Can You Recommend a Good Primary Care Provider?

 Perspective/Opinion

Can You Recommend a Good Primary Care Provider?

by 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 email 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 an Associate Professor in the Division of Infectious Diseases in the Department of Medicine at MCW. He is Medical Director of the Inclusion Health Clinic.

Understanding Sexual Harassment Reporting at MCW

 From the 12/11/2020 newsletter

 

 

Three Questions for Katie Kassulke – MCW Administrative Director of Faculty Relations/Title IX 

 

 

 

Understanding Sexual Harassment Reporting at MCW

 

 

The term, “Title IX” refers to a specific section of the Education Amendments of 1972 that protects people from discrimination based on sex in educational programs or activities that receive Federal financial assistance. Ms. Kassulke, the Administrative Director of Faculty Relations and Title IX coordinator for MCW, is responsible for coordinating the investigation of   reports and offering supportive resources and services. She was interviewed by Transformational Timeseditor, Bruce Campbell, MD …

 

 

QUESTION 1: How will recent Title IX legislative changes affect institutions like MCW? 

 

The U.S. Department of Education released new regulations governing reports of sexual harassment that went into effect in August 2020.  The regulations include new, narrow definitions of sexual harassment, requiring a significant shift in our grievance procedures, including a requirement that MCW hold live hearings.  In a hearing, both the reporting party and the accused will participate in cross examination of parties and any witnesses involved. 

 

MCW can maintain current investigation processes without live hearings for any report of inappropriate conduct such as unwelcome verbal comments, microaggressions or unprofessionalism that fall outside of the new Title IX definitions.  MCW is not unique in the practice of maintaining dual processes.  My role will be to carefully review all reports to ensure the appropriate procedure is used.  Both processes provide support and equitable treatment to all involved.

 

 

QUESTION 2: How does the office support victims when they come forward? 

 

It takes incredible courage for an individual to come forward and make a report.  I recognize that and seek ways to provide individualized support.  Support might include: 

·      providing resources such as arranging a no-contact order

·      helping arrange counseling

·      making academic accommodations

·      assisting with reporting a crime to law enforcement

Listening can be the best initial response to provide support. Reports may come to me from witnesses, colleagues, and/or the person who is experiencing unwelcome behavior.  I seek to understand how the reporting party  wants to proceed after a  report is provided.  Sometimes, individuals want to proceed with a full grievance process, and at times they prefer alternative resolution options.  Under the new regulations, we can now explore mediation, restorative justice, or other options.  

 

In my role, the regulations require I must avoid any type of judgment and remain neutral. What this means is I reserve making any judgment until fact finding and full grievance processes are completed, and I offer equitable treatment including supportive resources to all parties involved.

 

 

QUESTION 3: How has the #MeToo movement affected how you see your work?

 

The #MeToo Movement began in 2006 when Tarana Burke first coined the phrase and is designed to raise awareness of women subject to abuse.  The Movement has encouraged many individuals across the world to come forward and has shined a spotlight on how power structures have facilitated widespread sexual harassment.  #MeToo not only promotes hearing victims’ voices, it also hopes to force largescale changes. 

 

I am committed to providing a safe space for all involved parties to be heard and to reach appropriate resolution for each incident.   It is my hope all people come forward and make a report of any type of oppression or abuse they are experiencing.  

 

The #MeToo movement has made it clear to me that I can make a difference by addressing inappropriate behavior starting with disrespect and helping everyone know how to be an ally by speaking up when they see any type of unprofessionalism.  I love MCW’s focus on maintaining a culture of professionalism and work hard to support the efforts, and the IWill MCW that engages the MCW community in conversation and action around gender equity.  The annual Respect Training provided by MCW is another area I focus on to promote guidance about our policies, expectations, how to make a report, be an active bystander, and how to seek out resources.

