Addressing Health Disparities in the LGBTQIA+ Community

© 2020. All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.

ISBN (Print): 978-1-09834-715-4

ISBN (eBook): 978-1-09834-716-1

Table of Contents

Preface

Sade Kosoko-Lasaki, MD, MSPH, MBA

Acknowledgement

About the Authors

Contributing Authors

Description of the LGBTQIA Health Disparities Elective

Chapter 1. Introduction

Mark Duane Goodman, MD

Chapter 2. The Education of the Medical Students

Michael White, MD, MBA

Chapter 3. Accepting Care of LGBTQIA Patients: A Clinical Perspective

Michael A Greene, MD

Chapter 4. Medical Students Write Up

Chapter 5. Conclusion

Index

Medical Students Write up

LGBTQIA Youth: Vulnerabilities within Palliative Care

Badding, Tyler

Health Disparities Related to Stroke in the LGBTQIA Population

Roesch, Zachary

Disparities in the Prescription of PrEP in the LGBTQ+ Community

Pfeifer, Bradley

Sexual Coercion Among Homosexual Men in Prison and Mental Health Repercussions: A Case Study in Pollsmoor Prison, Khayelitsha, Cape Town, South Africa.

Tahseen, Ahmed

Depression and Suicidality Among Gay, Lesbian, and Bisexual Youth Populations

Morelli, John

The Impact of Discrimination on Transgender Health

Simon, Brittany

Barriers to Cervical Cancer Screenings in Transgender Men

Williams, Christopher

Unintended Pregnancies in LGBTQIA Adolescents

Mulder, Hanna

The Gender Nonconforming and/or Transgender Pediatric Patient

Van Galder, Hannah

Access to Healthcare of POC Gay Males and Bisexual, Lesbian and Transgender People of All Races in Comparison to White Gay Males

Safa, Hussein

Medical Considerations for Transgender Patients in the United States Military

Getchell, Courtney

Health Disparities Faced by Women Who Have Sex with Women and Recommendations.

Kohl, Mitchell

Barriers Faced by the Transgender Community in Seeking OB/GYN Care

Salinas Calma, Rei Christian

Transgender in Omaha: Disparities in Mental Health Care

Kiblinger, Sana

Mental Health Professionals and PrEP for the LGBTQIA Community

Bosi, Theodore

Medicine and Law: End of Life Care Considerations for Lesbians, Gay Bisexual and Transgender Patients

Saffold, Joseph

A Literature Review and Discussion of the Incidence and Prevalence of Mental Health Issues in the LGBTQIA Community

Clark, Tiffany

An Exploration of Health Disparities in LGBTQ American Indian/Alaska Natives

Bahe, Brianna

Suicide in Queer Adolescents

Giancola, Nicholas

Approaches to Improve the Knowledge and Skills of Healthcare Professionals about LGBT Community

Anonymous

Depression in the Gay and Lesbian Community

Anonymous

Eating Disorders and Disordered Eating Behaviors among Sexual Minorities in Adolescents

Anonymous

Special Considerations for Routine Health Maintenance for Lesbian, Bisexual, and Transgender Patients

Anonymous

Suicide Among Transgender Adolescents

Anonymous

PrEP for HIV Prevention and the Rise of Other STIs: LGBT Health Provision for Primary Care Providers

Anonymous

Sexual Health and STIs among Sexual Minority Women

Anonymous

The Rise of Gynecologic and Breast Cancer in the LGBT Community: Exploring the Barriers and Risk Factors among Lesbians and Transgender Men.

Anonymous

Preventative Care for Lesbian Women

Anonymous

Preface

Sade Kosoko-Lasaki, MD, MSPH, MBA

The office of Health Sciences Multicultural and Community Affairs (HS-MACA) at Creighton University was created in 2000. HS-MACA pioneers and synthesizes community, education and research efforts in the development of future health care professionals who are culturally aware and work toward the elimination of health disparities. The mission of the office is to promote Creighton University as a recognized leader in the training and development of a multicultural health care workforce that serves to reduce health disparities in underserved and diverse communities through research, culturally proficient education, community interaction and engagements through Ignatian values.

Its vision statement states that HS-MACA will be recognized and respected as an innovative department that pioneers and synthesizes community, education, research and the development of future healthcare professionals who are culturally aware and work toward the elimination of health disparities.

