Case Scenario: The Impact of Social Determinants of Health on LGBTQIA+ Patients

• The current literature demonstrates that there is a prominent need for curricular content in medical and professional healthcare programs that focuses on preparing students to provide patient-centered and culturally competent care to LGBTQIA+ patients.

• To address the health and healthcare disparities impacting LGBTQIA+ patients, students must understand the intersectionality of minority stress and the social determinants of health.

• To encourage students to engage in active thinking and clinical decision-making, educators should intersperse active learning techniques, such as simulations and case-based learning, throughout the curriculum.

Inadequate inclusion of lesbian, gay, bisexual, transgender, intersex, and asexual (LGBTQIA+) healthcare content exists in medical education curricula^1–3  to prepare clinicians to address the numerous health and healthcare disparities^4–6  that impact the LGBTQIA+ patient population. Regarding the medical school curriculum, researchers have demonstrated that medical students were exposed to an estimated average of 5 hours (United States and Canada) and 11 hours (United Kingdom) of LGBTQIA+-specific content during their entire professional education.³  Specific data regarding the amount of time spent covering LGBTQIA+ content within athletic training professional education do not exist at this time.

Integrating LGBTQIA+ content into the curriculum of professional healthcare programs is essential for preparing clinicians to deliver quality care while engaging with diverse populations in a way that honors their identities, beliefs, customs, and values in line with the principles of cultural humility.^7,8  Cultural humility involves an approach to patient care that emphasizes self-reflection and assessment, valuing patients’ knowledge of their own social and cultural backgrounds, openness to creating balanced power dynamics in the patient-provider relationship, and a lifelong commitment to learning.⁹  It includes recognizing the limits of one’s own knowledge and being open to learning from patients about their experiences while maintaining an awareness of one’s own cultural influences and biases.⁹  In athletic training education, particularly when teaching about equitable care for LGBTQIA+ patients, educators should focus on empowering students with respectful curiosity and affirming communication skills to enhance patient-centered care through an emphasis on cultural humility rather than solely improving knowledge and competence.^8–10  However, without Commission on Accreditation of Athletic Training standards requiring the specific inclusion of LGBTQIA+ content within professional programs, many athletic trainers (ATs) may enter the workforce without the essential education and cultural humility training needed to care for this population.¹¹ 

Without formal and informal educational experiences facilitated through professional programs, it is no surprise that many ATs reported in a recent study that their education relevant to transgender patient care primarily came through media outlets (32%) or personal experiences with family, friends, or themselves (33.7%).¹²  In the same study, only about half of the respondents (48.1%) agreed that they felt competent in caring for transgender patients, with less than half (45.6%) reporting feeling competent using appropriate terminology while communicating with transgender patients.¹²  Similarly, in medical education, most medical students felt not competent or somewhat not competent providing care to gender minority patients (76.7%) and patients with a difference of sex development (81%).¹³ 

The absence of sufficient LGBTQIA+-specific content in the curricula of professional healthcare programs contributes to a lack of clinicians prepared to meet the healthcare needs of this population.^1,4,13  Without access to adequately trained clinicians, LGBTQIA+ patients, including those in athletic populations, experience higher rates of chronic illness, behavioral health concerns, substance abuse disorders, and suicidal ideation.^14–16  Additionally, due to a lack of providers with adequate training, many LGBTQIA+ patients have reported negative healthcare experiences, including lack of access to preventative care,¹⁷  denial of care from healthcare providers,¹⁸  and experiences of stigma, bias, and microaggressions.^19,20  Although the solution to these disparities is multifaceted, comprehensive inclusion of LGBTQIA+ topics and their intersection with the social determinants of health (SDOH) within professional healthcare curricula can better prepare providers to address the needs of the LGBTQIA+ patient population.

Understanding the influence of SDOH on the health and well-being of LGBTQIA+ patients and how they contribute to the inequities that exist is vital in being able to provide more comprehensive care for this patient population. As the first point of contact for many patients, ATs must understand the relationship between SDOH, health, and healthcare disparities and how they ultimately impact the health and well-being of the LGBTQIA+ population. Therefore, this educational technique provides athletic training educators with a case scenario to implement in professional education. This case scenario directly aligns with Commission on Accreditation of Athletic Training standards 57, DEI 1, and DEI 2 that focus on analyzing and developing strategies that minimize the impact of clinician-based bias, prejudice, and privilege on patient interactions.²¹ 

This educational technique, featuring a case scenario with discussion and debriefing questions, integrates the principles of cultural humility by presenting a realistic case for students to navigate. It creates opportunities for students to apply clinical reasoning in a way that centers the patient’s needs while also focusing on SDOH and exploring how ATs can improve health outcomes and access to healthcare for the LGBTQIA+ population.

