Abstract
BACKGROUND
While issues related to lesbian, gay, bisexual, and transgender (LGBT) health are increasingly incorporated into medical training, there remains limited guidance and opportunities for continuing medical education in LGBT health. It is unclear how participation in LGBT-specific training is distributed across physician specialties and practice regions. Additionally, national data assessing cultural competency training for physicians are scarce and do not delineate LGBT-specific training or training completed prior to, during, or after graduate medical education.
METHODS
Using data from the 2016 National Culturally and Linguistically Appropriate Services Physician Survey, this study evaluated patterns of post-residency cultural competency training, as well as associations between LGBT-specific training and provider perceptions of patient care outcomes.
RESULTS
Provider specialty, practice region, and receiving cultural competency training as a trainee were associated with post-residency LGBT-specific training. Surgical providers (odds ratio [OR]: 0.42; confidence interval [CI] 0.25–0.73; p = .002) and those practicing in the South (OR: 0.49; CI: 0.26–0.92; p = .025) had lower odds of completing LGBT-specific cultural competency training while in independent practice. Post-residency LGBT-specific training was associated with provider agreement that cultural competency training improves the quality of care (OR: 2.76; CI: 1.44–5.28; p = .002), patient satisfaction (OR: 2.55; CI: 1.32–4.93; p = .005), and patient comprehension (OR: 2.03; CI: 1.05–3.90; p = .034).
CONCLUSIONS
Our findings provide disaggregated analyses that nuance the assessment of cultural competency interventions and support a broader effort to increase attention to LGBT health in continuing medical education.
Keywords
Introduction
Despite national calls across the United States (US) to improve care for lesbian, gay, bisexual, and transgender (LGBT) patients and increased attention to LGBT health in medical school and residency curricula, there is still a paucity of LGBT cultural competency training in continuing medical education (CME).1,2 A previous study of US academic centers revealed that only 15% had a list of physicians who had participated in LGBT cultural competency training. 3 There is virtually no data on the amount or frequency of LGBT health CME completed by providers nationwide, especially in nonacademic settings, and existing CMEs have limited effectiveness data. 2 We use the term “cultural competency” in this article to align with the literature and data analyzed, recognizing that cultural humility (defined by life-long learning and critical introspection) is preferred to “competence.” A recent systematic review found that LGBT cultural competency training has largely focused on knowledge acquisition and feasibility, with much smaller and variable effects on provider perceptions and attitudes. 4 National data on provider perceptions of the impact of cultural competency training on patient care outcomes do not disaggregate training specific to LGBT communities or differentiate between undergraduate, graduate, or post-residency training. 5 It is also unclear whether rates of attaining LGBT-specific training after residency differ across specialties and geographic practice regions. To address these gaps, we evaluated patterns of post-residency LGBT-specific cultural competency training and associations with provider perceptions of patient care outcomes.
Methods
We performed a cross-sectional analysis of the National Culturally and Linguistically Appropriate Services (CLAS) Physician Survey accompanying the 2016 National Ambulatory Medical Care Survey. 6 The Centers for Disease Control used this supplement in 2016 only, limiting the inclusion of more contemporaneous data. A total of 2,700 hospital- or office-based physicians in specialties other than anesthesia, pathology, or radiology were eligible for the survey. 6 There were 397 respondents, of which 392 provided self-reported information on cultural competency training subtypes and were included in this study.
Participants were categorized as having post-residency LGBT-specific cultural competency training, cultural competency training not specific to LGBT communities, or no related training. Provider perception outcomes of interest were recoded into a 3-point Likert scale (eg, disagree/agree/strongly agree or never/sometimes/often) and included knowledge of patient beliefs and values; perceptions of patient satisfaction, comprehension of and adherence to treatment and lifestyle recommendations, trust, and quality of care; and consideration of cultural factors in assessing medical needs and conducting health education. Bivariate analyses were performed using chi-squared and Fisher's exact tests to evaluate for differences between groups. We used Brant tests to test proportional odds assumptions. Multivariate logistic regression was then performed with applied survey weights, controlling for physician sex, age, race, ethnicity, specialty, and cultural competency training as a trainee. LGBT-specific training patterns across physician specialties and practice regions were analyzed using standard logistic regression. Statistical significance was set at 2-tailed α < 0.05 for all analyses, conducted using Stata 18.0 (College Station, TX).
This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (Supplemental Appendix A). 7
Results
Respondents were predominantly male (67%), White (71%), and 50 years or older (68%) (Table 1). Almost half (47%) had completed some form of post-residency cultural competency training, and of those participants, 68% completed training specific to LGBT communities. In total, 45% of all participants received cultural competency training in medical school or residency. Primary care respondents and those who had received cultural competency training as a trainee more often reported post-residency cultural competency training. The type of cultural competency training also differed by specialty and region of practice: surgical providers (odds ratio [OR]: 0.42; confidence interval [CI]: 0.25–0.73; p = .002) and those practicing in the South (OR: 0.49; CI: 0.26–0.92; p = .025) had lower odds of completing LGBT-specific training (Table 2).
Physician demographics, practice information, and CC training (unweighted: n = 392; weighted: n = 291,180).
