I’ve had an opportunity recently (here and here) to write about patient safety in the context of care for transgender patients. Thinking about issues related to providing them with safe and effective care leads back to the basics of patient-centered care. Patient centeredness is hardly a new concept, but thinking about it through the eyes of transgender patients and their providers has given me new appreciation for the potential it has to transform care and influence the way we approach all encounters.
When I first began talking with people and reading about safety issues in transgender medicine, examples of care denied, unsympathetic clinicians, and patients who become discouraged and defensive were easy to find. Many problems stem from providers’ personal discomfort and lack of knowledge. And transgender patients who feel awkward or distrustful are less likely to be forthcoming with their histories and health-related questions, which also causes problems.
The disconnects on both sides can mean that transgender patients don’t receive routine medical care because they can’t find understanding providers, are denied services, or react to being treated badly by shutting down.
Put simply, the patient’s transgender status may prevent clinicians from seeing them for who they are. And patients who have been treated badly in the past may not share what is most important to them.
Sometimes transgender status is not relevant but still gets in the way of receiving good quality care.
In an article titled “The dangers of trans broken arm syndrome,” a transgender patient describes seeking emergency care for a broken arm. The physician on duty was so distracted by the patient’s transgender status, care for the broken arm was delayed. The patient reported, “In the five minutes it takes to grill me on gender stuff and write it all down, the orthopod has squandered a quarter of the time they have to fix my broken arm.”
Put Assumptions Aside
Commenting on an article about the needs of transgender patients, David Matheson, MD, recommends that clinicians set aside all assumptions about the patient:
…the most important need [the authors] identify is the need for healthcare practitioners to treat people as people, not as members of this or that group, but as people with their own specific needs, their own specific anatomy and their own specific psychology and outlook. Stereotyping always has an appeal in human reasoning as it saves time compared to actually seeing what is in front of oneself.
Matheson cites philosopher Ludwig Wittgenstein’s advice, “Don’t think, but look,” as the way to avoid assigning false values or judgments to the person you face – disarmingly simple advice, helpful in all circumstances.
All patients and clinicians, too, deserve to be accepted as individuals, each with a unique history and set of strengths, weaknesses, problems, victories, and mysteries. Matheson alludes to the apparent efficiency of working with stereotypes; they allow us to prejudge situations, reach decisions quickly, and often cause harm.
In all settings, not just medicine, more time per project, more hours in the day, and days in the week might make it easier for all of us to slow down and pay close attention to individuals, be they friends, strangers, co-workers, loved ones or patients. I have to believe, however, there is efficiency in authentic, respectful person-centered interactions even in the busiest of circumstances.
In the context of medicine, true patient-centered care leads to improved communication, fewer misdiagnoses, better care and better quality of life for both clinicians and patients, transgender or not. What could be more efficient?
Note: The photo that accompanies this post is the work of Ted Eytan, MD, MS, MPH, Family Physician and medical director in The Permanente Federation, Kaiser Permanente. He is also an accomplished photographer. To see more of his work, visit tedeytan.com and his Twitter feed, @tedeytan
In the late 1980s, when transgender individuals were known as “transsexuals,” a Chicago Tribune editor who grew up in Brooklyn and had the heart of a tabloid guy sent me to interview a woman in New England who’d called our newsroom with a complaint. She was trying to get her health insurance to cover the “coup de grace” changing her from a man to a woman and they wouldn’t. Suffice it to say that I went in with many prejudices and much apprehension — which the interviews and my due diligence afterwards changed. Knowing transgender people since then has confirmed my feelings of compassion. Link to the original story here:
Michael, this has been a good learning experience for me, too. Great article, thanks for sharing it.
Thank you for using my photograph. As I always do, I’ve written a thank you blog post: https://www.tedeytan.com/2018/04/07/25539
I read the 1989 piece, Michael, and reflected on how the significant ethical failures of the medical profession then shaped our generation of physicians, who are now changing everything :). Worth noting that one of the academic institutions you mentioned, set back this medically necessary care for about 30 years through their behavior, and still, in 2018, they have been identified as a significant anti-citizen by the Human Rights Campaign’s Healthcare Equality Index.
Other organizations, including mine, consistently rank 100% on this Index, as we did in 2018, again.
Also interestingly, this week while I thanked Engaging Patient, I terminated the license of another publication who used my photo to promote transphobic beliefs, and as has happened 100% of the time so far, they removed my photo politely without incident. Says something about a world that’s learning to love better, doesn’t it. ( https://www.tedeytan.com/tag/license-termination ).
Thanks to both of you for your work then and now to make this century so enjoyable for physicians like me,
Thank you for this article. There can never be enough about unconscious bias and especially for the patient who is transgender. Transgender is an umbrella term for people who are trans-sexual or people who sometimes present as the opposite gender they were assigned at birth. (cross dressers / drag performers) A person who is trans-sexual usually lives always as the opposite gender they were assigned at birth. Many of the articles talk about training clinicians yet it is also the “support” staff that need training. It could be caseworkers, reception and even custodial staff who should understand that not everyone fits into a mold of a specific gender. There is a lot to it and like all new interests – its one step at a time.