The goals of the department include the following:

To recruit underrepresented or disadvantaged students and faculty in the Health Sciences schools who will promote health and health equality to a diverse population;

To provide and promote retention activities for culturally competent underrepresented students and faculty;

To promote, expand and cultivate cultural awareness to campus and community;

To address health disparities through teaching, research and community advocacy;

To seek funding opportunities for innovative, integrative and coordinated approaches for the continued and expanded training of diverse health care professionals.

The Medicine Gender and Sexuality Alliance (MedGSA) at Creighton University was created in 2015. The organization aims to establish a safe place for LGBTQIA individuals at Creighton University Medical School. The organization aims to educate about LGBTQIA terminologies and inclusivity. The members hold educational lectures, documentary screenings and informal talks and conversations about topics relating to LGBTQIA issues.

In the same year, 2015, members of the MedGSA organization approached the leadership of HS-MACA to consider designing a course to cover a variety of topics regarding barriers to accessing health care in the LGBTQIA community. Dr Kosoko-Lasaki, the Associate Vice Provost of HSMACA reached out to Dr Mark Goodman, a professor in Family Medicine at Creighton University to help with the design of the course. Members of the MedGSA organizations suggested topics to consider for the course and helped to provide logistical support for the course. The LGBTQIA elective was designed using an existing template of another health disparities elective that Dr Kosoko-Lasaki offers to M4 Medical students. In 2016, Dr Kosoko-Lasaki reached out to Dr Michael White, cardiologist and at that time, Associate Dean for Medical Education at Creighton University, to serve as one of the course directors for the two weeks elective for M4 students.

The LGBTQIA Health Disparities: Issues and Strategies is a two-week course approved by the education committee of the medical school at Creighton University. The course is offered to M4 students and is designed to help students identify the specific health care needs of the LGBTQIA community and the health disparities that affect its members. Students choose their area of focus but are encouraged to choose an area relating to their specialty of interest in residency training. The students also determine the importance of responding respectfully to and preserving the dignity of the LGBTQIA community both within and outside of health and social systems.

The curriculum is attached to this document for the reader’s review.

Currently, thirty-eight students have taken this on-going elective. We present the reflections and submission of twenty-eight students in the following chapters in the book. Majority of the students have graduated from medical school. We were able to obtain consent from 19 students to attach their names to the excellent write ups they researched and submitted. The remaining students are described as anonymous as we were not able to obtain their consent to attach their names with their work. The names of the anonymous student writers are kept on record at Creighton University.

This book will serve as a resource to other medical students, health professions students in Dentistry, Pharmacy, Occupational and Physical Therapy, Nursing, Public Health and the Social Sciences.

Acknowledgement

Sade Kosoko-Lasaki, MD, MSPH, MBA

I thank God the Almighty for his blessings and for giving me the ability to edit this book. My husband, Dr Gbolahan Lasaki, PhD has been a source of encouragement with his unconditional love and support. My children and their families have given me the fortitude and strength both directly and indirectly to continue to give the best of my ability to all God’s children even as we address disparities in health care.

Ms Phebe Mercado Jungman, my administrative Specialist at Creighton University has done an excellent job of copyediting and collating the manuscript while Twister Jover is responsible for the cover photograph and design. I appreciate their efforts tremendously.

Finally, I want to thank the leadership at Creighton University, especially the president, Fr. Daniel Hendrickson, PhD and the provost, Thomas Murray, PhD for their true commitment to diversity in all its forms.

The staff of Health Sciences’ Multicultural and Community Affairs (HS-MACA) at Creighton University and all the wonderful students, faculty, staff and community that we serve have made this book possible through their comments, challenges and goodwill. The medical students who took the elective that formed this book have done an exceptional job.

My co-authors, Dr Mark Goodman and Dr Michael White are wonderful people to collaborate with. I have enjoyed the experience. Thank you.

Mark Duane Goodman, MD

I honor and thank each of our students, who are creating a better world.

I honor and thank my teachers and mentors, especially Dr. Kosoko-Lasaki for the opportunity to contribute to a kinder and more inclusive world.

I honor and thank my half-side, Rick Shever for being my wingman.

I honor and thank Creator; it has been a wonderful journey thus far.

Michael White, MD, MBA

I am grateful for the support and opportunity of many individuals to allow my participation to edit this book to continue contribute to the growth of knowledge of disparities in healthcare. Specifically, my wife Jolene, who is a constant foundation to build all the success with support and dedication to our families. My daughters Kayli, Emma, and Avery who continue to mature and bring their gifts to their friends and our families.

