‘In Dialogue’ Episode 16: Transforming Health: Inclusive, Personalized Care

Introduction:
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Saroo Sharda (SS):
My name is Dr. Saroo Sharda. I’m a practicing anesthesiologist, in addition to my roles as a medical advisor and Equity, Diversity and Inclusion lead at the CPSO.

Welcome. Thank you for joining us for another episode of “In Dialogue.” I am so thrilled to be hosting this episode during Pride month. As I hope that you know, at CPSO, we stand with our health system partners in celebrating the contributions and accomplishments of Ontario’s 2SLGBTQIA+ physicians and health leaders. And I’m very excited to be joined by one of those leaders today: Dr. Jordan Goodridge.

Hi, Jordan. Thank you so much for being with us.

Dr. Jordan Goodridge (JG):
Hi, thank you so much for having me. It’s my pleasure being here today.

SS: Jordan, you do a variety of work in this space, and I know that you wear lots of different hats and have been involved in lots of different organizations. Can you tell us just a little bit about some of that work and then we’ll dive in deeper to find out in-depth more about some of those pieces?

JG: Absolutely. So, my training is in family medicine, but I also completed an HIV Enhanced Skills program with the University of Toronto. A lot of the work that I do centres around HIV care, 2SLGBTQ health, and I’ve done that in a number of different ways so far over my career, which I’d like to think is still relatively early on.

I’ve worked with the Sherbourne Health Centre in downtown Toronto on the 2SLGBTQ health team. The clients that we see generally all fall under that umbrella, at least within the team that I primarily work on. And that’s where I’ve worked as a family physician for slightly over four years. Right now, I’ve transitioned into more of a consulting role in terms of providing HIV consults and doing transition-related surgery assessments to help support some of my colleagues at the Sherbourne Health Centre.

I also do work with Rainbow Health Ontario, as well as CAMH — the Centre for Addiction and Mental Health — here in Toronto, doing lots of educational work to other working staff, physicians, residents, nursing students, nurse practitioners, etc., just in terms of providing transgender and gender-affirming health care.

And finally, I am also a faculty member at the University of Toronto, where I’m currently a course director. And I do a lot of teaching there as well to the medical students largely around 2SLGBTQ health, HIV care and a few different areas as well.

SS: You’re busy, Jordan — busy with things that clearly are a passion of yours, and so important to the way that we provide safe and inclusive and culturally safe health care. I wonder if we can talk a little bit about HIV care to begin with? Can you explain to us what you have found to be some of the specific issues and barriers to care that are faced by patients with HIV? What has been A) your experience of that as a physician providing care and B) some of the important lessons that you’ve learned from that that maybe you want to share with others?

JG: Absolutely, yeah. I find that patients with HIV can face a number of barriers to accessing care. But I think one of the main messages that I want to convey today is that each patient is completely different. And each of their barriers, each of their goals for care can differ depending on a number of factors that may actually be unrelated to their HIV. For instance, we know certain populations that are already disenfranchised are at a higher risk of HIV transmission and acquisition. We know for instance, Black, Indigenous and other people of colour, as well as sexual and gender minorities, such as the transgender community, men who have sex with men, are disproportionately affected by HIV. While HIV in itself can act as a stigmatizing diagnosis, can affect how individuals interact with their world and interact with their healthcare providers, there are a lot of other intersecting factors as well that actually can affect their engagement and care and present as barriers to care.

So, that’s one of the main messages I want to convey is not forgetting about all of those different identities that any given patient might have and how that can play out in terms of their care. For instance, knowing that say Black transgender individuals are at a higher risk of HIV, but being Black and being transgender can affect how they interact and engage with the healthcare system. We recognize that we have worked in historically oppressive systems, and that can absolutely influence the ways that patients do or don’t choose to engage in care. So, I think first and foremost, recognizing all of those factors, doing reflection on what our own biases are working in a system that’s been historically oppressive, and then recognizing how we can intervene to best help support our patients, which isn’t a one size fits all approach, but, actually, rather has to be quite individualized.

