Dear First-Year Medical Student

A version of this letter was originally given as a talk to the incoming class of medical students at the Stanford University School of Medicine during their orientation in August 2019.

Dear First-Year Medical Student,

Congratulations on starting medical school! This is the beginning of your journey of becoming a doctor. You worked very hard to get to this moment and for many of you it’s the realization of a long-held goal or dream. It might also be a little bit scary, because “holy sh#t this is real I’m really in medical school when is somebody going to figure out I don’t belong here?” You belong there, and I’m grateful to you for embarking on this journey. The world needs more healers and I hope you’ll be one of them.

This is the beginning of a remarkable process of learning and change. You’re at medical school to learn how to do something, to practice medicine. Yet the next four years will also teach you how to be. What I mean by this is, over the next four years (and after), you’ll learn the concrete skills and clinical knowledge you’ll need to be a competent physician. Through both a formal and an informal curriculum, you’ll learn to think and act like a doctor and how to interact with your patients and colleagues. You’ll learn ways of knowing, ways of perceiving your patients and ways of embodying what being a doctor looks and feels like. The next four years will change you. They will teach you a new way of being. They will make you into a doctor.

My question for you in this moment is, what kind of doctor do you want to be? I don’t mean which specialty or subspecialty – you do you! – I mean, how do you want your patients to feel before, during and after a visit with you? Your answer to this question matters to me because how you care for someone can be as healing as whatever medicine or medical interventions you offer them, or as harmful as the health issue that brought them to you in the first place. For many people, and certainly for many LGBTQ+ folks and other sexual and gender minorities, going to the doctor isn’t simply a neutral experience of accessing health care. It’s a visceral, embodied experience that carries with it physical and emotional legacies of past and present traumas – including at the hands of the medical system – and the felt impacts of the intersecting oppressions that may be limiting their ability to thrive or even survive.

I’m writing to you because I care about the kind of doctor you become and what this means for your future patients. As an LGBTQ+ health advocate, I’m passionate about helping queer and trans people and communities survive and thrive and I see you as allies and accomplices in this work. Research from the US, Canada and Europe shows a consistent pattern of LGBTQ+ people avoiding or postponing needed medical care and preventative screenings because they’ve experienced disrespect or discrimination from health care providers; transgender people report this at much higher rates than sexual minorities.* I know far too many LGBTQ+ people who avoid or delay accessing health care because they’re afraid of discrimination. I feel fiercely hopeful that this can change and I want to be part of making it happen.

I’m writing to you because of the joy I hear in people’s voices when they tell me about receiving LGBTQ+-affirming care. I see relief in their bodies when they feel safe enough to let down the burden of fear and self-protection and open to the possibility of health care that feels genuinely healing. I’m writing to you because I know what that feels like in my queer body. I want all LGBTQ+ people – indeed, all people – to have access to this kind of care. I want to be part of making health care more affirming, equitable, liberatory and just. Let’s imagine this kind of health care into being, and then let’s work together to make it a reality.

I know that you’re a diverse group when it comes to your knowledge of LGBTQ+ health. Some of you already know a lot about LGBTQ+ people and communities while others might be newer to this topic. Some of you are members of the LGBTQ+ community and others aren’t, or aren’t yet. (I started grad school thinking I was straight and look at me now!) Some of you are coming into medical school with a strong interest in LGBTQ+ health and others might be drawn to different topics, populations or specialties. Some of you might feel very comfortable with LGBTQ+ people, others less so. So there’s already a lot of difference among you when it comes to this particular topic, but you have one thing in common: as physicians, you’ll all care for LGBTQ+ patients. It’s the thread that weaves us together and it’s what makes this topic relevant to you now and during medical school, no matter what knowledge and experience you’re bringing into school with you or where you end up four years from now.

We have another thing in common: we all have experience being patients. Think back to those experiences. Have you ever had an encounter with a doctor or health care provider that felt uncaring? Like they weren’t listening or didn’t get you? What about a time where you felt like you had to omit information or not tell your doctor or other care provider the truth because you felt afraid of being judged or shamed? How many of you have had experiences as patients that felt downright discriminatory? What was going through your mind during those experiences? How did it feel in your body? How did it affect your willingness and motivation to go back to that provider or seek care again?

