You’re superficial,” the dean of the curriculum explained to me as we sat in an empty lecture hall. I had just finished a lecture when he pulled me aside to share his assessment of my progress as a student. By this point in my second year of medical school, I had become more focused on the health and well-being of lesbian, gay, bisexual, transgender, and queer [LGBTQ] persons and communities, and to be told I was superficial for trying to address significant disparities experienced by LGBTQ people was a punch to the gut. I had not planned on being focused on LGBTQ health as part of my training. But, as LGBTQ issues were glaringly absent from my training, I became a student advocate. And despite becoming the go-to person on LGBTQ issues for some faculty, focusing on population health and social determinants of health was not of value to some in my school’s administration. As I concluded my exchange with the dean of our curriculum, I realized charting a career in LGBTQ health was going to be a turbulent journey. It comes as no surprise that as an out gay man crafting a career that addresses the health of LGBTQ communities is motivated by personal experiences. Having had a physician walk out on me when I came out to her, I know firsthand some of the discrimination LGBTQ people face in even accessing health care. Before returning to school to become a physician, I worked at a federally qualified health center providing care for our overlooked and marginalized communities. Seeing compassionate physicians addressing the varied needs of LGBTQ folks, such as gender-affirming care for transgender patients or cancer screening for bisexual women, I wanted to join their ranks. But nearly every step of my medical training provided unique challenges to have a career in LGBTQ health. I still recall the classmate who said, “the admissions committee admitted too many gays.” These experiences are not unique to me, and we are beginning to understand how pervasive they are. Even beyond the stigma faced by society, LGBTQ medical students face higher rates of harassment and subsequent burnout within our profession. And with physician job dissatisfaction predicting “departure” from medicine, discrimination and harassment from supervisors, colleagues, and patients are likely important factors discouraging LGBTQ physicians’ careers in medicine, let alone ones focused on LGBTQ health. In addition to experiencing discrimination, LGBTQ people in medicine are discouraged from pursuing careers that are connected to their identity. The absence of LGBTQ content and/or presence of anti-LGBTQ sentiment in the pre-clerkship, clerkship, and hidden curriculum of clinical training in particular sets the tone for how LGBTQ health is viewed in our profession. Further, the effects of the hidden curriculum are pervasive and insidious. For as long as we have been surveying on the topics of the treatment of LGBTQ patients, medical students, residents, and physician educators report witnessing colleagues making derogatory remarks about LGBTQ patients or treating them poorly. These interactions throughout training influence career choice and lay the groundwork for how physicians wed their identity to their profession. It is why some specialties are considered “friendly” or “unfriendly” towards LGBTQ applicants. It is not surprising that most LGBTQ students applying for medical school do not disclose their sexual orientation or gender identity for fear of discrimination, and nearly half do not disclose when applying for a residency. While some may judge this behavior to be overly cautious, studies suggest that fears of disclosure are valid. Perhaps most importantly is that beyond the personal risk of being out as LGBTQ, there are a dearth of out mentors, fearful of any professional harm for being out. Despite discouragement from administration, I was fortunate to complete a residency that valued my identity and my desire for a career in LGBTQ health that spanned education, research, and advocacy. While some in my residency program were uncertain of my trajectory, none discouraged me. As my career path brought me further into population health and disparities research, I found myself faced with finding fellowship training to gain essential skills. Unfortunately, after the supportive environment of residency, the fellowship search felt dismal. Beyond facing faculty who actively tried to redirect me away from LGBTQ health as a research topic, I encountered out LGBTQ faculty who stated they did not “understand how LGBTQ health is a relevant career” or noted that “you won’t receive any funding or grants.” These encounters were both disappointing and informative. Disappointing because there were so few mentors in LGBTQ health to offer training or even serve as examples of success, and informative because I knew which programs to avoid; if they could not even imagine such a career how would they advise me? I could only wonder what barriers these LGBTQ faculty had faced to internalize such dispassionate assessments of my interests to discourage my career trajectory. Research and training opportunities supporting careers in LGBTQ health are rapidly emerging. In 2016, the National Institutes of Health designated LGBTQ as a health disparity population for research purposes. In addition to explicitly seeking research proposals addressing LGBTQ health, the NIH has committed resources to LGBTQ health through the creation of the SGM Research Office. In addition to research careers, numerous fellowship opportunities, including those funded by the American Medical Association Foundation, have emerged to train anyone interested in pursuing a career in LGBTQ health. After much searching, I was fortunate to find a fellowship that though inexperienced in LGBTQ health recognized an opportunity. Faculty and mentors worked from a growth mindset rooted in finding what I needed to succeed rather than what they knew they had to offer at that moment. With their and others’ support, despite the discouragement and fears of being “superficial,” I now try to serve as an example to other students and trainees who wish to pursue a career that weaves their personal and professional interests in LGBTQ health. I would like to thank Jessica Halem, MBA for her years of mentorship and editorial guidance on this article. I would also like to thank my husband, Chad Rubalcaba, JDg for over a decade of support as I navigated this relatively uncharted career path. Source