SS: And what I’m hearing from you is making me think about these ideas of cultural humility and being curious, and not thinking about any marginalized group as a monolithic group of people — we all have these intersectional experiences. And perhaps, I think where we sometimes struggle as healthcare providers is that we do consciously or unconsciously start to group people together. And then that ends up leading to certain stereotypes, which then affect the way we interact and the way we provide care. So, I think it’s that balance that we’re always looking for, of recognizing that there are these systems of oppression that affect certain groups of people and that cannot be ignored. And then there’s also the individual within that system, who has all of their own experiences and life experiences, and the way that the healthcare system has treated them in the past that they then bring into that interaction.

So, maybe a follow-up question then is, in your team at Sherbourne or all the other places that you work at, what kind of things do you do to help patients or clients feel safe and confident in sharing questions, concerns that maybe they haven’t been able to bring to other providers? What are some of the things that you do, recognizing that not everybody has access to a place like Sherbourne? Particularly, I’m thinking about patients in more rural communities. So, how can we, as healthcare providers, think about some of that framing in helping people feel safe coming to us with their questions and their concerns?

JG: Absolutely. I think first and foremost is just making sure that your healthcare environment is one that’s inclusive of individuals from many different identities. So, thinking about the pamphlets and brochures and posters you may have in your waiting room. Are the images they’re presented of individuals from diverse backgrounds? Do you have representation of 2SLGBTQ identities, of Black, Indigenous and other people of colour? Of different kind of family structures? Because I think a lot of the time what happens is we don’t recognize the ways in which a lot of these resources can be presented in a more heteronormative, sis normative framework. And so, thinking, “Do I have signages up in my clinic that demonstrates to these populations that we are aware that they exist and we want to help? Do we have gender-neutral bathrooms?” That can help patients to feel more included in their space. Does the intake form that we use for our clinic or in the hospital actually allow patients to identify their own gender rather than circling the binary “male” or “female”? There’s a lot of things that even before a patient sees their health care provider, a lot of cues in their environment that will tell them whether or not they can let their guard down a little bit, whether or not they might feel safe.

And then we try to reduce the barriers of care as much as possible. I am very fortunate to have training in HIV primary care and to work at Sherbourne — really a centre of excellence in providing to 2SLGBTQ care. But I recognize that healthcare providers might not have received a ton of training in these areas. So, I think one of the ways that we can help to address these barriers is reducing as much as possible the burden of care that falls on the patient, whether that’s having to see a ton of specialists for conditions that potentially could be managed by their family physician. I think one of the real benefits of antiretroviral therapy, of HIV therapy improving so much over the years is that we have treatments that are easier to continue patients on, that have less adverse effects or consequences to their health over the long term — a lot of primary care physicians can actually continue patients on. So, even just reducing the number of times that patients have to go to a specifically-labeled HIV clinic, which actually may in itself be stigmatizing to the patient, that even of itself is a great way to help reduce barriers to our patients.

SS: Those are really, really helpful, Jordan, because not only are you talking about unpacking our own biases and thinking about some of the ways that we may, consciously or unconsciously, uphold systems of oppression, but you’re also giving us really practical examples. And actually, what you’re saying about space really resonates for me, because we did a CPSO Dialogue article on this (which we’ll link), which was about how you create these kinds of safe, inclusive spaces. And I think it was specifically at that time talking about trans patients or people who identify as trans, but, certainly, some of those principles are the same.

And I was just thinking about my own personal biases and the fact that I’ve had to be really intentional when talking to my kids because we’re a pretty heteronormative family. Of course, we have friends who are queer. But being really intentional about what kind of books am I choosing for my kids to read? Are they representing different kinds of family structures? Because it’s very easy not to think about that. And so, I think I’m using that example as being unaware of this doesn’t necessarily make us bad people. I think we often go to this good and bad binary when we talk about equity work too. It’s really just about being intentional about, “Yeah, of course, I have biases. Of course, I’m going to uphold these things without realizing. And how do I become intentional about that?” So, thank you for that.