I recognize the commitment of the healthcare delivery partners; Common Spirit Health with both CHI Health and Dignity Health, Valleywise Health and District Medical Group, that allow Creighton students to be an integral part of care delivery as an essential component of learning. Without these environments, our students would not be able to have the experience to see the direct impact that health disparities have on our patients.

Thank you to Drs. Kosoko-Lasaki and Goodman for allowing me to collaborate on this important work, as well as Ms. Phebe Jungman to coordinate all of these efforts and bring this to fruition.

About the Authors

Sade Kosoko-Lasaki, MD, MSPH, MBA

Sade Kosoko-Lasaki, MD, MSPH, MBA is associate vice provost for Health Sciences, professor of surgery (ophthalmology) and professor of preventive medicine and public health at Creighton University. She is co-founder and co-director of Creighton’s Center for Promoting Health and Health Equity (CPHHE) and is a multiple national award winner and an internationally renowned researcher in minority health with a focus on increasing the health care workforce.

Dr. Kosoko-Lasaki has led Creighton University’s participation in the training and education of a diverse group of faculty and students at the pre-collegiate and collegiate levels in Nebraska which has resulted in the award of several multi-million-dollar award research initiatives. In addition, her efforts helped achieve the designation of the Creighton School of Medicine as a Center of Excellence in Minority Education from 2005 to 2008.

She leads Creighton’s Office of Health Sciences-Multicultural and Community Affairs through programs such as the pre-Medical, pre-Dental and pre-Pharmacy and Health Professions post baccalaureate and pre-matriculation programs;the Health Careers Opportunity Program (HCOP); the Health Professions Pipeline Program; Cultural Proficiency Seminars, Community Outreach Primary Care (COPC) and Health Disparities Initiatives with a focus on community-based participatory research.

As co-founder and co-leader of CPHHE, a community-university collaborative virtual center designed to promote wellness in the Omaha Community, Dr Kosoko-Lasaki and her colleagues have developed a Racial and Ethnic Approach to Community Health (REACH) initiative to reduce chronic disease health disparities in the African American community in Omaha with funding from the U.S. Centers for Disease Control.

Dr. Kosoko-Lasaki has built collaborative relationships locally, nationally and worldwide while serving as a community/academic leader in the Omaha area. She oversees the recruitment of disadvantaged students to Creighton’s health science schools, and mentors these students to retain them. Dr. Kosoko-Lasaki has lectured nationally and internationally on cultural proficiency and health disparity issues, focusing on the promotion of pipeline programs that prepare and support disadvantaged students from fourth grade through health professional schools, so the students can become successful health care providers.

As an ophthalmologist with a public health degree, Dr. Kosoko-Lasaki is passionate about training and educating individuals in developing countries on blindness prevention, specifically Vitamin A deficiency, which is the leading cause of preventable blindness in children and a major public health problem throughout the world. She is also a specialist in the treatment of glaucoma.

She has served as a consultant to UNICEF, USAID and Helen Keller International in Burkina Faso, Niger, Mauritania, Chad and the Philippines.

Since 1986, Dr. Kosoko-Lasaki, a clinician and surgeon, has researched the prevalence of glaucoma in blacks in St. Lucia, West Indies. With a focus on detecting and treating glaucoma — the most common cause of blindness in African Americans and Hispanics – she has initiated health fairs and screenings throughout the Washington DC metropolitan area, in Nebraska, Iowa, Kansas, the U.S. Virgin Islands and in the Dominican Republic.

In 2001, she created a program for blindness prevention at Creighton University entitled, Preventing Glaucoma Blindness in Nebraska: A Creighton University Initiative, which targeted individuals at risk for glaucoma blindness in Omaha and surrounding states. Dr. Kosoko-Lasaki had a clinical practice at Creighton University Medical Center from 2000-2015 where she took care of a majority of African Americans and Hispanics: a population with high prevalence of glaucoma. Currently, she practices ophthalmology (Glaucoma) at the Veterans Health Administration in Nebraska and Western Iowa.

Dr. Kosoko-Lasaki has written over a hundred and fifty publications in peer-reviewed journals and has co-authored Maintaining the Target Intraocular Pressure: African American Glaucoma Specialist, a textbook, Cultural Proficiency in Addressing Health Disparities and recently a book, Diversity and Inclusion in a More Perfect University: HS-MACA Twenty Year History of Success.

Dr Sade Kosoko-Lasaki is married to Dr Gbolahan Lasaki, PhD, a petroleum engineer. She has three children of her own and three stepchildren. They are blessed with four grandchildren.