When have you felt really cared for and comfortable with a doctor or other health care provider? What did they do to make you feel that way? What was going through your mind during those experiences? How did it feel in your body? How did it affect your willingness and motivation to go back to that provider or seek health care again? I encourage you to reflect on your answers to these questions. It’s helpful to remember and feel into your experiences as patients, not because these experiences are one-size-fits-all – they aren’t, particularly if you’re white or cisgender like me – but because I hope these recollections will help you empathize with your patients. It’s hard work to be a patient! And it can be scary, vulnerable, emotional work, too. There’s the pain and distress of whatever brought your patient into the hospital or the clinic, and then there’s the experience of actually accessing and receiving care. Think back to your answer to the question, how do you want your patients to feel before, during and after a visit with you? What would it be like to use your answer to this question as a touchstone during your medical training as you learn, practice and imagine your way into becoming the doctor you aspire to be? What can you learn from your own experiences as a patient?

It feels meaningful to write to you because my book The Remedy: Queer and Trans Voices on Health and Health Care was inspired by my early experiences teaching first-year medical students about LGBTQ+ health. Back then, I would come to class with PowerPoint slides crammed full of statistics about the health disparities the LGBTQ+ community faces. It was like I was trying to build a case for why LGBTQ+ health should matter to future physicians, but if documenting and quantifying our health disparities were enough all LGBTQ+ people would be healthy today. It’s important to me to ground my work in evidence and I’m grateful to the growing community of researchers advancing our knowledge of LGBTQ+ health, and to the educators and clinicians who are translating that evidence into curriculum, protocols, policies and practice. Yet The Remedy grew out of my realization that something was missing from this body of knowledge: people’s stories. I decided to create a book that centred LGBTQ+ people’s voices and perspectives on health and health care; I knew that our stories could foster empathy and understanding in a way that statistics couldn’t.

Stories are powerful systems change tools. As Ella Saltmarshe puts it, “Stories make, prop up, and bring down systems. Stories shape how we understand the world, our place in it, and our ability to change it.” Let’s change the story of what LGBTQ+ health care looks and feels like. As future physicians, how can you develop the skills and knowledge you need to help your LGBTQ+ patients change their stories about accessing health care? I want us to create new stories together, and I want those stories to change systems. A systems change lens is important because there are connections between your actions as a physician and the larger systems and structures in which your work is situated. Health and illness don’t exist only in individual patients; they emerge out of how people interact with and are acted upon by the larger dynamics of privilege and oppression that operate at the levels of groups, communities and whole societies.

Medicine is part of society, which means it’s shaped by the same oppressive dynamics that shape the world around it. Power and privilege are in our medical school classrooms, hospitals and clinics. Racism is there. Colonialism is there. Gender inequity, sexism and sexual violence are there. Ableism is there. Fatphobia is there. Classism is here. Ageism is there. Homophobia, biphobia and transphobia are there. I name these things in part as a reminder that they’re present, and so we remember that these oppressive forces are working on all of us, whether as student or teacher, patient or provider, advocate or administrator. They are working on me and they are working on you, both to our advantage and disadvantage, in the way that we each carry with us a unique combination of intersecting privileges and oppressions. This is as relevant to your success and wellbeing as a medical student and physician as it is to the health of your patients, and it’s a call to action to work against all the ways systemic oppression shows up in medicine so we can build a health system that is more liberatory and just.

If you’ve read The Remedy, you’ve been introduced to some of the ways these dynamics play out in LGBTQ+ people’s experiences of accessing health care, particularly for community members who experience greater stigma and discrimination on the basis of their identities. Here I’m thinking of trans and gender-diverse people, especially trans women and trans feminine people. I’m thinking of LGBTQ+ people who are racialized, particularly Black and Indigenous trans women and trans women of colour. I’m also thinking of bisexual people, who experience higher rates of stigma and discrimination both in medicine and in the LGBTQ+ community. I’m thinking of LGBTQ+ people who are poor, undocumented, disabled, fat, those who use drugs, do sex work, are homeless or incarcerated. I have no doubt in my mind that the health system can and must do better for gender and sexual minority patients in the contexts of their intersecting identities and health needs.

