scenario. By engaging in reflective discussion and guided self-assessment during the debrief, learners can gain valuable insights into their performance, identify areas for improvement, and solidify their understanding of key concepts.

In addition to formative assessment methods, summative assessment strategies can also play a crucial role in evaluating learners’ performances in SP encounters. Summative assessment focuses on measuring the overall achievement of learning objectives and may involve the systematic evaluation of learners’ proficiency in clinical skills, decision-making abilities, and communication competencies. One common form of summative assessment in SP encounters is the use of standardized scoring rubrics or checklists. These tools provide objective criteria for evaluating learners’ performances based on predefined benchmarks related to the learning objectives. Facilitators can assess learners’ adherence to clinical protocols, accuracy in information gathering, appropriateness of diagnostic and treatment recommendations, and effectiveness in patient communication.  Appendix 3 describes various assessment methods that could be used.

Ultimately, with the incorporation of both formative and summative assessment methods into the SP experience, educators can ensure a comprehensive evaluation of learners’ competencies and readiness for real-world clinical practice. While formative assessment facilitates ongoing feedback and skill development, summative assessment offers a final measure of achievement and proficiency, guiding learners’ progression toward professional competence and excellence.

The described educational technique has several advantages. Education drives clinical practice, and incorporating SP cases in which learners must provide care for a patient that is gay should help the learners provide better patient-centered care as clinicians. Additionally, the case can assess psychomotor and affective skills. Learners may also benefit from Safe Space or Safe Zone training to increase their cultural competence to acknowledge differences when making clinical decisions and providing patient-centered care. Safe Space or Safe Zone training may be offered at the home institution, or Safe Space Ally Training for the Athletic Trainer is available at the National athletic Trainers’ Association (NATA) Professional Development Center. Safe Zone and Safe Space Trainings focus on creating a supportive and inclusive environment for individuals that identify as LGBTQIA+. The trainings typically cover a range of topics, including LGBTQIA+ terminology and identities, the effect of heteronormativity and cisnormativity on individuals and society, the experiences of LGBTQIA+ individuals in various settings (such as school, work, and health care), and ways to support and advocate for LGBTQIA+ people. By completing Safe Zone training, learners can become better equipped to support and advocate for LGBTQIA+ individuals and to create a more inclusive and welcoming environment for all. Additionally, the NATA LGBTQ+ Advisory Committee curates resources to help advance inclusion initiatives and ways to get involved to promote inclusion.²⁹ 

The use of simulations and SPs is well documented within athletic training professional education as a teaching technique. Standardized patients allow students the opportunity to engage in a real-time patient encounter in a safe learning environment where students can make mistakes without any negative effect to their patient.³⁰  Related to student learning outcomes, SPs have been documented to improve student clinical skills, communication and interpersonal skills, and overall confidence as a health care provider.^21,31–38 

This SP care allows students to engage with a patient population not always encountered during clinical education. In our experience using this SP case, learners responded positively to interacting with an LGBTQIA+ patient in a safe learning environment. Learners perceived the most important take-home message from the encounter was the importance of establishing rapport immediately. Because of the nature of the questions asked of the patient (eg, questions related to sexual activity and sexual history), the patient needs to be comfortable with the clinician to answer questions honestly. Most learners shared that they were comfortable asking questions related to the patient’s sexual orientation, gender identity, and sexual history. However, few reported exposure to this type of patient during clinical education, further emphasizing the importance of this SP within professional education.

Standardized patient experiences have been shown to be a viable way for learners to work with a variety of patients. Learners may not have the opportunity to provide services to patients in the gay community and may not be involved with sensitive conditions like an STI exposure. This educational technique allows learners to provide services in a safe environment. Additionally, debriefing allows learners to discuss what went well, what needs improvements, and ask any questions in a safe environment. Thus, their care for patients who identify as gay should improve.

1. Demonstrate effective communication skills by creating a supportive and nonjudgmental environment for Lane to discuss his concerns.

2. Demonstrate empathy and sensitivity in addressing Lane’s emotional response to his potential exposure to chlamydia, including managing anxiety and stress.

3. Demonstrate cultural sensitivity by respecting Lane’s confidentiality and autonomy throughout the encounter, while also recognizing potential cultural factors that may influence his decision-making process.

4. Reflect on personal biases and assumptions related to sexual health and actively work to provide inclusive and equitable care to Lane, regardless of sexual orientation, gender identity, or other demographic factors.

5. Collaborate with Lane to develop a personalized plan of action, including discussing the importance of seeking medical evaluation and testing for sexually transmitted infections (STIs).

6. Provide education on safe sexual practices, including the consistent and correct use of condoms to prevent the transmission of STIs.

7. Use motivational interviewing techniques to support Lane in making informed decisions about his sexual health, including discussing options for notifying his recent sexual partner(s) and accessing appropriate medical care.

8. Identify the appropriate steps to assess Lane’s risk factors and potential exposure to STIs, including gathering relevant medical history.

9. Apply knowledge of the signs, symptoms, and transmission of chlamydia to conduct a focused assessment and provide accurate information to Lane.

10. Identify appropriate resources and referrals for Lane, including local health care providers specializing in sexual health services and counseling or support groups.

11. Demonstrate adherence to patient confidentiality guidelines and legal regulations by maintaining the privacy of Lane’s personal health information throughout the encounter, including proper documentation and secure storage of sensitive information.

1. Checklists: Develop a checklist outlining specific tasks or actions that the learner should perform during the encounter, such as conducting a thorough patient history, discussing risk factors, providing education on sexually transmitted infections (STIs), and discussing options for testing and treatment. The specifics of the checklist depend on the learning objectives.

2. Rating Scales: Use a rating scale to assess the learner’s performance across different domains, including communication skills, clinical reasoning, professionalism, and empathy. Each domain can be rated on a Likert scale or a similar numerical scale.

3. Global Rating: Provide an overall assessment of the learner’s performance based on the facilitator’s holistic impression. This global rating considers the learner’s ability to manage the encounter effectively, demonstrate appropriate clinical judgment, and establish rapport with the patient.

4. Peer Assessment: Implement peer assessment, in which other learners observe the encounter and provide feedback on the learner’s performance. This can offer valuable insights from different perspectives and promote peer learning.

5. Self-Assessment: Encourage learners to reflect on their own performance after the encounter. Self-assessment prompts can guide learners to identify strengths, areas for improvement, and strategies for enhancing their clinical skills.

6. Video Review: Record the simulated encounter for later review and analysis. Facilitators can use the video recording to provide feedback, identify learning opportunities, and facilitate self-reflection by the learner.

7. Standardized Patient Feedback: Solicit feedback from the standardized patient regarding his or her experience during the encounter. This can include assessing the learner’s communication effectiveness, empathy, and ability to address the patient’s concerns.

8. Objective Structured Clinical Examination (OSCE): Incorporate the simulated encounter into an OSCE format, in which learners rotate through multiple stations, each assessing different clinical skills. OSCEs provide a standardized method for evaluating learners’ clinical competencies.