Mark Duane Goodman, MD

Enjoy the journey if you can, it’s all quite humorous after all!

That gregarious attitude led Dr. Mark Goodman into a vocation where he would be able to interact with people. Combine that with his desire to find a career that mattered and it’s no wonder he became a doctor.

The environment at Alegent Creighton Health Clinic plays right into Dr. Goodman’s extroverted nature. He has built himself a fine list of consultants that he knows and trusts. The benefits of working as part of a team go directly to the patient.

Dr. Goodman enjoys teaching caregivers of the future so he can leave a legacy for future generations. Research and publications can do only so much but passing the gift of medicine to the students and residents keeps giving.

Dr. Goodman lists yoga, triathlons, travel and dogs as some of his favorite things. He is also passionate about seeking justice, meaning and kindness in his life.

Michael White, MD, MBA

Michael D. White, MD, currently serves as the Executive Vice President and Chief Medical Officer of Valleywise Health in Phoenix, Arizona. Valleywise Health (formerly Maricopa Integrated Health System) has a proud tradition of being both the community safety net health care system, with a mission and commitment to serving the underserved and Arizona’s only public teaching hospital. Valleywise Health consists of Valleywise Health Medical Center, the only Level I Trauma Center in Maricopa County verified by the American College of Surgeons to care for both adults and children, Arizona’s only nationally verified Burn Center serving the entire Southwestern United States, the McDowell Healthcare Center, the largest provider of HIV primary care in Arizona, women’s and pediatric refugee health services, the Arizona Children’s Center, three behavioral health centers, and 12 FQHC sites throughout Maricopa County. Dr. White joined Valleywise Health in August 2019.

Dr. White currently also serves as Associate Dean for Technology and Informatics at the Creighton University School of Medicine. He continually identifies opportunities to enhance the learning environment for healthcare clinicians of the future. Dr. White is an Associate Professor of Medicine in the Division of Cardiology. He joined the faculty of Creighton University School of Medicine in 2008. He previously served as Associate Dean for Medical Education in 2013 and held that role until 2015. In this prior Associate Dean role, Dr. White oversaw the curriculum for undergraduate medical student education.

Dr. White is a practicing interventional cardiologist. He is board-certified in internal medicine, cardiovascular diseases, and interventional cardiology. He received his Bachelor of Science degree in biology from Creighton University. Dr. White received his medical degree from the Creighton University School of Medicine. He also completed a residency in internal medicine and a fellowship in cardiovascular disease. He completed a fellowship in interventional cardiology at Duke University in Durham, North Carolina. Dr. White earned his MBA degree from Creighton University in 2019.

Contributing Authors

Faculty

Dr. Michael Green

Dr. Michael White

Dr. Mark Duane Goodman

Dr. Sade Kosoko-Lasaki

Medical Students

Ahmed Tahseen

Brianna Bahe

Bradley Pfeifer

Brittany Simon

Christopher Williams

Courtney Getchell

Hanna Mulder

Hannah Van Galder

Hussein Safa

John Morelli

Joseph Saffold

Mitchel Kohl

Nicholas Giancola

Rei Christian Calma

Sana Kiblinger

Theodore Bosi

Tiffany Clark

Tyler Badding

Zackary Roesch

*Anonymous Authors (10)

*These are students who we could not reach to sign a release of their write-ups for publication

Description of the LGBTQIA Health Disparities Elective

The LGBTQ Health Disparities is an independent study (elective) offered to medical students at Creighton University in the fourth-year curriculum. The course plan and output are described below:

Course Plan

Week 1 – Research

Schedule meeting with Dr. Kosoko-Lasaki during week 1.

View 10-minute LGBTQIA Healthcare Training Video: "To Treat Me, You Have to Know Who I Am." https://www.youtube.com/watch?v=NUhvJgxgAac

Attend one of the three (3) 90-minute GLMA webinars "Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People." http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1025&grandparentID=534&parentID=940&nodeID=1

Read from Health Disparities and the LGBT Population – book provided The importance of sexual orientation disclosure to physicians for women who have sex with women. Willes, K., & Allen, M. (2014, April). In V. Harvey. & T. Heinz Housel (Eds.), Health Care Disparities and the LGBT Population. Lanham, CT: Lexington Books.

Coming Out Conversations and Gay/Bisexual Health: A Constitutive Model Study. Manning, Jimmie (2014, April) In V. Harvey. & T. Heinz Housel (Eds.), Health Care Disparities and the LGBT Population. Lanham, CT: Lexington Books.