Abbreviations: CC, cultural competency; LGBT, lesbian, gay, bisexual, and transgender; CLAS, Culturally and Linguistically Appropriate Services.
CLAS recorded binary sex; information on gender identity was not collected.
CLAS collapsed non-White races to minimize disclosure risk to participants.
CC training by physician specialty and region (unweighted: n = 392; weighted: n = 291,180).
Abbreviations: CC, cultural competency; LGBT, lesbian, gay, bisexual, and transgender; OR, odds ratio; CI: confidence interval.
Logistic regression by specialty: Primary care (ref); medical care (OR: 0.68; CI: 0.41–1.13; p = .134); surgical care (OR: 0.42; CI: 0.25–0.73; p = .002).
Logistic regression by region: Northeast (ref); Midwest (OR: 0.65; CI: 0.36–1.19; p = .164); South (OR: 0.49; CI: 0.26–0.92; p = .025); West (OR: 0.90; CI: 0.50–1.64; p = 0.742).
Compared to those with no post-residency cultural competency training, those with LGBT-specific training had higher odds of agreeing that cultural competency training improves the quality of care (OR: 2.76; CI: 1.44–5.28; p = .002), patient satisfaction (OR: 2.55; CI: 1.32–4.93; p = .005), and patient comprehension (OR: 2.03; CI: 1.05–3.90; p = .034) (Table 3). There were no differences in outcomes when comparing respondents who completed cultural competency training that did not include LGBT populations to those who did not complete any training. No statistical differences were found across groups for the other outcomes.
Multivariate logistic regression for physician perceptions of patient-related outcomes by cultural competency (CC) training (unweighted: n = 392; weighted: n = 291,180).
Abbreviations: CC, cultural competency; LGBT, lesbian, gay, bisexual, and transgender; OR, odds ratio; CI: confidence interval.
Reference group: no post-residency CC training.
Discussion
This study builds upon prior analyses of nationally representative CLAS data demonstrating associations between cultural competency training and physician characteristics, behaviors, and practice settings by providing disaggregated and multivariate analyses for training that addresses LGBT populations.5,8
While differences in cultural competency training across physician specialties or practice regions have not been previously identified, our subgroup analyses show that surgical providers and those practicing in the South have significantly lower odds of receiving LGBT-specific training, a gap likely to widen in light of increasingly disparate policies and legislation affecting LGBT people and the training of health care providers across the US.8,9
The care of LGBT patients is heavily impacted by health and healthcare disparities, and prior studies have shown that provider attitudes and perceptions of LGBT identities affect patient care outcomes and are modifiable by cultural competency training.4,10,11 Our results suggest a correlation between LGBT-specific cultural competency training and improved provider perceptions of patient satisfaction, comprehension, and quality of care. Interestingly, no differences in these outcomes were found between respondents who had cultural competency training not specific to LGBT communities and those who reported no form of post-residency training. This has several implications for the assessment of cultural competency training, not least the potential confounding influence of curricular content received as a trainee on the pursuit of CME in topics not ubiquitously included in medical curricula, such as LGBT health. Additionally, evaluating cultural competency training as a conglomerate is difficult and may mask meaningful health outcomes findings. As the concept of cultural competency is complex with distinct aims across topics and populations addressed, there is immense heterogeneity in training types and outcomes of interest. 12 Future research should consider an evaluation approach that focuses on specific communities or issues, and explore measures beyond self-report.
Major limitations of the study included the high nonresponse rate, vulnerability to social desirability bias given the focus on provider perceptions, and limited assessment of concepts such as patient satisfaction and quality of care, which were not further defined in the survey. There is a clear need for updated national data that details the content and quantity of cultural competency training. Given the sample size, data saturation may not have been reached for the study, and a power analysis was not performed.
Conclusions
Novel analyses of a national dataset reveal disparities in LGBT cultural competency training acquisition and demonstrate an association with improved provider perceptions of patient-centered outcomes. Our work highlights opportunities to improve the assessment of future interventions, and, importantly, supports a call to standardize CME in LGBT health.
Supplemental Material
sj-docx-1-mde-10.1177_23821205241287441 - Supplemental material for Association of Lesbian, Gay, Bisexual, and Transgender (LGBT) Cultural Competency Training With Provider Practice Characteristics and Perceptions of Patient Care
Supplemental material, sj-docx-1-mde-10.1177_23821205241287441 for Association of Lesbian, Gay, Bisexual, and Transgender (LGBT) Cultural Competency Training With Provider Practice Characteristics and Perceptions of Patient Care by Elaine Hsiang, John P. Ney, Allison L. Weathers and Nicole Rosendale in Journal of Medical Education and Curricular Development
Footnotes
Author Contributions
All authors contributed to the study design. EH and NR performed data analysis and initial manuscript drafting. All authors contributed to manuscript revisions and approved the final draft.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability
Ethical Considerations and Consent to Participate
Our institution does not require ethical approval for de-identified, publicly available data as defined by the US federal regulations summarized in 45 CFR 46.102(e), thus this study does not require Institutional Review Board oversight. Informed consent was not required for the information presented in this article given the use of Centers for Disease Control data made publicly available for public health research, and per the ethical considerations above.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a resident research funding grant from the UCSF Clinical and Translational Science Institute.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
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