I wanted to expand a little bit on something you said near the end of that answer, which is that you’ve had the opportunity to do specific training. You work at this centre of excellence. You have a whole team of people around you. What about folks — and I’m thinking specifically, maybe now, about people who provide primary care in communities who don’t necessarily have access to that, they don’t have access to a Dr. Goodridge or a Sherbourne — what kind of advice would you give to them? What kind of advice have you given as a mentor and an educator at Rainbow Health to people like that, or even to institutions who are trying, but maybe struggling with some of this and trying to understand how they bring this into their own practices in their own institutions?

JG: That’s an excellent question. Coming from the perspective of 2SLGBTQ inclusive care, I really, really appreciate Rainbow Health Ontario as an organization in general. Rainbow Health Ontario, or RHO, has a number of different training courses that are available to physicians, whether it be primary care physicians, specialists, as well as health care providers from other fields as well, that are really designed to help make sure that providers have at least a baseline in terms of cultural competence and understanding how to provide cultural safety to these clients. The good news too, with the Rainbow Health Ontario courses, is that they are CME accredited. So, for instance, for those family physicians who have to complete a certain number of MainPro credits anyways, it’s a really great way to do so, as well as to learn about this type of care and to really benefit the care that you’re providing to all patients — those who are out as 2SLGBTQ and those who are not. So, I really recommend that as a resource.

Rainbow Health Ontario provides a number of sessions, both in terms of how to provide hormone therapy to patients, what details to counsel patients on when prescribing, how to refer for transition-related surgeries. And so basically, I think that this is one of the ways that providers can help to fill that gap that they identify they might have as a result of not having learned or seen so many patients from these populations during their own training.

There are some other resources as well and I’m happy to say that overall, the number of resources have been increasing over the years. For instance, the Centre for Addiction and Mental Health, or CAMH, does also offer a program called the ECHO program. And a lot of different training courses are available through ECHO for, again, physicians as well as other interdisciplinary health care providers. One of their programs is the Trans and Gender Diverse ECHO program. So, I’d recommend individuals who are interested in learning more about 2SLGBTQ health to check out, for instance, one of those resources. Those are probably some of the main resources.

And then when it comes to HIV primary care, I recognize that that’s something that may be a bit more difficult when you’re no longer in your training to feel like you can get knowledge and expertise on. There are a lot of great conferences on HIV care that help to update physicians about the most recent advances in antiretroviral therapy. So, I encourage physicians to check those out to see what antiretroviral therapies are really now recommended, get information about their safety, their efficacy. And I think one of the things that people will recognize is that HIV medications and prescribing them are no longer something to fear as much as physicians have feared it the past. Just again, in terms of the effectiveness and the lack of concerning long term side effects, I think it really made these medications much more accessible to the prescribing physician.

SS: You make a good point, Jordan, that we may not necessarily be aware of that as physicians who are not taking care of HIV patients on a regular basis. And so really knowing, “Where can I go for that information?” And also, not being scared of saying, “I don’t know.” I think as physicians, we often get really like, “I’m supposed to know everything.” But knowing that there are these avenues —

Actually, we at the CPSO, a number of our staff, including myself and our senior team, did the Rainbow Health Ontario foundation’s course and we all found it excellent. And we had Rainbow Health Ontario come and do an interactive session for our board, and our Council and committees. And one of the things that really struck me in interacting with the fantastic people over there is that not only are they people with lived experience, but they are exceedingly well-trained educators. And it’s important for us to think about that. Of course, we want to approach our patients with humility and curiosity, but they’re not there to teach us — that is our job to do. And knowing that there are folks with extensive education expertise, like the folks at Rainbow Health Ontario, is a really important resource. So, thank you for highlighting that.

As you said, there’s been a plethora of resources that have come up in the last few years. Certainly, we’re having these conversations much more now than even when I was in med school 20 years ago. We weren’t really talking about to 2SLGBTQ health or gender-affirming care. It wasn’t part of how I was trained. But even with that increasing awareness and increasing education, I’m sure that you still see some fairly big gaps in knowledge or some misconceptions that still exist for healthcare providers with respect to treating 2SLGBTQ patients. Can you tell us what those seem to be in your experience? Where do people seem to really struggle?

