An LGBTQ+ Patient Asks: Can You Recommend a Good Primary Care Provider?

Originally published in the 12/18/2020 issue of the Transformational Times

An LGBTQ+ Patient Asks: Can You Recommend a Good Primary Care Provider?

Andy Petroll, MD

Dr. Petroll, who conceived and founded the Froedtert & MCW Inclusion Health Clinic, describes the role that the clinic plays to enhance services to the LGBTQ+ community in Milwaukee and beyond...

Since I began my career in medicine nearly twenty years ago, and as a member of the LGBTQ+ community, I would hear this question frequently. Usually, the next sentence was the questioner expressing a preference for a provider who was, themself, a member of the LGBTQ+ community, but stating that they would be willing to settle for someone who wasn’t. At minimum, they wanted a provider who would make them feel comfortable and would easily understand them when they talked about their sex life, their gender identity, or their relationships with their partner and families, while also providing them with the care they needed. I’d always do my best to make a recommendation, but I knew that what they were looking for was hard to find, especially if their insurance required them to stay within one health system or if they wanted a provider in a certain part of town. A handful of large and mid-sized cities had LGBTQ-focused clinics, many of which had been well-established for decades, but here in Wisconsin, there were none.

Identifying concerns for LGBTQ+ patients

What would often follow this question was a story about a negative experience in healthcare. Sometimes, their provider had not understood or had not wanted to hear about the kind of sex they were having. Maybe they were asked which parent was “really the mother.” Maybe they were called out of the waiting room by their legal name, rather than the name they actually used and that reflected their gender identity and appearance, sending shockwaves of embarrassment, anger, or fear through their bodies immediately before entering the exam room. Maybe they had asked for medication for HIV prevention and their provider was unfamiliar with or unwilling to learn about it or, worse, chastised them for even asking. In some cases, they had subsequently acquired HIV. Maybe they had had a good experience with their provider, only to have a staff member ask them an inappropriate question, or, horrifyingly, try to convince them that their sexual orientation or gender identity was immoral. Maybe their provider was “nice enough,” but “seemed uncomfortable” discussing sexual health, or never offered appropriate screening for STIs or certain kinds of cancers.

Of course, the stories I heard were a skewed sample. People who were satisfied with their care wouldn’t have reason to ask me for a recommendation or tell me their story. Nonetheless, after years of these conversations, I knew there was a demand for better healthcare for LGBTQ+ people. People wanted a combination of things:

• A physical space that made them feel like they belonged

• Clinic staff that would understand them without having to explain themselves

• A provider who would know what preventive tests they needed and who would comfortably listen to and competently answer questions about their sexual health

• A provider who could explain and prescribe medications that would affirm their gender

A provider who would know that it may have taken extraordinary courage for them to even come to the appointment.

Meeting an unmet need

The hope to meet these expectations formed the vision for the F&MCW Inclusion Health Clinic. The journey from conceptualization to inauguration was long. Along the way, when presenting this idea to senior leadership, I was met with enthusiastic support beyond my expectations. Appropriately, we were asked to formulate business plans similar to any new, proposed venture. After revising our plans, assembling MCW providers with significant expertise, training staff, decorating our clinic space, developing of a webpage, and doing outreach at community events, the plans for the clinic were approved. After more than three years of planning, we opened the F&MCW Inclusion Health Clinic in July 2018.

The goal is for the clinic to deliver comprehensive care within a clinical space that feels familiar and welcoming by providers who are experienced with and passionate about LGBTQ+ health. The clinic opened with six providers from several specialties (Internal Medicine, Infectious Diseases, Obstetrics/Gynecology, Psychiatry). The clinic population grew steadily, limited only by the number of new patient openings we had available. Over time, we delightedly welcomed additional enthusiastic providers from additional specialties (Endocrine, GI) into the clinic. Recently, we onboarded two new primary care providers to help meet the demand for our services including,notably, the clinic’s first transgender physician, bringing the number of providers to twelve.

The response

Reactions to the clinic have been more positive than I had even imagined. Often, patients start their first visit by expressing gratitude that the clinic was opened, even before we have provided them any care. Others express that their visit to the IHC was the first time they felt truly comfortable in a healthcare setting. Some are elated to begin their journey of gender affirmation easily and without barriers. Parents have been relieved to finally find a place where their adolescent children (we see patients age 15 and older) can get the care they need and have their questions answered. Community organizations and major corporations have invited us to speak about the clinic and a national conference requested that we present on the process of opening it. Patients travel from Milwaukee, throughout Wisconsin, and at least two neighboring states to see us. Our patients have been integral in providing feedback that has helped us improve. Some have pointed out the flaws in the multitude of systems and personnel that constitute their experience in our healthcare system. Some wish they didn’t have to wait so long to see us (thankfully, now, they don’t!). We are grateful for all types of feedback. We view this clinic as a community resource that should be continuously shaped and grown through input and feedback from the community we serve.

