Practice Makes Perfect: Objective Structured Clinical Examinations Across the UME-to-GME Continuum Improve Care of Transgender Simulated Patients

Transgender patients (ie, individuals whose gender identity differs from their sex assigned at birth) face more barriers to care compared to their cisgender counterparts (ie, those whose gender identity aligns with their sex assigned at birth), including discrimination and postponement or refusal of care.^1,2  Among these barriers are limited physician experience and training.³ 

Educational activities exist to help clinicians gain comfort and skills in caring for transgender patients, but these vary in modalities and the type of learners these interventions target.^3,4  Research suggests that longitudinal and integrated transgender health education improves learner skill and comfort, activates learners’ desire for more practice,²  and communicates that providing gender-affirming care is important and valued.⁵ 

Few studies looked at the impact of longitudinal and integrated transgender health training across the undergraduate medical education (UME) to graduate medical education (GME) continuum.⁴  Currently, transgender health education in medical school curricula is limited. More than half of training programs accredited by the Liaison Committee on Medical Education reported having no LGBTQIA+ training in their curricula.⁶  On average, medical school curricula include an average of 5 hours of LGBTQIA+ health education, primarily focused on HIV, differences in sex development, and safe sex.^2,6  Additionally, medical students do not get enough exposure to transgender patients: around 40% of students reported caring for no transgender patients, and those who did have prior experience cared for fewer than 5 transgender patients.^7,8  Transgender health education at the GME level is also lacking, with only a few specialties publishing about transgender health education in both didactic and clinical settings.⁶  Most specialties report minimal to no transgender health education during residency, despite multiple studies finding that residents and fellows believe in the importance and value of learning comprehensive gender-affirming skills needed to care for transgender patients.⁶  This suggests there is an opportunity to include more transgender health training and exposure in medical school curricula and/or throughout training.

The aim of our study was to describe whether and how exposure to transgender health skills during medical school impacted trainees’ competency in this area during residency. We describe outcomes from an objective structured clinical examination (OSCE) station where residents were tasked with managing the care of a standardized patient (SP) who identified as transgender.

As part of their required annual formative assessment in 2022, New York University Grossman School of Medicine (NYUGSOM) residents in the internal medicine (IM) residency program participated in an OSCE where they rotated through multiple simulated clinical encounters with SPs. An OSCE station with an SP who identified as transgender was included with an aim of assessing how residents care for transgender patients. This case was developed by program leadership (R.E.G., a content expert on gender-affirming care, and S.Z., an expert in simulation), and reviewed by a member of the transgender community with lived experience who also served as an SP (C.L.).

We compared performance on the case between 2 groups of residents: (1) residents who had trained at the same medical school (continuum residents) and had previously participated in an OSCE at NYUGSOM as part of their UME curriculum featuring a transgender SP with feedback; and (2) residents who attended different medical schools (noncontinuum residents) and who therefore did not participate in the NYUGSOM transgender OSCE. During their first year of medical school prior to clerkship training, continuum residents attended lectures on transgender health that involved education on barriers to care and gender-affirming hormone therapies, a conversation with a transgender community member, and a workshop on inclusive sexual history taking, followed by participation in an initial OSCE case with a transgender SP.

All NYU residents (continuum and noncontinuum) attended a similar lecture regarding transgender health with more detailed information about hormones and surgery, consistent with their level of training.

The OSCE station involved caring for a 37-year-old transgender male patient who was admitted to the hospital for abdominal pain. Residents had 10 minutes to confirm the SP’s affirmed name and pronouns, evaluate the abdominal pain, complete a sexual history and relevant organ inventory, and identify the need for additional testing.

We recruited 3 transgender SPs through online and social media forums, and they were compensated as any other SP ($28/hour compensation). Each of the 3 SPs, who identified as transgender (and importantly had lived experiences to draw upon), received 3 hours of SP training on how to play the role of the patient, assess performance using the checklist, and give effective feedback. During the encounter, the SPs were instructed to act intimidated by clinicians and to not readily offer any information about their gender identity unless prompted. The SPs were to remain open with the residents if they said something awkward (and not openly offensive) and to express displeasure but remain cooperative if the resident made any overtly judgmental or offensive statements. Full resident and SP case instructions are available as online supplementary data.