JG: So, we know that the 2SLGBTQ populations are disproportionately affected by a number of different health conditions. And I think that some of these health conditions, as physicians and other health care providers, we’ve been relatively well-trained to manage. For instance, we know there are higher rates of cardiovascular disease in 2SLGBTQ populations. And I’d say that, in general, we’re pretty well taught about how to screen for abnormalities and lipid levels or diabetes. But there are certain areas that I think we can improve on as a profession. We know, for instance, certain groups within the 2SLGBTQ umbrella are disproportionately affected by sexually transmitted infections. And I think that it’s prudent to our patients to learn about the different ways that STIs can present in these populations and recognize other important screening tools that we might not always consider in the heterosexual, cisgender counterparts. Things like throat swabs and rectal swabs for chlamydia and gonorrhea, I think are still being under-ordered and under-utilized when it comes to diagnosing and screening for STIs. That’s just one of many examples that I think we don’t necessarily — that I think physicians aren’t necessarily trained extensively on is the area of sexual health. And that’s one thing that I would encourage people to take more time and, if you are able to use resources to learn about them, I would recommend it. There are some really great resources out there.

Another kind of topic or area that I can think about is pre-exposure prophylaxis, or HIV PrEP. We’ve had some really great Canadian guidelines come out and be released in the CMAJ. So, I’d recommend individuals to check out those guidelines to learn about what indications are for prescribing HIV PrEP to prevent HIV infection in those who are HIV negative. And I think this can go a really, really long way. I think that a number of 2SLGBTQ clients who would benefit from HIV PrEP have had to self-advocate. They’ve had to go to their primary care physician and they’ve had to do education around this treatment that sometimes physicians aren’t really aware of or knowledgeable about. But again, if we can take onus and learn about these different tools that can really benefit these populations, I think it could go a really long way in ensuring that those patients who would most benefit from it and that sometimes aren’t able to access these medications, it helps to ensure that we are doing our due diligence and making sure that we can help support our patients in accessing this care really as much as possible.

One last area, and there’s multiple, but one other area that I want to touch on that I think there’s a quite a big gap in terms of us as providers being able to help support and provide patients care is in transgender health in general. I know when I went through medical school, there was relatively minimal training when it came to prescribing hormones or referring to transition-related surgeries and what that process entailed. And I think that that resonates with a lot of physicians who are probably listening to this podcast. We recognize that based on limited teaching hours, it maybe isn’t always something that’s given the amount of time and attention that it would benefit from or deserve. And so, this is an area where I think we could do much better. I think that providing hormones as a part of transitioning to a lot of our clients can seem intimidating or scary in terms of prescribing and knowing what our part in the whole transition for this patient would involve. But I think it’s some of the most rewarding work we can do. I think helping a client to align their physical appearance with a gender identity can be a huge goal for some individuals that really benefit every aspect of their life and every aspect of their health. So, although it can seem like it’s daunting and that it may take a little bit of time upfront in order to learn what would be needed in order to prescribe hormone therapy or for surgeries, it’s really something that can have the most lasting and important impact in a lot of the lives of our patients.

SS: Thank you for that. That was really compelling the way that you bring that at the end there in terms of just how much of a huge impact it has on the lives of patients. I mean, not just quality of life, but even — I know we did a podcast with Dr. Alex Abramovich and his research is in rates of suicide in trans folks, especially trans youth. So, I mean, we’re talking about people’s health and wellness from the most fundamental grounding of what that means. So, thank you for that reminder.

I want to just ask you a quick question, which is maybe the flipside of what you talked about with STIs, and maybe certain swabs and tasks not being used enough in certain populations. I’ve personally come across, as a physician, patients telling me that they were offended that as a queer person in a long-term, monogamous relationship with their partner, that they are now being asked questions about STIs. And I’m just wondering, what is the balance? So, maybe comes back to what we were talking about at the very beginning that people are not monolithic and communities are not monolithic, and how do we approach with curiosity and humility? But how do we get that balance, recognizing that what you’re saying is very true and that the experiences of other people are very different? How do you approach that with patients, especially if there’s not an existing relationship already?