Because that’s the thing: your LGBTQ+ patients will never show up as just one part of their identities; they’ll show up as complex and multifaceted people with their own stories, relationships, joys and challenges. They’ll bring their histories with them, including their past experiences of accessing health care. They’ll bring their health risks and disparities, and they’ll also bring strength, resilience and courage. They’ll bring their whole selves into their encounters with you, though they may be inclined to conceal or guard some parts of themselves out of fear that they won’t be met with respect, understanding and compassion. As you begin your medical education, what do you need to learn to prepare you to care well for your LGBTQ+ patients and enable them to bring their whole selves into an encounter with you? How will you meet them, and what skills, knowledge and parts of yourself will you bring into these patient encounters?

As you begin this learning process – this process of becoming a doctor – I want to offer you some ideas to bring with you into your medical education. They’re a distillation of some of the things I’ve learned about how shifts in health care providers’ mindsets or practices can have a substantive impact on the care of LGBTQ+ patients.

  1. It’s okay to not know everything and it’s okay to make mistakes.

    Not knowing stuff and making mistakes can feel super uncomfortable, especially when you’re used to feeling and being seen as smart and accomplished. Being smart and accomplished probably got you into medical school! My advice to you in this moment is, practice getting comfortable with the discomfort of not knowing, of not always being an expert, of making mistakes and being wrong. It can feel shameful when this happens, and as physician and medical educator Sandy Miles (2019) reminds us in a recent paper on shame in the formation of medical professional identities, shame can make us withdraw or lash out at ourselves and others. You’re going to bump up against this experience repeatedly in medical school and in clinical practice (not to mention in life). Build your resilience and skills around how to respond with curiosity, humility and compassion – including for yourself! – when you don’t know everything or when you get something wrong. Not knowing stuff and making mistakes is a normal part of the learning process and it’s part of the mindset you need to grow and develop as a physician.

    This mindset is especially helpful when you’re caring for LGBTQ+ patients. My observation is that successful LGBTQ+ patient care is often built in micro-moments of discovery, connection and repair. Imagine you’re seeing a trans patient for the first time and you get their pronoun wrong. What do you do? Do you: A) Freeze up and quietly panic for a second and then pretend like nothing happened? B) Sink into shame and self-recrimination, apologizing so much that your patient starts comforting you? Or C) Say, “I’m sorry. I got your pronoun wrong. Let me start that part over.” I encourage you to choose option C.

    Your LGBTQ+ patients won’t expect you to know everything about us, our identities or our communities. We know that you’re human and that you sometimes make mistakes – maybe you get our pronoun wrong, or you make an assumption about the kinds of sex we have (or don’t have) or who we have (or don’t have) it with. Where you show yourself as a physician is how you choose to respond in those moments. What will you do when you make a mistake or don’t have all the answers? How can you have compassion for yourself and also commit to ongoing learning, growth and doing better next time? How do you do that in a way that doesn’t cause you to sink into shame and stop you from connecting with your patients? What can your experiences as a learner teach you as you prepare to move into your clinical work with patients?

  2. Look in the mirror, look out the window.

    Implicit and explicit bias show up in medicine and medical education, as they do in other sectors and parts of our lives. Many people are doing the important work of researching and implementing strategies to mitigate against these biases so as to foster more equitable and affirming health care. As you do the important work of examining your own biases and how they show up in your learning and practice, I encourage you to make links to the bigger picture. In a recent article on the connections between implicit bias and structural racism, Kathleen Osta and Hugh Vasquez remind us that, “in order to lead to meaningful change, any exploration of implicit bias must be situated as part of a much larger conversation about how current inequities in our institutions came to be, how they are held in place, and what our role as leaders is in perpetuating inequities despite our good intentions.”

    In this vein, Osta and Vasquez call on us to do two things**: first, “to look in the mirror to notice how our particular lived experiences have shaped our beliefs, attitudes and biases about ourselves and others.” With this increased self-knowledge, they say, “we also need to look out the window to understand how racism, classism, sexism and other forms of systemic oppression operate in our institutions to create systemic advantage for some groups...and disadvantage for other groups.” Implicit and explicit bias don’t just exist in individual bodies; they’re connected to larger systems and structures.