 

 

Resources:

MCW Title IX Webpage

IWill MCW

MCW Policies

·      Professional Conduct Policy

·      Anti-Harassment and Non-Discrimination Policy

·      Prohibiting Sexual Harassment and Abuse in Education Programs

 

Integrating the Basic and Clinical Sciences in the Minds of Learners: Where the Rubber Meets the Road in Transforming Medical Education

From the 12/18/2020 newsletter

 

 

Workshop Review

 

 

Integrating the Basic and Clinical Sciences in the Minds of Learners: Where the Rubber Meets the Road in Transforming Medical Education

 

 

Jacob Prunuske, MD, MSPH and Amy J. Prunuske, PhD - Faculty members at MCW-Central Wisconsin

 

 

Drs. Prunuske describe a recent workshop that illustrates the key concepts to transforming medical education …

 

 

On November 24, 2020, MCW hosted an event co-sponsored by the Office of Academic Affairs and the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education that reflected MCW’s commitment to transforming how we approach medical education. The afternoon event consisted of a plenary and two workshops. 

 

 

Plenary Session: Promoting Cognitive Integration and Student-Centered Learning

 

The plenary was delivered by Amy Wilson-Delfosse, PhD, the Associate Dean for Curriculum at Case Western Reserve University School of Medicine, and Leslie Fall, MD, the Chief Executive Officer of Aquifer, a non-profit dedicated to delivering high-impact, virtual health care education.  The session focused on the key principle that cognitive integration must occur in the learner’s mind and thought processes. Medical educators must, therefore, design educational experiences that foster cognitive integration because that is the essence of what it means to be a doctor. Facts, figures, pictures, and diagrams are all available with quick internet searches, yet the availability of this material does not make someone a doctor. Rather, clinicians must be able to integrate the basic and clinical sciences within the context of patient needs, family dynamics, and community resources, and then develop appropriate differential diagnosis and management plans. Educators must support this cognitive integration and not limit their teaching to a simple transfer of facts and figures. 

 

Basic scientists and clinicians sometime lack a common language to describe key concepts. This disconnect increases the cognitive load for medical students and decreases the likelihood that students will learn to truly integrate basic and clinical concepts. To help alleviate this load, educators should identify the top clinically relevant concepts every medical student must be able to understand and apply in clinical situations to make safe, effective, and high-quality decisions. To meet this goal, medical educators must craft learning objectives that challenge students to justify clinical decisions using core basic science concepts.

 

 

Webshop: Student Centered Teaching and Learning (Dr. Wilson-Delfosse)

 

Following the plenary, Dr. Wilson-Delfosse presented the first webshop. Participants identified the MCW “Ideal Learner” as curious, reflective, humble, self-aware, adaptive, and collaborative. These characteristics align well with the educational philosophy of the Master Adaptive Learner framework. With the support of a robust coaching and support system, medical students must engage in four critical phases to develop the skills of a master adaptive learner: 

 

·      Planning phase: students identify gaps, select opportunities for learning, and search for learning resources. 

·      Learning phase: students critically appraise the resources they use for learning and intentionally practice effective study and learning strategies. 

·      Assessment phase: students assess themselves and receive feedback from others. 

·      Adjusting phase: students demonstrate an ability to transfer learning to both routine and novel clinical situations. 

 

Dr. Wilson-Delfosse highlighted a practical application: the Master Adaptive Learner Checklist. This checklist provides a template for medical educators to assess whether any given educational session fosters master adaptive learning skills development. MCW participants in the webshop were given the opportunity to apply this checklist to instructional vignettes, highlighting the value of the checklist for improving and aligning educational sessions.

 

Finally, Dr. Wison-Delfosse emphasized our role as medical educators in attending to student learning experiences and serving to energize and invigorate student excitement about learning. 

 

 

Webshop: Integration of Basic Sciences into Clinical Reasoning and Decision Making (Dr. Fall) 

 

Dr. Fall presented the second webshop. She described how the use of integrated illness scripts and mechanism of disease mapping supports student learning by integrating basic, clinical, and health systems sciences. This results in improved retention of information. Mapping of mechanisms of disease creates visual representations that foster integration of key scientific concepts and provide frameworks for exploring the art and practice of clinical medicine. 

 

MCW participants then applied these concepts to case-based learning strategies. By comparing and contrasting causal mechanisms of disease and illness scripts, participants provided rationales for laboratory evaluation, imaging, and clinical next steps. 

