Authors: Megan Rutte, Joanna Mayhew, Lauren Fraser, Megan Hebda
How do you help PA students grasp the diversity in patient populations or the barriers and disparities that certain patient populations face? The faculty at Shenandoah University’s PA program attempted to address these questions during the fall semester of 2013.
Rachel Carlson, EdD, MSBS, PA-C, the program’s director, gave students the opportunity to speak with a panel of adults representing different vulnerable patient populations. The panel included a female military veteran who served in combat, a homosexual woman of a minority race, a deaf woman and a transgender individual.
The class was split into four groups, and each spent an hour with one of the panel participants. The panelists discussed their interactions with the healthcare community, and students were able to ask sensitive questions in a safe environment. To wrap up the event, a spokesperson for each group highlighted key points and suggested how the information could be applied to future patient interactions.
The panel was enlightening. It fostered compassion and improved understanding of the participants’ unique cultural situations. All students were grateful for the candid discussions, and we look forward to applying this cultural competency to our practice.
Below is a reflection from the students about their experience with the panelists.
Megan Rutte, Shenandoah University PA student
My group’s panelist was a middle-aged woman who has been deaf since birth.
She is married to a deaf man and has two hearing children. She spent much of her youth in a community with a large deaf population and extensive community resources. However, after marrying and having children, she and her family moved to a rural area where resources for the deaf community were extremely limited.
She was able to share her personal stories about barriers to care and the challenges of raising two hearing children. The providers who cared for her children did not know how to communicate with her, or which resources to use.
The panelist stressed that all providers should be well-versed with the Americans with Disabilities Act of 1990. It states that all medical facilities, even private practices, are required to provide a qualified interpreter in a timely manner. It’s the responsibility of the medical facility to have the interpreter present and to pay the interpreter’s fees. It’s considered inappropriate to use family members, especially minors, as interpreters.
In a primary care office, interpreters often must be scheduled weeks to months in advance. As a result, when a deaf person experiences an unexpected illness, they are often forced to use ER resources where interpreters are on call.
Although practitioners often believe that writing can be an effective form of communication, our panelist taught us that the deaf have a distinct language. Think about it: Would you find it acceptable for your healthcare provider to write notes and not speak with you? Written communication is a good tool for patient education and medical directions. But it can’t replace meaningful communication.
I’d like to conclude with a few thoughts to keep in mind when interacting with deaf patients.
- Deafness has no correlation with mental acuity. Treat each patient with respect, and never assume that deafness hinders a person’s ability to understand and comprehend.
- Practitioners should communicate with deaf patients using in-person interpreters or video relay services that enable telephone conversations between hearing and deaf individuals.
- When using an interpreter of any type, it is important to speak directly to the patient. The interpreter is merely a conduit through which communication can effectively occur.
To learn more about the deaf culture, visit the National Association of the Deaf.
Joanna Mayhew, Shenandoah University PA student
I spoke with a self-described “diversity trifecta”: an African-American female who is a lesbian.
She is married, though the state she lives in does not recognize the union. She and her wife recently adopted a child. But according to her state law, same sex adoptions are “not allowed.” Only her wife is able to legally adopt their child.
She said several providers assumed her wife was her sister, cousin or friend. In addition, almost all of her prior healthcare providers assumed she was in a heterosexual relationship. When asked, “How many men are you currently sexually active with, or have you been sexually active with,” she would respond, “zero.” Only one provider asked about sexual activity with women.
I must admit, when I noticed her wedding ring at the beginning of our session, I also assumed she was married to a man. And I’m not sure I would have clarified her sexual orientation if she were my patient.
Lesbian, gay, bisexual and transgender (LGBT) patients may be hesitant to talk about their relationship and family structure due to fear of judgment or prior bad experiences. And they have different sexual health concerns from heterosexual patients. Most providers are not familiar with the needs of this population.
In addition, state laws dictate how nontraditional families are allowed to interact in the medical setting. Because this panelist cannot legally adopt her child, she’s encountered several barriers to being an active part in her child’s medical care in urgent cases deemed by a medical facility to be “family-only” medical situations.
Tips to pass along:
- When treating an LGBT patient, always ask the relationship of anyone accompanying him or her.
- Familiarize yourself with health issues unique to the LGBT population.
- Make sure you ask the right questions.
- Never assume the patient’s gender, sexual orientation or how they want to be referred to, and remember that your body language is as significant as your words.
Lauren Fraser, Shenandoah University PA student
Women and military personnel are both stereotyped. But what if you’re a woman in the military?
I interacted with a female combat veteran who married a fellow combat veteran. Her husband was injured in war and suffered a traumatic brain injury (TBI). This created the perfect storm for our participant: Not only did she have to suffer through the thoughts and angst created by her war memories, but she also had to suck it up and care for her husband, who was going through the same thing—only worse.
As she spoke about her experiences and hardships, some important things stuck out in my mind.
First and foremost, do not, under any circumstances, assume that only male military members have been in combat. Females have been in combat whether or not they’re formally recognized as “combat veterans.” The preconception that only men have experienced combat is becoming increasingly intolerable as more females enter the military. Hundreds have served in Afghanistan and Iraq.
At the same time, remember that combat veterans are normal people living everyday lives. While it is important to screen for conditions such as post-traumatic stress disorder and TBI, it is not appropriate to do so in the hallway when patients are coming in for something like a flu shot. While we have to be sensitive to the unique risks in this population, we can’t stereotype and think that it is OK to casually ask every veteran about their mental or emotional well-being as a side conversation. We need to make sure that our actions and words are appropriate and sincere– including the appropriate timing.
Megan Hebda, Shenandoah University PA student
When I saw the lineup for our special guests, my first thought was, “Please, any group but the one with the guy in the dress!”
To my dismay, I was assigned to the “cross-dresser” (a term I later learned to be incorrect). I frantically looked around for an escape, unsure of why I was so uncomfortable. “I don’t know anything about people who are transgender,” I thought. “How am I supposed to relate? How am I supposed to talk to him…or is it her?”
Honestly, I was scared, intimidated and felt awkward…until she began to talk.
The first topic that she addressed was the quick facts every provider should know.
- Never assume that transgender patients are homosexual. “Gender identity” and “sexual orientation” are two different things, and in fact, she said most transgender patients are straight.
- Always address a transgender patient by the pronoun that corresponds to what he/she is dressed as. Even though our panelist was a male, “she” is preferred when wearing women’s clothing.
She then began educating us on what it means to be transgender. Ever since she was a child, she had a strong desire to put on women’s clothes. Because this habit was shunned by society and frowned upon by her family, she tried to hide it and overcompensated by undertaking so-called “manly” pursuits, such as becoming an Army infantry officer. Throughout her life, the compelling desire to “dress” continued, despite conscious efforts to suppress those feelings.
Our panelist described dressing as a sense of overwhelming relief—like she just “took a hit.” Dressing makes her into a kinder, happier person instead of an angry person, stressed and fatigued from fighting a constant internal battle. Unfortunately, being transgender strains family and work relationships.
It’s also important to realize that transgender and transsexual are not synonymous. People who are transgender generally do not wish to realign their gender with medical intervention.
Hearing our panelist’s story changed my opinion of transgender patients. Because of this experience, I more thoroughly understand the underlying battle that some transgender patients face every day. This internal conflict affects patients’ health and leads to difficult relationships, anxiety and depression.
All PAs should be aware of what it means to be transgender and accept these patients according to their gender preference.