To accomplish the learning objectives (Table 1), a case scenario has been designed for use by athletic training educators to expose students to the intersection of SDOH and the health and healthcare disparities experienced by LGBTQIA+ individuals. The case scenario (Table 2) details the experience of a secondary school patient who encounters harassment, discrimination, and parental abandonment as the result of having his sexual orientation involuntarily disclosed in a process commonly known as being outed. This case scenario explores the role an AT has in providing care, support, resources, and referrals after the fallout many LGBTQIA+ individuals experience when having their sexual orientation and/or gender identity involuntarily disclosed. To ensure time for adequate discussion, educators should anticipate 75 to 90 minutes to complete this educational technique.

To facilitate this educational technique, athletic training educators should first split students up into small groups of 3 to 5 individuals. The students will stay together in these groups for the entirety of the case scenario and will regularly engage in guided small group discussions. After being divided into small groups, the educator should establish the rules of engagement for the upcoming discussions. Example rules of engagement that focus on establishing a space meant for learning and personal growth can be found Table 3. It is strongly recommended that the educator(s) be prepared to engage in difficult conversations and intervene should classroom discussion shift away from constructive dialogue.

Once the students have agreed to adhere to and uphold the rules of engagement, the educator(s) can provide the students with the first section of the case scenario, which involves economic stability. Students should be given time to read the section before being presented with the discussion prompt. After being presented with the discussion prompt, each group should be given the small group discussion questions, located at the end of each section, and provided 10 to 15 minutes to converse. After completion of the student discussion, the educator(s) should facilitate any class discussion that arises and assess student preparedness to move on to subsequent sections of the case scenario. The educator(s) should follow the same process for sections 2 through 5 of the case scenario, which discuss neighborhood and built environment, access to quality education, social and community context, and access to quality education, respectively. It is recommended that the educator sequence the presentation of this material using a PowerPoint or other modality so as not to allow the students to jump ahead in the case scenario. At the case scenario’s end, the educator(s) should use the remaining time to facilitate a whole class discussion and debrief (Table 2). During these class discussions, the educator(s) should be prepared to guide students through these difficult, but applicable, conversations.

To achieve the learning objectives of this educational technique, athletic training students should be provided with foundational information regarding SDOH and their link to overall health and well-being of patients. Additionally, it is recommended that athletic training students complete Safe Space/Safe Zone/Ally Training (or your institution’s equivalent) to be able to engage with this case scenario with the appropriate level of understanding, respect, and confidence to discuss sensitive and potentially traumatic topics involving the LGBTQIA+ patient population.²² 

A greater understanding of health conditions from a patient-centered perspective requires the recognition of underlying causes, including the SDOH, because of their impact on overall health and well-being.²³  Often defined as the living, school, and work environment of people and surrounding forces or circumstances that influence daily life, these determinants stem from an unequal allocation of power and resources.²³  Failure to evaluate the social determinants and their importance in healthcare interactions are missed opportunities for ATs to provide culturally competent patient-centered care and promote patient health and well-being.²³  Unfortunately, a lower socioeconomic status of the school system correlates to fewer visits to the athletic training facility²⁴  and injury nondisclosure.²⁵  Thus, it is important for ATs to understand how SDOH impact the patients that they serve.

There is growing evidence that the methods used to teach clinical skills today are inadequate.^26,27  Today’s students have expressed deep frustration with passive approaches to learning^26,28,29  and instead prefer learning methods that encourage active participation, critical thinking, clinical decision-making, and opportunities to obtain feedback on their performance.^30,31  Learning is contextual,³²  so students need experiences in the classroom where they make clinical decisions similar to those made in autonomous practice.²⁶  It is imperative that teaching methods used during professional education parallel patient care. Success in solving one kind of patient care problem is a poor predictor of success when faced with other clinical situations.³²  Previous researchers^27,33,34  suggested that providing learning experiences in a context that mimics patient care, such as patient case studies or simulation, facilitated retrieval of relevant knowledge during practice. Thus, students must be exposed to learning experiences that they will encounter during patient care.³⁵ 

