Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Tiffany Karas. She's an established endocrinologist with Northwestern Medicine and a recipient of several Northwestern Medicine Physician Clinical Excellence Awards. And she's here today to highlight gender pathways, gender-affirming care, and creating a welcoming practice environment.

Dr. Karas, it's such a pleasure to have you with us, and I really do love this topic. As we're focusing on how physicians and clinicians can create an environment where all patients feel welcome and can better meet often complex health care needs, I'd like you to start by telling us some of the unique health care needs of patients in the LGBTQ community. What are some of the challenges you see most often and some of the barriers to health care that you've seen in your practice?

Tiffany Karas, MD: Melanie, first of all, thank you so much for having me here to talk about this. It's such an important topic in our current medical situation, and this is really important for all patient care, not just those who are gender nonconforming.

I think it's important to start with a couple statistics that highlight what a big topic it is about patients, transgender patients, gender nonconforming patients, and the issue of discrimination or the fear of seeking medical care. In 2020, the Institute for Health Policy and Leadership out of Loma Linda University found that 15% of LGBTQIA+ patients felt discriminated against or were denied care even for their children in various medical situations; 30% of transgender patients avoided care due to the fear of discrimination. And one in three transgender patients felt that they had to teach the provider about their transgender status to receive even care for an upper respiratory infection or chest pain, or something that is fairly run-of-the-mill.

In order to avoid those issues is really focusing on patient-centered care, asking the patient straight away, "What are your pronouns? What is your chosen name? How would you like me to refer to you? What are your goals for this appointment? What are you hoping to get out of this? And how can I be a part of that with you?" making it feel collaborative. There is a certain hierarchy that is inherent in a doctor's appointment or an appointment with any kind of medical provider. So, I think just being transparent at the very outset about what the goal is in terms of being a collaborative team together to safely give the care that this human needs that they're seeking this care for.

Melanie Cole, MS: Beautifully put, Dr. Karas. And what measures have you implemented to ensure that LGBTQ+ patients receive respectful and affirming care in your facility? Can you share some examples of successful interventions or practices that have improved patient trust, which I feel is so important, and satisfaction, and especially among marginalized or underserved communities?

Tiffany Karas, MD: Absolutely. In particular with the LGBTQIA+ community, from the very start of their appointment, we have safe space signage that is a combination of the pride progress flag, which includes colors for transgender patients, the traditional rainbow pride flag, and also a black and a brown stripe in there to present the intersectionality of patients who come to these appointments with not only their transgender or gender nonconfirming status, but also perhaps being BIPOC or folks of color who have also been marginalized in many medical situations. So, that sign on the door, I think, is a really nice visual cue to start the process of that appointment. It's before they even open the door. It's there in their faces saying, "This is a safe space for you and we're going to do everything we can to make sure that you feel welcome here."

And then once they come into the office, the folks upfront who welcome people, the PSRs, the patient service representatives, who welcome people and ask from the very start, "How would you like me to refer to you? Do you have a preferred name or a chosen name that you would like us to put into Epic?" And pronouns as well, feeling comfortable asking patients about those things, because sometimes it's really uncomfortable. Patients may come with an insurance card with a name that doesn't match their gender identity. And so, asking those somewhat uncomfortable questions and having a comfort level about that and being able also to say, "Oh, I'm really sorry. I made a mistake about that. I'd really like to do this better. Can you tell me how you would prefer me to address you?' and moving right along.

We do a lot of warm handoffs in our office. And what that means is the medical assistant who calls the patient back will confirm with the PSR what preferred name is needed. And then, I talk to the medical assistant to make sure there isn't anything that I need to be aware of before I go into the room. And then when I take the patient to the lab, I walk them over and I use their chosen name with the phlebotomist to say, "So and so is here for some blood work." So, there is not one place where that important information about their chosen name and their pronouns gets dropped.

Melanie Cole, MS: Tell us about patient feedback. As we're looking at new options for patients to self disclose sexual orientation and gender identity information and what you've just been saying and how self-disclosure has really helped patients and improved care, I'd like you to speak about the feedback you're getting.

Tiffany Karas, MD: Well, this is fascinating. Patients much of the time are very open when they feel it's a safe place to share some of their feedback. I have heard all kinds of things. And I think just making it that safe space for them to be able to say this did not go well, and this is what happened, and being transparent about validating their experience, being transparent about what I'm going to do myself to see if we can make this better.

Melanie Cole, MS: So, really, it makes a difference when you see how the patients feel about coming into your practice now. How do you facilitate communication and collaboration among various specialists and healthcare professionals? Because that's really what this episode is about, Dr. Karas. We're talking about being involved in a patient's complex care plan and trying to set up this friendly, gender-affirming practice. So, speak about collaboration and how you're working with other providers.