    To care well for your LGBTQ+ patients requires you to look in the mirror, and then look out the window at the structural reasons that might be impeding their ability to survive or thrive. Racism is an LGBTQ+ health issue. Poverty is an LGBTQ+ health issue. Mass incarceration is an LGBTQ+ health issue. Disability justice, environmental justice, prison abolition, decriminalization of drugs and sex work and supporting people’s rights to move freely and safely across borders are LGBTQ+ health issues. As you begin your medical education, what can looking in the mirror teach you about yourself and how that might shape the way you practice medicine? What can you learn by looking out the window at the larger systems and structures you and your patients are embedded in?

  3. Find out what good health means to your LGBTQ+ patients.

    There are many ways to understand what good health consists of, something I’m sure you’ll learn much more about over the next several years as you deepen your understanding of illness, disease, treatment, cures and care. As you do, I encourage you to remember the difference between textbook definitions of health and what good health means to your LGBTQ+ patients. Health and illness are felt, embodied experiences that affect and are affected by every aspect of our lives – where we live, who we’re in relationship with, what resources we have access to, and also what brings us joy, fulfillment and pleasure and where we find connection, strength and resilience.

    Your LGBTQ+ patient isn’t just a name on a chart, a medical concern or an anonymous person sitting in front of you in the treatment room. Like all patients, they’re people with their own lives, gifts, challenges, passions, wounds, families, relationships and communities. They’re people with their own stories. You may be the medical expert, but your LGBTQ+ patient is the expert on their life, their body and what good health looks and feels like to them. Experiment with asking your patients what good health means to them and charting their answers alongside other clinically relevant information. Think of it as an extremely low-tech form of personalized medicine. What would it look like to move from a one-size-fits-all definition of health to one that’s anchored in your patient’s lived experience and what matters most to them? How might this enable you to support your patient’s overall wellness and quality of life?

  4. Centre pride and pleasure, not shame and risk.

    Some of you might know what it’s like to be treated like a risk factor, like you’re somehow inherently dangerous because of who you are. Discussions of LGBTQ+ health are often framed in terms of risk factors and disparities, all of the ways we are less well or at higher risk of ill health because of the minority stress, oppression and violence we experience on the basis of our intersecting identities. Many LGBTQ+ people already feel shame or stigma because of messages we’ve received about ourselves from our families, our communities and the larger society. Being viewed through a lens of risk, disparity or stigma can contribute to feelings of shame, and that’s not health-promoting. It also doesn’t make people want to go to the doctor!

    I see radical potential in approaching LGBTQ+ health and health care from a place that centres pride and pleasure. I don’t mean ignoring risks or evidence of disparities; I mean shifting the lens through which you understand and interact with your patients. Think back to my advice about learning what good health looks and feels like for your LGBTQ+ patients. This is another layer to that advice, anchored in the idea that access to affirming, strengths-based, pleasure-centred, sex-positive health care grounded in principles of harm reduction could transform LGBTQ+ people’s experiences of going to the doctor.

    For example, I encourage you to keep an open mind and not make assumptions or judgements about your patients’ drug use and sexual behaviour. Offer them evidence-informed, developmentally sound advice and support grounded in principles of harm reduction. Learn how to practice affirming care and get curious about what helps your LGBTQ+ patients feel strong, resilient and happy. Imagine if our health system operated from a place where we supported and enabled people to feel pride in their identities, where we worked to understand what brings them pleasure and where we shared the information and tools they needed to reduce harm. How might you learn to use information on risk and disparities as a tool, not as the lens through which you perceive your LGBTQ+ patients? How might you find ways to work with them from an affirming, strengths-based perspective? As a future physician, how might learning about sex positivity, pleasure and harm reduction help you care better for your patients?