Case-based learning is an instructional method that integrates knowledge discovery, information processing, and active engagement throughout the clinical decision-making process.³⁶  Unlike passive learning strategies, such as traditional lecture, case-based learning provides opportunities for students to engage in clinical problem-solving³⁷  and critical thinking²⁷  within the context of a specific patient (similar to what will be encountered during clinical practice). As an instructional strategy, case-based learning allows students to safely integrate knowledge and clinical skills within a patient care environment before providing care.^38–40  Previous researchers⁴¹  have classified case-based learning as a best practice for healthcare education because of enhanced learning through the application of knowledge to practice.⁴¹ 

The method by which case-based learning is delivered varies.^36,37,41,42  Common types of case-based learning activities used in healthcare education include case scenarios or patient cases. Regardless of the type of case-based techniques presented, a patient scenario serves as the mechanism for students to review, analyze, and respond to questions or prompts about what steps they would provide during a plan of care.⁴²  As an active learning strategy, case-based learning emphasizes clinical problem solving and clinical decision-making skills by providing a progressive patient scenario that students navigate through.⁴³  Despite the type and delivery mode, case-based learning allows students to apply knowledge and skill within the context of patient care in a safe learning environment.

As a result of case-based learning activities, students reported increased confidence in their clinical skills^37,44  and high satisfaction with the learning activity.^37,44,45  Previous researchers also noted that other types of simulations and active learning strategies have improved confidence,^46–48  ability to self-reflect,⁴⁸  and psychosocial intervention and referral skills.^49,50  As an educator, it is also important to consider what you can glean from students’ participation in case-based learning activities to impact your teaching pedagogy and continuous program improvement.⁵¹ 

The debrief following the implementation of the case-based learning activity must not be neglected. Debrief is an essential component in healthcare education that follows an education activity and allows students to analyze their actions,^52–54  reflect on their thought process,⁵⁴  and assimilate improved behaviors into clinical practice.⁵⁵  The goal of the debrief is to ask questions that require the student(s) to critically think about what happened, allowing students to self-identify areas where improvements are needed, identify steps for improving skill, and reflect on their communication skills.⁵⁶ 

Despite the body of professional literature that supports active and engaged instructional strategies supporting the use of case-based learning and other types of simulations, several barriers exist that preclude AT educator use. The most frequently reported barrier preventing the use of simulations and case-based learning has been time investment.^57,58  Educators spend an exorbitant amount of time in developing and revising patient cases.⁵⁸  Previous researchers have noted logistical constraints⁵⁸  (eg, scheduling and need for specialized space), cost⁵³  (eg, patient simulators), financial and human resources,^57,58  and lack of familiarity in using simulation and case-based learning.^57–59 

Inclusion of LGBTQIA+ content within AT professional education is a valuable way to provide students with content-specific knowledge and ultimately improve the health outcomes of their LGBTQIA+ patients. Although students may have foundational knowledge on SDOH, application and interventions are population specific. As such, AT students must be provided with exposure and opportunities to apply their knowledge and skills safely within the context of LGBTQIA+ patient care. Providing students with a broader understanding of SDOH, and their impact on the LGBTQIA+ community, allows for the development of critical thinking and clinical problem-solving skills. Thus, AT educators must use active and engaging learning strategies that allow students to apply, integrate, and synthesize learning to optimize patient-centered care and health outcomes.

While being understanding of the sensitive nature of the content included in this case scenario, the authors encourage educators to take this case and modify its length, specifically the number of discussion and debriefing questions, to meet the learning objectives of their course and class session in a time-efficient manner. Additionally, to further alleviate time constraints associated with a detailed case scenario like this, educators may also consider unfolding this scenario section by section over the span of multiple class sessions. Adapting the length and depth of discussion can also provide flexibility in tailoring the educational technique to the curriculum’s specific needs, goals, and objectives.

When teaching content that includes themes related to SDOH, sexual orientation, gender identity, minority stress, and health disparities, it is crucial for educators to provide students with foundational prerequisite information before using more advanced educational techniques. After foundational information is provided, students should be given the opportunity to apply this knowledge in a meaningful way through active learning techniques like this case scenario. Through the combination of providing foundational knowledge, using evidence-based teaching techniques, and incorporating active learning techniques, educators can better prepare students to understand and address SDOH, especially as they relate to LGBTQIA+ individuals.

We also recommend that educators engage in self-reflection, taking inventory of their own knowledge and potential biases before teaching this material. This practice of cultural humility can help ensure that the content is delivered with sensitivity and accuracy, fostering a more inclusive and equitable learning environment for students.^8,10  Moreover, when students observe cultural humility being practiced by their educators, it may inspire them to cultivate similar values in their own lives and future clinical practice.⁸