The SPs evaluated each resident’s performance using a checklist that rated residents on 5 domains: information gathering (4 items), relationship development (5 items), education and counseling (3 items), gender-affirming care skills (6 items), and case-specific abdominal pain information gathering (1 item), see Table 1. Items were rated on a behaviorally anchored “not done,” “partially done,” or “well done” (WD) scale. In addition, the SP gave each resident a global recommendation and professionalism rating, using 4-point scales. Our original communication checklist was developed through the Macy Initiative on Health Communication⁹  and adapted for this case to include assessment of case-specific skills in gendering-affirming care and abdominal pain information gathering. Our checklist has demonstrated internal consistency (Cronbach’s alphas 0.70-0.95), significant and positive association with similar student performance metrics,^10-13  and sensitivity in capturing effects of interventions.^14,15 

Following the case, residents received both written and verbal feedback from the SPs and debriefed with a faculty observer who had expertise in caring for transgender patients. Residents completed a post-OSCE evaluation where they rated whether the case was educationally valuable and shared their experience about their participation in the case.

We used a mixed methods approach to explore the potential impact prior transgender health exposure and practice during medical school may have had on competency in providing gender-affirming care during residency.

Quantitative Analysis: We calculated summary scores (mean % WD) for each item and domain. Wilcoxon rank sum tests for nonparametric data were conducted to test for statistically significant differences in performance between the 2 resident types. All checklist data were analyzed using R Core Team (2021).¹⁶ 

Qualitative Analysis: We analyzed SP open-ended feedback comments given to each resident using the framework method for content analysis.¹⁷  This method was chosen because we used domains and items assessed on our checklist as a guide for organizing the behavior codes but remained open to other themes that emerged from the SP’s feedback. Two authors (C.P.B. and J.A.W.) read through all SP comments to generate codes individually and then met regularly to discuss and jointly create a codebook. This codebook was shared with the entire study team who discussed the data and reached consensus on a final working code book. One author (C.P.B.) then applied codes to the SP comments. Comparisons were made between continuum and noncontinuum residents to identify potential differences in SP feedback about care provided.

The same process was repeated when analyzing the resident responses on the post-OSCE evaluation to identify main themes between and across the 2 groups. Analyses of SP open-ended feedback and resident responses were carried out using Dedoose (Version 9.0.54).¹⁸ 

We ensured trustworthiness of our results by having an interdisciplinary team of both clinicians and nonclinician educational researchers within and outside of NYUGSOM who varied in their levels of expertise in transgender health education.¹⁹  This helped to ensure our interpretations were free from biases and reflected the authentic experiences of the SPs and residents.

This project qualified as an educational quality improvement project through NYUGSOM’s Institutional Review Board, and therefore resident consent was not required for participation in this project.

A total of 101 residents participated in the case (continuum [n=24], noncontinuum [n=77]). See Table 2 for breakdown by postgraduate year (PGY) and SP rater.

Continuum and noncontinuum residents performed similarly in 4 of 5 domains, with significant differences in the abdominal pain information gathering domain (92% vs 65%, P<.01, 95% CI 0.11-0.43). Continuum residents were more frequently recommended or highly recommended compared to noncontinuum residents (88% [21 of 24] vs 70% [54 of 77] WD, P<.05, 95% CI 0.98-31.79) and were all rated mostly professional or completely professional (100% [24 of 24] vs 94% [72 of 77] WD, P<.05, 95% CI 1.35-12.50) by the SP. Continuum residents’ summary scores were better overall in the gender-affirming care skills domain, compared to noncontinuum residents, though differences were not statistically significant. See Table 3 for full results.

Feedback comments from the SPs revealed notable differences between continuum and noncontinuum residents when it came to areas of improvement, including need for more experience and better skills in fostering SP comfort, asking about gender identity, and using gender-affirming language (see Table 4 of SP-reported areas of improvement).

The SPs noted when residents demonstrated a clear lack of experience with transgender patients, and this occurred exclusively with noncontinuum residents. Residents’ lack of experience was noted as a barrier to obtaining relevant clinical information related to the patient’s gender identity needed to address the abdominal pain.

Though uncommon, SPs described encounters that made them feel uncomfortable, which happened only with noncontinuum residents who exhibited awkwardness and nervous nonverbal communication.

Only noncontinuum residents avoided talking about patient’s gender identity, which the SPs hypothesized was due to residents’ lack of experience and fear of causing discomfort.

When it came to specific skills, most noncontinuum residents received feedback about needing to use more inclusive/affirming language and preferred terminology when talking with transgender patients.

Fifty-one residents completed the resident post-OSCE evaluations (continuum [n=14], noncontinuum [n=37]). We found no clear differences in experience or perceived value of the case between continuum and noncontinuum residents. Most residents across the 2 groups (80%, 41 of 51) rated the case to be “very valuable,” attributing it to the opportunity to practice skills in a safe space.