Meet with Dr. Kosoko-Lasaki to discuss assignments/progress.

Schedule meeting with Dr. Greene the 2-week elective. Dr. Greene will provide advice and counsel to the students as complete LGBTQIA Health Disparities Research. To schedule this meeting email Dr. Greene ([email protected]) (This meeting must be after final topic is approved by Dr. Kosoko-Lasaki).

Identify healthcare disparities facing lesbian, gay, bisexual, and transgender individuals (this topic is used to create final paper)

Obtain final paper topic approval from Dr. Kosoko-Lasaki.

In addition to meeting Dr. Greene, students must meet with at least one person who is knowledgeable about the Health Disparity topic chosen.

Week 2 – Write Paper

Write a 6-page, double-spaced paper on the subject. Paper should be written APA style. Your paper must address the following categories:

Introduction

Background

Public Health

Global Perspective

Research (interactions)

Recommendations

Conclusion

Paper due date 48 hours before final meeting with Dr. Kosoko-Lasaki.

Meet with Dr. Kosoko-Lasaki to review paper.

Present the paper at a disparity-related forum such as Common Ground or other Health Disparity program before graduation from medical school.

Chapter 1.

Introduction

Mark Duane Goodman, MD

Throughout human history there have been individuals who did not sexually conform to the mainstream: and throughout human history these persons have been variously maligned, celebrated, killed, honored, bullied and protected. Perceptions are changing today: but discrimination and misinformation persist. Our book is an attempt to add to the conversation in the pursuit of justice and tolerance especially as it relates to the care of our patients and the education of our students.

The arc of the moral universe is long, but it bends toward justice. Theodore Parker 1853

Our compilation is a collection of edited submissions from our Creighton medical students over the past few years. To deepen their understanding, we asked the students to attempt to evaluate the medical system from the viewpoint of someone in the LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) community, and then write about it. Many students discovered injustice, and some identified the special burdens that came with being LGBTQ and in need of medical care. Some of the essays reveal how communities and governments also participate in injustice, not just medical caregivers or medical systems.

LGBTQ persons have an interesting history with medical caregivers: recognizing, for example, the deep and extraordinary bonds between a person living with HIV in the 1980’s and his or her caregiver, which were often defined as heroic, generous and incredibly kind. Consider also ACT-UP, (AIDS Coalition To Unleash Power) which had a loud voice for fast-tracking potential life-saving treatments at a time when the medical system was moving too slowly.

Despite existing protections, LGBTQ people face disturbing rates of health care discrimination—from harassment and humiliation by providers to being turned away by hospitals, pharmacists, and doctors. The CAP (Center for American Progress) survey data show the types of discrimination that many LGBTQ people face when seeking health care.

Among lesbian, gay, bisexual, and queer (LGBTQ) respondents who had visited a doctor or health care provider in the year before the survey:

8 percent said that a doctor or other health care provider refused to see them because of their actual or perceived sexual orientation.

6 percent said that a doctor or other health care provider refused to give them health care related to their actual or perceived sexual orientation.

7 percent said that a doctor or other health care provider refused to recognize their family, including a child or a same-sex spouse or partner.

9 percent said that a doctor or other health care provider used harsh or abusive language when treating them.

7 percent said that they experienced unwanted physical contact from a doctor or other health care provider (such as fondling, sexual assault, or rape).

Data from a large observational study suggests that 24% of transgender persons report unequal treatment in health care environments, 19% report refusal of care altogether, and 33% do not seek preventive services.

LGBT youth are at a higher risk for substance use, sexually transmitted diseases (STDs), cancers, cardiovascular diseases, obesity, bullying, isolation, rejection, anxiety, depression, and suicide as compared to the general population. LGBT youth receive poor quality of care due to stigma, lack of healthcare providers’ awareness, and insensitivity to the unique needs of this community. Young LGBT individuals find it difficult to report their sexual identity to their clinicians. Some clinicians are not well trained in addressing the concerns of members of this community. A study conducted in Washington DC showed that 68% of sexual minority youth reported about not discussing their sexual orientation, and 90% reported reservations about reporting them to their clinicians.

As with all patient populations, effectively serving LGBT patients requires clinicians to understand the cultural context of their patients’ lives, modify practice policies and environments to be inclusive, take detailed and non-judgmental histories, educate themselves about the health issues of importance to their patients, and reflect upon personal attitudes that might prevent them from providing the kind of affirmative care that LGBT people need. By taking these steps, clinicians will ensure that their LGBT patients, and indeed all their patients, attain the highest possible level of health.