  5. Learn about trauma-informed care and consent.

    At a population level, the LGBTQ+ community experiences higher rates of violence and trauma. These experiences can be both triggered and exacerbated by the health system, and it can make it harder to go to the doctor. I recently listened to an interview with Carl Streed, a primary care physician and researcher at the Boston University School of Medicine. In it, he gave a beautiful example of how he acknowledges the history his LGBTQ+ patients might be bringing into the room with them during their visits. He tells those patients, “I’m glad you’re here. I know it was probably hard to come here. Tell me what I can do better and how we can do this. Thank you for being here.” I must’ve listened back to that part of the interview three times in a row. What a profound and simple way to welcome a patient and help create a feeling of safety.

    I encourage you to learn about trauma-informed care and how to practice good consent skills. By doing so, you can minimize the likelihood of triggering a trauma response in the person you’re caring for and help your patient feel seen and safe. My observation is that, in health care, consent sometimes gets treated as a “one-and-done” sort of transaction where we ask for it once at the beginning of an encounter and assume that it covers every interaction that follows. Instead, approach the process of asking for consent as an ongoing conversation with your patient.

    This doesn’t need to add a lot of extra time or complexity to your interactions – it can be as simple as checking in before touching, moving or otherwise interacting with your patient’s body, listening to what they say and, if they say no or not right now, figuring out an alternative strategy that allows you to do what’s clinically necessary while respecting your patient’s boundaries. This will look different depending on how emergent or acute the situation is, and the extent to which you’re able to communicate with your patient, but it’s essential in fostering a feeling of safety and trust. As you begin your medical education, what knowledge and skills do you need in order to practice trauma-informed care? What knowledge and skills do you need to become skilled at consent, and how might you need to go beyond the textbook to gather this knowledge?

  6. Put on your own oxygen mask first.

    My last piece of advice is to figure out what you need to do this work in a healthy and sustainable way, now and throughout your training and practice. Find ways to hold onto your empathy and buffer against burnout; both are integral to your wellness and effectiveness as a physician, especially in your care of marginalized populations. Understand what you need for self-care and commit to it; hold yourselves and others lovingly accountable to those commitments. Become part of a caring community of medical students – in my experience, generosity goes a lot further than competition. Have your classmates’ backs; practice being in allyship with each other across your intersecting identities.

    To the LGBTQ+ medical students reading this, I know that we often feel called to this work because it’s so tightly interwoven with our identities and relationships. We are trying to save ourselves and our loved ones; we’ve already lost too many of our kin to the cumulative health impacts of oppression. Please know that you don’t have to do this work alone and that you’re allowed to rest and take breaks. Remember that you’re part of a lineage of healing, survival and activism that spans generations; you don’t need to fix everything all at once, or all by yourself. The work of making health care more affirming, equitable, just and liberatory belongs to all of us, regardless of sexual orientation, gender identity or other aspects of who we are.

You’ve got a lot of learning ahead of you so might want to take these suggestions and tuck them into the pockets of your brand-new white coats or another place you can keep them close. I also encourage you to identify one learning goal. What’s one thing you’d like to learn to help you care for your future LGBTQ+ patients, and what steps will you follow to gain that knowledge? By putting this learning into practice, you’ll become a better doctor, not just for your LGBTQ+ patients, but for every person you care for.

It’s the beginning of medical school. My question for you in this moment is, who do you want to be four years from now? How do you want this experience to change you? My invitation to you is to change on purpose, and to change in service of equity, justice and liberation. As a future physician you’re stepping into a position of power, even if you may feel like you’re at the bottom of the hierarchy right now. As a medical student and future physician, you have the potential to bring care and healing to people and communities who have been systematically denied that equity and justice. Imagine how it would feel to be part of changing this, and then learn and practice your way into making that imagining real. That is how healing happens. That is how you become the kind of doctor we need. That is how we rewrite the story of LGBTQ+ health.

Thank you for the courage, curiosity and dedication I know you’ll bring to your medical education. I’m grateful to be in this work with you. I’m excited to witness the doctor you become and to find out what you learn along the way. Good luck!

Zena

Notes:

*For example, see the Lambda Legal Report When Health Care Isn’t Caring, the European Union LGBT survey, recent survey data from the Center for American Progress, the results of the Canadian trans youth health survey, and research on trans people’s experiences with family doctors and in emergency departments.

**Osta and Vasquez credit Emily Style of the SEED Project with originating the metaphor of the window and the mirror.