Tiffany Karas, MD: This takes a great deal of effort and time and patience. And it's so important to have this sense of collaboration, not only with the patient, but also with the rest of the care team. And much of the time, they have a therapist. We love them to have therapists. There are a lot of changes that people feel emotionally as they are undergoing gender-affirming hormonal care. And so, keeping in touch with that therapist, again being transparent with the patient. I would love to have your therapist information, so if there's any problem, I could reach out to them. Certainly if you don't wish me to do that, or if you don't wish them to give me information, that's okay. But let's open the dialogue about everybody being on board with how to best care for you as the patient.

It's a lot of letter writing. It's a lot of being willing to call the other parts of the care team and say, you know, "Hey, I'm worried about this patient" or "Hi. We're so and so and we are going to initiate this care and this is how I want things to go with this. Can we be part of the same team?" So, it's a time-consuming yet very important part of the care of patients who are seeking care for gender-affirming hormones.

Melanie Cole, MS: Dr. Karas, I'm sure that you've seen cases where patients have experienced discrimination. We're all hearing about it and more and more, of course, in the media and certainly bias in healthcare facilities. In your own experience, what steps do you take when you hear about these situations?

Tiffany Karas, MD: I hit it head on with every single patient. If it's discrimination that they themselves experience, I want to take the time to understand what happens. I want to take the time to go to the person or the entity in our medical healthcare to make that better so that it doesn't happen again.

One of the very common places this happens is misgendering on the phone. Our language is very biased and very binary. We as humans like to show respect by calling people miss or sir or ma'am, and there are a lot of transgender patients who fear talking to people on the phone, because that is the one place that so often they're misgendered. And so oftentimes, the patient will say when they're calling the call center, "I would prefer to be called first name" or "I would prefer to be called ma'am versus sir." And that is very difficult for patients to say. So, I think understanding what the situation has been, where the patient felt discriminated against or misgendered, and then going to the source and not in a punitive way, but in a very growth mindset way of saying, "Hey, how can we do this better?" How can we, at the very start of this phone call, say, "How would you like me to refer to you? I see that your legal name is this. Is this the name that you would prefer me to call you during this phone call?" It takes two seconds, and it could go a long way to making people feel affirmed.

Melanie Cole, MS: Well, along those lines then, speak about resources, training, continuing education that you and your staff utilize to stay updated on best practices for creating this inclusive healthcare environment.

Tiffany Karas, MD: So, when I first started doing this about four to five years ago, I started with enhancing transgender care through our healthcare system at a place called Fenway Health Institute. It's similar to Howard Brown, but in Boston. And they have just a very lovely, well-thought-out educational program for folks who are trying to get into this care. And everywhere from surgeons to providers of hormones to mental health providers, social workers and everyone through the healthcare continuum.

The other institution that most of us as providers of care in this population look toward is WPATH, which is the World Professional Association for Transgender Health. They established guidelines, the first set in the 1970s. And every few years, they publish a set of standards of care. Standards of Care 8 came out exactly a year ago. And those are based on the research that we have available to us. They're based on expert opinion. Through WPATH, there are many places to get support to answer questions because so much of what we do is not evidence-based because the evidence isn't there. There's a lot of crowdsourcing that we do in certain patient situations. I feel like I've got a team of people, a community of people that I can go to as expert resources to say, "Okay. Let's collaborate on this particular situation. How do we do this better?" How do we give the patient the care that they seek in the safest way possible?

Melanie Cole, MS: As we get ready to wrap up here, Dr. Karas, and this is such an important topic for other providers to hear, I'd like you to discuss the role of medical ethics in ensuring that all patients are treated with dignity and respect in your practice and beyond, and how you feel healthcare organizations and policymakers can support physicians in their efforts to create that more inclusive and patient-centered healthcare environment.

Tiffany Karas, MD: I'd like to break that question down into a couple different parts. I think, thinking about the pillars of medical ethics, first being autonomy, respecting a patient's right to self-determination; and then beneficence, the duty to do good; the non-maleficence, the duty to not do bad or do no harm is the oath we all took as healthcare providers; and justice, to treat all people equally and equitably. I think thinking of those pillars every single time we see a patient for any reason is so important. And I don't think I can say it any better than that.

And then, as far as what healthcare systems can do to support this care, it's important. We need to do it. This is not a phase. This is not something that I think we can ignore. But physicians, providers need the time to spend with these patients, because they are so complex. And I think that's a big thing, is the time that it's going to require to do this work right.

I think we need money. We need funding. It takes a village to take care of these patients, and that village is really expensive. And then, I think the willingness to change. Healthcare systems need to be willing to kind of go out on this limb of providing care that might not be popular, or flashy, or ultra-efficient, or even lucrative, but it's human and it's important.

Melanie Cole, MS: It's compassion.

Tiffany Karas, MD: It's compassion, it's empathy, it's what so many of us went into this profession seeking.

Melanie Cole, MS: It certainly is. And I thank you so much for joining us and really giving us your insight and experiences, because it's so important for other providers to hear. Dr. Karas, thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org to get connected with one of our providers.

And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please always remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.