The Stonewall riots of June 28, 1969 are considered the starting point of the modern gay liberation movement. Stonewall memorial marches evolved into the PRIDE marches of today. In 2001, the Netherlands became the first country to legalize same-sex marriages. As of November 1, 2019, same-sex marriages are legal in 30 countries. The gay rights movements of the 1970’s was overshadowed by the AIDS crisis of the 1980’s and beyond: and now resumes with new vigor.

Today, societies around the globe still struggle with gender non-conforming and the same sex relationships, churches, governments and nations are sometimes digging their heels, and sometimes changing: sometimes parting and sometimes reconciling: just like all other human relationships. Thank you for permitting the essays from our students to contribute to the conversation.

References:

Shabab Ahmed Mirza & Caitlin Rooney, Discrimination Prevents LGBTQ People from Accessing Health Care, Center for American Progress, January 18, 2018, https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care (accessed June 1, 2018).

Grant, IM, Mottett LA, Tanis J, Harrison, J, Herman, JL, Keisling, M. Injustice at every turn: a report of the National Transgender Discrimination survey July 5, 2018

Cureus. 2017 Apr; 9(4): e1184 PMCID: PMC5478215, PMID: 28638747 Monitoring Editor: Alexander Muacevic and John R Adler

Improving the Health cAre of Lesbian, Gay Bisexual and Transgender (LGBT) People: Understanding and Eliminating Health Disparities, Kevin L Ard MD, MPH, and Harvey J Makadon MD, The National LGBT Health education Center, The Fenway Institue; Brigham and Women’s Hospital and harvard Medical School Boston, MA

https://www.history.com › topics › gay-rights › the-stonewall-riots

https://www.usatoday.com › story › money › 2019/06/13 › countries-wher…

https://www.pewforum.org› fact-sheet › gay-marriage-around-the-world

Chapter 2.

The Education of the Medical Students

Michael White, MD, MBA

Introduction

The goal of medical education is to produce physicians who are prepared to serve the fundamental purposes of medicine. To achieve this goal, physicians must possess the attributes that are necessary to meet their individual and collective responsibilities to society. If medical education is to serve the goal of medicine, educational curricula must address learning objectives for programs that reflect an understanding of those attributes. Medical knowledge is accelerating exponentially, and it is essential to train students with the skills related to life-long learning that will allow them to be successful throughout their careers. This allows a learner to progress from undergraduate through medical education (medical school) to graduate medical education (internship and residency) into continuing educational programs after completion of training.

Contemporary medical education is rooted in the fundamentals presented by Dr. Abraham Flexner in his seminal report released in 1910. Flexner promoted a move away from an apprenticeship model of training to an academic model of education which included didactic instruction, research, and ultimately the real-life application. In the late 1990’s, due partly to the Institute of Medicine reports¹ on medical errors and the need for better healthcare delivery, medical education professionals began to shift curricular focus to systems-related competencies. The Association of American Medical Colleges (AAMC) has recommended that medical students should accomplish 13 Entrustable Professional Activities (EPAs) prior to graduation and entering residency education. These foundational skills are necessary to build upon to be a successful physician. The Accreditation Council on Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) endorsed the move towards competency-based education in 1999 with approval of the six core competencies which in addition to system-based practice included: patient care, medical knowledge, interpersonal and communication skills, professionalism and practice-based learning and improvement.

In order to achieve a successful career in medicine, a physician must be able to assimilate new and changing information. A key process in this is to develop a process of reflection that will allow maximization of deep learning and professional practice. Initiation of courses within undergraduate medical education curricula that promote a practice of reflection early in the process of professional formation as a skill to be refined throughout a career.

Adult Education

A key step forward improving educational programs in medicine involves appreciating the way adults learn. In order to reach a medical student audience more effectively, educators must understand assumptions regarding adult learners. In 1926, Albert Lindeman identified a series of 5 assumptions regarding adult learners.

Adults are motivated to learn as they experience needs and interests arise that require increased knowledge or training. To be successful, learning activities need to be centered around these points.

An adult’s orientation to learning has foundation in life events. Organizing learning in this way are around situations and not subjects.

Experience is the richest source for adult learning and therefore reflection on these experiences are one of the core methodologies for adult learning.

A successful educator of adult learners recognize that adults want to direct their own learning. Medical educators serve as a guide and a partner in the inquiries determined by the learner.

Differences among adult learners increase with age and therefore educators need to optimize the learning environment by adapting to the style, place, and time of learning.

The motivation to