Do we really need a specialized LGBTQ+ clinic? Shouldn’t every provider be able to provide care to this population?

These are appropriately challenging questions that I heard several times during the journey to develop the IHC. In theory, the questioners are right. Ideally, all clinics and providers should be able to provide competent, comprehensive, and affirming care to LGBTQ+ patients. In reality though, without purposeful efforts in every clinic, staff members who create a welcoming environment, and providers who become culturally fluent and clinically competent delivering LGBTQ+ healthcare, patients will continue to have the kinds of negative experiences I described above.

Reaching beyond our walls

In addition to striving to be a center of excellence for LGBTQ+ healthcare, we also view the IHC as a catalyst for improving LGBTQ+ health in our region. We regularly provide clinical education on LGBTQ+ health to providers in our system and our state. This semester, our newly approved M4 elective in LGBTQ+ health began offering MCW students the chance to graduate with a more in-depth understanding of how to provide LGBTQ+ healthcare. We also regularly provide clinical experiences for MCW housestaff. I hope that with continued educational efforts, there will come a day when a clinic like the IHC is no longer needed. Until then, the IHC, and other clinics like it, are essential for the lives, health, and dignity of LGBTQ+ people.

It has been an honor to be able to bring the IHC into being. I couldn’t possibly name all the people whose support and hard work were essential in developing the clinic. Nonetheless, I am extremely grateful for their work and their encouragement. I am humbled by the passion and dedication of my colleagues in the clinic, both providers and staff members, and by the administrators from multiple departments who pour their hearts into supporting this multispecialty clinic.

Our work will continue. We see many ways to expand the size and scope of the clinic to better meet our patients’ needs and will continuously pursue these ideas. We will continue to solicit and react to our patients’ feedback with the goal of optimizing their care. We will continue to educate learners to populate the healthcare professions with competent and enthusiastic providers of LGBTQ+ healthcare. We will know we achieved our goal when every LGBTQ+ person can walk confidently, without fear or hesitation, into our clinic, and every medical clinic, and receive outstanding, complete care, with the dignity they deserve.

RESOURCES:

• If you want to learn more about the Inclusion Health Clinic, visit Froedtert.com/lgbtq

• If you are interested in having our group provide LGBTQ health training for your clinic or department, please contact me.

  
  

If you are interested in self-directed learning on LGBTQ health, I recommend the National LGBTQIA+ Health Education Center (https://www.lgbtqiahealtheducation.org/) which has dozens of high- quality learning modules.

Andrew Petroll, MS, MD, is a Professor in the Division of Infectious Diseases in the Department of Medicine at MCW. He is Medical Director of the Inclusion Health Clinic.

Implicit Bias and the Motherhood Penalty – Opting Out vs. Helping Out

From the March 31, 2023 issue of the Transformational TImes - Women's History Month

Implicit Bias and the Motherhood Penalty – Opting Out vs. Helping Out 

 

 

Elizabeth “Libby” Ellinas, MD, and Adina Kalet, MD, MPH  

 

In this Director’s Corner, Drs. Libby Ellinas and Adina Kalet call for ongoing, proactive attention to the subtle and mostly unconscious gender bias in the workplace that lowers career expectations for women and parental engagement for men and deprives all of us a more equitable world. If you would like to explore ways to mitigate gender stereotypes and second-generation gender bias, please consider making an IWill Pledge... 

 

Dr. Kalet’s story (1993):  

When I gave birth to our first child in 1992, my husband and I had parallel jobs -- same hours, same salary, same responsibilities, and we even had offices side by side. Except for the fact our colleagues, students, and staff acted as if my door was “always open” and his was “always closed,” we pretty much had the same daily routines. I took a six-month, mostly unpaid leave, because there were no formal maternity leave benefits at the time. He took two weeks paternity leave and returned to paid work. 

As the end of my leave approached, we discussed each returning to work four days a week so we could have a family life that included each of us having a full weekday with our child and -- along with a creative mixture of other childcare arrangements -- two meaningful work lives. When I went to my boss to discuss this, he said, “Sounds exactly right; we will support you in being ‘part-time.’” When my husband went to his boss, he said, “Don’t do it! You will ruin your career!”  

 

Two facts about this experience perplexed me. First, neither of us requested part-time work, given the demands of our clinical schedules, which included mandatory evening clinical hours. We proposed more than full-time hours, confined to four weekdays.  

Second, we worked for the same man.  