JG: It’s an excellent question. It’s actually a question that came up yesterday, when I was teaching a group of international medical graduates who are completing a program in order to enter residency here in Canada. And so, we had a great, really rich discussion about this, about recognizing the way that certain populations, as a whole, are disproportionately affected by certain health conditions, while also individualizing the care that you provide to patients. And this is really an approach that I’d recommend for every provider in terms of every patient that they see. It’s not just making assumptions. And I think that sometimes in the healthcare and in our field, sometimes it can benefit from us having certain memories or cues, or we do sometimes by default stereotype in order to make sense of the world around us. But I think recognizing how those stereotypes can be harmful, recognizing that someone’s sexual orientation or identity does not necessarily tell you anything about their risk of sexually transmitted infections or otherwise.

So again, individualizing that and saying, “Well, what really matters when it comes to something like STI testing and screening is an individual’s sexual behaviours.” And so, you should be asking every patient routinely about whether they have one regular sexual partner, no partners or multiple partners. What it looks like when they’re using protection or barriers to prevent STIs or other tools, like HIV prep. So, being open to a number of different types of relationships, a number of different types of sexual behaviours, and being open and asking about that in a way that doesn’t stigmatize patients. Normalizing that you recognize people may have zero, one or multiple sexual partners — that you’re not judging whatever answer that they’re providing. But really informing patients the reason that you’re asking these questions, which is in order to identify an individual’s health care needs and see how you can help support them in the best way possible.

SS: I loved how you framed that as not making assumptions and normalizing that we’re going to ask these questions to everybody. And it reminds me of an instance I had with a patient where, as an anesthesiologist, I was asking about substance use, which is a standard question for me to be able to provide a safe anesthetic, and them wondering why was I asking that and was I stereotyping them in some way? And so, I think really making sure patients understand why you’re asking because sometimes we assume that they know why we’re asking and, of course, assumptions can sometimes be very unhelpful.

This has been really, really great. And we could probably talk for at least another hour and not cover everything that we want to talk about. But is there anything else you want to leave our listeners with before we say goodbye today? And we’re going to make sure that we include all the amazing resources that you have mentioned in links. Anything else that you just really want to emphasize in terms of how we provide care to this population?

JG: I would say, first and foremost, just make sure that you’re really providing an open, inclusive environment to your patients. And really, as long as you’re approaching things from an air of curiosity, as long as it’s clear to your patients that really anytime you’re asking any questions or inquiring or trying to help support them, it is really to help benefit them first and foremost. But in order to do that, it’s really important that we involve our patients in these healthcare discussions, in these decisions that we make. And, particularly, I think that’s important with some of these disenfranchised populations, such as 2SLGBTQ individuals or those living with HIV. So, I’d say do what you can in order to learn the information you need, and help develop the skills and competence to provide safe and effective care to these populations. But don’t be afraid to ask for help, to reach out to your colleagues who might have more experience in working with some of these populations. Don’t be afraid to read around these resources and ask clarifying questions, to use the OTN econsult service or other services that help connect you with other individuals who might have more knowledge or experience.

I think sometimes people can feel overwhelmed or feel like they don’t have the ability to provide the best care possible. But one of the things that I want to emphasize with providers is that by breaking down some of these barriers, by minimizing the number of healthcare providers that they see, by creating really healthy relationships and rapport with your patients, you can actually provide the best care possible to patients and sometimes it just means getting a little bit of support. So, I’d really encourage you to think about how much influence you can have and really how much of a difference you, as a provider, can make in the health of your patients by getting that support, and by gaining the skills and the knowledge that would be needed to most effectively help these patients.

SS: What a great note to end on! Thank you so much for being with us today, Jordan.

JG: Thank you so much for having me. It was a pleasure.

Closing:
Thank you for joining us. Please visit CPSO Dialogue for more in-depth discussions about health care.