The Use of Race/Ethnicity and Sexual Orientation and Gender Identity in Clinical Care: A Needs Assessment

Background The ACGME’s Clinical Learning Environment Review (CLER) has shown that few institutions have a formal strategy to address health care disparities (HCD) involving learners and faculty in system-based solutions. As a part of the ACGME Pursuing Excellence initiative, ISMMS GME aims to focus on addressing HCD in the areas of race and ethnicity and sexual orientation and gender identity. We assessed learner and faculty attitudes toward incorporating race and ethnicity (RED) and sexual orientation and gender identity (SOGI) data as part of building an educational curriculum.


Background
The ACGME's Clinical Learning Environment Review (CLER) has shown that few institutions have a formal strategy to address health care disparities (HCD) involving learners and faculty in system-based solutions. As a part of the ACGME Pursuing Excellence initiative, ISMMS GME aims to focus on addressing HCD in the areas of race and ethnicity and sexual orientation and gender identity. We assessed learner and faculty attitudes toward incorporating race and ethnicity (RED) and sexual orientation and gender identity (SOGI) data as part of building an educational curriculum.

Methods
Using the Mayo Clinic Learners' Perception of Health Disparities survey as a guide, we developed a survey that evaluates how strongly learners and faculty considered RED and SOGI when developing patient-provider relationship, differential/diagnosis, clinical decision making, and treatment plan on a 5-point Likert scale. Participants included internal medicine residents and ambulatory care faculty at Mount Sinai Hospital.

Results
Overall, 73 (56%) learners across all years and 14 (67%) faculty responded (See Table 1). Both learners (70%) and faculty (76%) agreed or strongly agreed that patient's self-reported RED is important when developing a patientprovider relationship. However, when asked the same question about developing differential diagnosis and clinical decisions, 60% of learners vs. only 43% of faculty indicated agree or strongly agree. Even though 56% of learners consider RED in developing the treatment plan, 50% of faculty rarely or never ask learners to consider RED (See Table 2).  Both learners (81%) and faculty (93%) agreed or strongly agreed that patient's self-reported SOGI is important in developing a patient-provider relationship. However, when asked the same question about developing differential diagnosis and clinical decisions, 83% of learners vs. only 56% of faculty indicated agree or strongly agree. Both learners (67%) and faculty (71%) consider SOGI in developing treatment plans ranging from sometimes, usually, and always. Despite the faculty's lower tendencies as compared to learners when considering RED or SOGI for differential diagnoses and treatment plan, 43% agreed or strongly agreed that teaching about how to use RED in developing differential diagnosis and treatment plan is an important part of medical education, and 64% for SOGI (See Table 2).

Conclusion
While learners and faculty agree that knowing a patient's RED and SOGI is important for provider-patient relationship, faculty are less likely than learners to consider them for the development of differentials and treatment plans. Given the potential benefits of incorporation of RED and SOGI data into clinical care, we identified a need for further education and training given the attitudinal and self-assessed behaviors noted in our needs assessment. In addition to a didactic curriculum for trainees, our data highlights the need for robust faculty development given faculty attitudes and uncertainty.

Faculty Learner
Q7: *Faculty-ONLY* I believe that teaching learners to consider a patient's self-reported racial/ethnic identity in developing their differential diagnosis and treatment plan is an important part of medical education.

Strongly Agree 7%
Agree 36% Neither Agree Nor Disagree 29% Disagree 21% Strongly Disagree 7% Q8: *Faculty-ONLY* I believe that teaching learners to consider a patient's sexual orientation and gender identity in developing their differential diagnosis and treatment plan is an important part of Medical Education.