Many residents identified the opportunity to practice with transgender patients and discuss their care in a safe space, with feedback from the SP, to be helpful.

Several residents mentioned how practicing using nongendered, patient-centered language was especially helpful in improving skills and comfort.

Residents across both groups described having few prior clinical encounters with transgender patients and described how the case increased their comfort and preparation for caring for transgender patients.

A few residents described a sense of humility and enthusiasm about continuing to learn more about and practice caring for transgender patients in the future.

Our findings suggest that continuum residents may have had a learning advantage due to their previous participation in a transgender OSCE during medical school. Continuum residents, compared to noncontinuum residents, exhibited better performance on the domains of case-specific information gathering, gender-affirming care skills, and global ratings. Furthermore, continuum residents’ greater experience and comfort in this area was highlighted by the fact that their noncontinuum counterparts exclusively received SP feedback about their lack of experience and comfort.

The fact that continuum residents performed better on several domains that they were similarly assessed in during medical school and exhibited greater confidence and competence in caring for a transgender SP demonstrates the durability of their skills and their ability to generalize learning from a previous exposure to this new encounter. This advantage aligns with the concept of distributed practice where learning becomes more durable when opportunities for practice are spaced out over time (compared to massed together during a short period of time) and new learning encounters build upon previous learning.^5,6,20-25  These findings suggest that trainees benefit from repeated exposures to and practice with transgender health skills over time as it promotes retrieval, consolidation, and competency in providing affirming care to transgender patients.

Residents across both groups did not score as high on the gender-affirming care skills item “made SP feel welcome and comfortable as a trans-identified patient” (continuum=71% [17 of 24] vs noncontinuum=58% [45 of 77]), which identifies a curricular gap. One area that may address this gap is the use of nongendered terms, preferred terminology, and inclusive/affirming language, which was frequently identified as a challenge by SPs and residents. Currently, transgender health topics covered in UME and GME curricula focus little on interpersonal skills, such as affirming patients and use of language.⁶  Experiential learning opportunities, such as OSCEs, with transgender patients within UME and GME curricula is one strategy for providing trainees with valuable exposure to transgender patients, practice with inclusive and affirming language and interpersonal skills, and feedback about their performance from individuals who identify as transgender or nonbinary.^2,26-28  Most medical schools and residencies have SPs, but including members of the transgender community with lived experiences in the development and implementation of transgender OSCEs is imperative.

Overall, our results suggest the following steps forward for transgender health education: (1) Introducing transgender health training early in medical education can provide trainees with learning advantages that may improve their skill and comfort with caring for transgender patients; (2) Skills acquisition around how to build rapport, affirm patients, and use appropriate language is an important and desired area of improvement; and (3) Experiential opportunities (OSCEs or patient-as-teacher forums) should be incorporated within UME and/or GME curricula so trainees can interact and practice with and receive feedback from transgender patients to improve their gender-affirming care skills.

One limitation is that we did not collect data on noncontinuum residents’ prior transgender health experiences. Our findings indicated that regardless of noncontinuum residents’ prior experiences (or lack thereof) in their respective medical schools, continuum residents exhibited better performance that may be attributed to our medical school’s transgender health curriculum. We also did not look at residents’ prior experiences with real transgender patients; therefore, their performance on this case may not reflect their care in actual practice. Third, differences in ratings among 3 different SPs may be a confounding factor. However, each SP saw a fairly equal distribution of continuum vs noncontinuum residents; the pattern in which continuum residents performed better in specific domains persisted when we looked within individual SP’s ratings; and all SPs consistently identified the same areas of improvement, giving us confidence in our results. Lastly, other factors, such as training in a large American city with a sizeable population of transgender individuals, may explain the differences between groups, limiting the generalizability of our results to other training programs.

Future research should look at whether integrating transgender OSCEs across the UME-to-GME continuum improves trainees’ interactions with transgender patients beyond the simulated environment.

Our data demonstrate that exposure and the opportunity to practice clinical interactions with a transgender-identified SP during medical school is associated with better performance in caring for transgender SPs during residency.

The authors would like to thank the following for their participation and for ensuring a successful OSCE: the residents, standardized patients, and NYSIM, a public and private partnership of NYULH and City University of New York.

The online supplementary data contains the full resident and standardized patient case instructions.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented as a poster at the Society of General Internal Medicine Annual Meeting, May 10-13, 2023, Aurora, Colorado, USA.