Dr. Ellinas’s story (circa 2003): 

As a young faculty member, and then as program director for the Obstetric Anesthesiology Fellowship, I had many opportunities to discuss fellowship opportunities with anesthesiology residents. 

When I spoke to women residents, I would sometimes encounter “interest if...” This would occur when someone was a great practitioner, and expressed interest in perhaps pursuing a fellowship “if…” That would be followed by a statement indicating she was putting her career second; usually second to her partner’s career: I will consider a fellowship if my partner gets his fellowship where there happens to also be space for me. Many were also feeling the time pressure to have children. I have not had that same conversation with a man.  

Maybe the woman’s answer was just a polite way of saying she really was not that interested in the fellowship. If not, I wondered whether a prioritization of the husband’s career would extend beyond the fellowship. Those fellowships would benefit both their careers and were open to both equally. What pressure was there – and coming from what direction – that resulted in the husband’s fellowship being prioritized over the wife’s fellowship? 

Now (2023) 

Second-generation gender bias refers to practices that may appear neutral or even favorable to women, but that discriminate against a gender because they reflect hidden, subtle, or silent bias.

The motherhood penalty is part of that bias: 

Mothers suffer a penalty relative to non-mothers and men in the form of lower perceived competence and commitment, higher professional expectations, lower likelihood of hiring and promotion, and lower recommended salaries.” (“Mothers suffer a penalty relative to non-mothers and men in the form ...”) This evidence implies that being a mother leads to discrimination in the workplace.

For men, on the other hand, having a child benefits their careers. They are seen as more stable, worthy of higher salary and more competent. So, when it comes to the differences between mothers and fathers at work, “the disparity is not because mothers… become less productive employees and fathers work harder when they become parents — but because employers expect them to.” 

Dr. Kalet and her husband’s boss had two children. He regularly talked about his home life as a means of relating to the women who worked for him, although he did not do this with the men. It was obvious he viewed himself as a feminist and a great supporter of women in medicine.

However, his own wife did not work outside the home, and took care of almost all the daily needs of making a home and caring for the family. This probably contributed to his blindness or insensitivity to the challenges of being a working parent in a dual-career family. This manifested as having unrealistic expectations of his team for time flexibility in clinical coverage, calling last-minute, early morning or late afternoon meetings, and expecting writing tasks to be done evenings and weekends.  

Because he himself was not forced to be organized and planful when opportunities arose, he waited until the last minute to recruit help from more junior members of the faculty so that only those with few responsibilities, other than work, could take advantage. Parents who might have been interested would have needed more notice to engage in the work. In these ways, he created inequities for leadership and academic opportunities. Had our institution had policies and incentives for him to be a more equitable leader, he would have embraced them readily.  

If we want to help women be successful in the workplace -- and reach what they perceive as their full potential -- we need to be aware of subtle (and not so subtle) biases that persist in the ways we work and think about our workplace and ourselves.  

 

The authors encourage everyone to: 

• Educate ourselves about second-generation gender bias and maternal bias. Both are often implicit, so we will not know about them unless we look for them.
• Encourage everyone to take full parental leave. Make it both straightforward and possible for the birthing parent.  
• Encourage fathers to take full leave. Discourage work productivity during this time to incentivize parent-child bonding and build other skills critical to equality in the home sphere. 

We encourage MCW to: 

• Continue to support salary equity efforts.  
• Address known and emerging second-generation gender bias in hiring and salary equity.  
• Consider more generous paid leave policies for parents.  
• Consider creative scheduling options for parent flexibility as the needs of families rapidly evolve. 
• Support lactation spaces and develop a culture that assists lactating persons toward success.
• Continue to offer equal parental leave, regardless of gender.  

See Info scope for details about MCW’s parental leave for faculty and staff. 

 

Dr. Kalet’s status update:  

My husband continues to have his “Daddy Day” long after our children have left home, his colleagues have adjusted to the fact he doesn’t attend routine meetings or teach on Fridays. As a result, as the needs of the family evolved, he was able to “protect” time for other work and personal pursuits. In fact, we both have had long satisfying careers, albeit with many difficult bumps along the way. Being a “good worker” has required remaining sensitive and responsible to institutional needs, learning to advocate for ourselves and others effectively when needed, and a willingness to compromise. All of this has been a continual negotiation and renegotiation around our work and with our bosses and supervisors, each other, and our kids.  

 

No careers have been ruined. 

 

Libby Ellinas, MD, is Director, Center for Advancement of Women in Science and Medicine and Associate Dean, Women's Leadership, Professor, Anesthesiology and a member of the Medical Education Data Science Laboratory at the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education at the Medical College of Wisconsin. 

 

Adina Kalet, MD, MPH, is Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.