 

 

We look forward to applying the ideas and concepts presented during this event to our efforts to redesign our MCW curriculum. We encourage you to watch and review these sessions and explore opportunities to promote Cognitive Integration and Student-Centered Learning in your courses and clerkships. 

 

Recordings of the sessions are available here:

 

·      Plenary Session
Webshop 1- Student Centered Teaching and Learning

·      Webshop 2- Integrating Basic Sciences into Clinical Reasoning & Decision Making

 

 

 

 

Jacob Prunuske, MD MSPH is the Assistant Dean for Clinical Learning at MCW- Central Wisconsin.

 

Amy Prunuske, PhD is on the basic science faculty at MCW-Central Wisconsin.

 

 

A great miracle is happening here. Rededication is needed.

 From the 12/18/2020 newsletter

 

 

Director’s Corner

 

 

A great miracle is happening here. Rededication is needed. 

 

 

Adina Kalet, MD MPH

 

 

This week Dr. Kalet reflects on this season of miracles in our medical, societal, and spiritual lives, as we celebrate some remarkable achievements and ready ourselves for the future ...  

 

 

The photographs are spellbinding: first responders, nurses, environmental service workers, transporters, laboratory technologists, physicians in full PPE, sleeves rolled up at the ready to receive the vaccine. The science – messenger RNA presenting small bits of the SARS-CoV-2 spike protein to recruit our immune systems – is a miracle. The rapidity and coordination with which the basic and clinical scientists and government approval processes advanced to save lives is astonishing. The administration and engineering know-how enabling mass production, distribution, and inoculation is wonderous. 

 

Like the generations of physicians who experienced the end of the polio epidemic, the taming of tuberculosis, and the turning of HIV/AIDS into a chronic manageable disease, this generation should be inspired by the awesome power of civil and political society, health care systems, science, and medicine pulling together to address the existential threats to humanity. Many have been overwhelmed from the sacrifice, work, commitment, and persistence it has taken to make the miraculous a reality. Many on the front lines have been infected. Some suffer from late effects of the virus. Some have died. Modern miracles are not magic. 

 

At the same time, the Electoral College met and affirmed that we will have a new president and vice-president this coming New Year. Never in my lifetime have the gears of democracy been so transparent and inspiring. The campaign, the voting during a pandemic, counting and recounting, certifying and recertifying, and vigorously defense of the “voice of the people” were affirmed through the judicial process. We have disagreed and debated, we have exerted ourselves and have made a choice. This process has opened fissures in our civic life. We are in the midst of a major social upheaval, a tipping point, a moment of reckoning. We are exploring new territory. It has been truly miraculous and grueling.  

 

As I write this, it is the sixth night of Chanukah, a word that means “dedication.” On Chanukah, we celebrate a “Great Miracle.” We light candles and eat fried potato pancakes, jelly doughnuts, and chocolate coins. We play games and exchange gifts. We are celebrating, literally, having to clean up and make do after having survived a horrific era of bloody war and civil unrest. Chanukah recalls an historic, not biblical, event that took place during the 3^rd Century BCE.  The metaphorical miracle of Chanukah is that a bit of lamp oil lasted way longer than it should have, keeping the “eternal light” in a nation’s holiest space aflame while a a fresh supply could be procured.  But the miraculous thing we celebrate is that we had the privilege of cleaning up the mess and rededicating our places and spaces to the important work of the body, mind, and spirit. And many of us survived to tell the story. 

 

As 2020 ends, we have now breeched over 300,000 COVID-19 deaths in the US alone. More deaths from a single cause than in any war, although not unusual when compared to other pandemics.  Boxes of vaccine have landed in airports in every state, placed on trucks, delivered to the receiving docks of health care facilities, defrosted, and injected into the arms of our colleagues, friends, and family. 

 

The masked front-line workers in the photographs receiving their immunizations are people who continue to care for us, our health care team, our community, and our most vulnerable. It will likely be many months until we are free to lower our masks, but an end is in sight. 

 

I am looking forward, along with our MCW Kern Institute community to taking stock, cleaning up, and reorganizing in a better way, facing the austerity and dedicating ourselves to the challenging tasks ahead both within the house of medicine and well beyond. Together, we await the miracles yet to come. 

 

 

Adina Kalet, MD MPH, is the 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.