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Intl J Surgical Education (IJSED)
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Mousavian M, Ranganathan K, Park YS, Anshul K. What Interventions Can Be Utilized to Enhance Gender-Affirming Education? Intl J Surgical Education (IJSED). Published online October 15, 2024. doi:10.5281/​zenodo.14838201
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  • Figure 1. Delphi study process
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  • Figure 5.1. Current educational modalities (top of pyramid has highest prevalence)
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  • Figure 5.2. Recommended educational modalities (top of pyramid has highest priority)
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  • Figure 6.1. Current evaluation modalities (top of pyramid has highest prevalence)
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  • Figure 6.2. Recommended evaluation modalities (top of pyramid has highest priority)
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Abstract

Objective

This study aims to provide an actionable list of recommendations for improvement of gender-affirming education within residency training programs within the United States.

Methods

A set of possible recommendations were prepared and presented to a committee of experts in the field of gender-affirming care to reach consensus through a four-stage Delphi method. The responses of the experts were recorded, analyzed, and reported back to the panel of experts until final recommendations were approved by the team. Two rounds of surveys were conducted. Ten experts were identified through Massachusetts General Hospital and Brigham and Women’s Hospital, and seven agreed to participate. Surgical and nonsurgical providers with a dedication to gender-affirming care were identified and recruited for the study, representing fields of adult medicine, endocrinology, surgery, and psychiatry.

Results

The results demonstrate strong endorsement of lectures and didactic opportunities on transgender and gender diverse (TGD) care, accommodation of trainees to provide dedicated clinical care for TGD patients, as well as creation of a new standard in medical note writing that takes gender diversity into account, in that order of priority. The panel did not reach consensus with regards to mandatory assignment of trainees to dedicated TGD care clinics or hiring a TGD individual and educator to observe patient care provided by trainees and attendings to give feedback and recommendations. The panel recommends delivery of educational modalities to be prioritized in the order of bedside teaching, simulation-based learning, and lecture-based didactics. Furthermore, the experts recommend case presentations, observed interviews, and objective structured clinical examination (OSCE) as preferred evaluation modalities.

Conclusion

Gender-affirming care education benefits from installation of robust, intentional, and instructive interventions as part of medical curricula within various post-graduate training programs. The results of this Delphi consensus study demonstrate the importance of establishing a strong didactic-based lesson plan on TGD care, facilitation of clinical care opportunities and community engagement, and improvement of medical record standards to embrace inclusive language.

Introduction

Gender-affirming care includes medical and surgical interventions that allow individuals, specifically transgender and gender diverse (TGD) patients, to successfully affirm their self-identified gender identity.1 These treatments can include hormonal therapy, psychiatric intervention, bottom surgery, top surgery, and facial surgeries. Barriers to gender-affirming care have been described to include necessity of psychiatric consultation by insurance companies,2 varying treatment insurance coverage and out-of-pocket costs,3 lack of resources for patient recovery,4 access to proper and safe care, and finding appropriate physicians and surgeons.5,6 Provider-based barriers include lack of robust and structured curricular designs within training programs, dedicated gender-affirming clinics, and a lack of competency-based evaluation for gender-affirming care and education.7–9

Addressing disparity and deficiency in gender-affirming care can begin within our undergraduate and post-graduate training programs. One of the initial steps in providing quality care is to better educate trainees on the science of gender-affirming care, innovations, resources, and cultural sensitivity training on the topic of gender diversity. Curriculum enhancement and cultural responsiveness training are crucial in reducing healthcare disparities among TGD patients.10 Additionally, a vigorous clinical exposure is imperative in transfer and application of knowledge. For instance, creation of dedicated clinics with a designated curriculum plan for a defined period of participation has been shown to increase resident knowledge and improve comfort in serving priority patient populations.11 Accreditation Council for Graduate Medical Education has instilled requirements to have programs train their residents on culturally sensitive medical treatment, such as abortion care, and similar requirements can be established for programs with regards to GAS.12 Additional strategies include addressing stigmatization of TGD patients, increasing affordability, as well as expanding resources to areas short of access.13 An expert study allows for additional insight to interventions that can be utilized in addressing educational gap in gender-affirming care (GAC).

This study aims to provide a generalized and inclusive list of modalities for improvement of GAC education within residency programs across the United States. The recommendations were evaluated through a four-stage Delphi consensus survey, and the results may be applicable to undergraduate medical and health-professions trainings as well.

Methods

Preparation

Based on the barriers identified in What are the barriers to health professionals’ training on gender-affirming surgical care from patients’ and clinicians’ perspectives? a set of recommendations were prepared and presented to a committee of experts in the field of gender-affirming care to reach consensus through a four-stage Delphi method. The Delphi method was selected for this study as there is a lack of adequate research and analyzed data within the field, hence the reliance on human judgement and expert opinions as an initial step to inform future interventions.14 Furthermore, the anonymous nature of the survey allows for candid and unfiltered responses, in the hopes of overcoming biases that may be introduced in a more personal and identifiable manner of data collection.15

The major educational and learning principle behind the recommendations proposed in this study was Reflective Learning. In this study, we utilized Reflective Learning, in particular Dewey’s Process of Reflection, to frame and interpret our results. Reflective Learning is an educational theory that places importance on students reflecting on their educational experience, with the intention being development of skills to examine strengths as well as areas of improvement.16 There are few reflective learning theories, such as Dewey’s Process of Reflection. Based on Dewey’s Process of Reflection, for reflective learning to take place, there needs to be continuity of learning material, such as lectures to hands-on experiences, with learning happening in community with others so the learners better understand personal and interpersonal aspects of intellectual growth (Table 3).17

Delphi Process

The Delphi technique utilizes a series of questions and recommendations proposed to a panel of experts seeking reliable consensus in a particular field.18 The responses of the experts were recorded, analyzed, and reported back to the panel of experts until final recommendations were approved by the team. In order to have a sufficient response, our aim was to include 7-10 experts, as additional number of experts has not been shown to provide additional benefit.19 In this study, Delphi method was selected as opposed to other consensus methods due to convenience, feasibility, as well as anonymity of ideas. The Delphi methods have been used before in various studies with success. In a study performed by Hanna, et al, the authors identified effectiveness criteria for environmental assessment using the Delphi method.20 In another study by Banayan, et al, the Delphi method was adapted and utilized in creating a scoring system for assessing team performance during maternal cardiopulmonary arrest.21

There are multiple possible approaches to Delphi studies, including Classical, Policy, Decision, and Ranking-type.22 As the scope of this study centers on reaching consensus on the relative importance of sets of recommendations, the Ranking-type Delphi is the modality of choice for this study. The four stages of this study were organized according to the methods used by Barnes, et al.23 The first stage of the study entails brainstorming all plausible interventions that can be utilized in GAC, which were initially designed by MM (Table 1 and Figure 1). The second stage included review of the proposed interventions by the coauthors, edits, and finalization of a final survey. The third stage included dissemination of the first round of surveys to the experts, and analysis of the returned data from the experts. Each item had a mean rank calculated, stating the mean of the answers provided by all the experts. In the fourth stage of the study, the second round of surveys was sent to the experts with the opportunities to change their rating of the eligible questions if desired.

Table 1.Delphi study process
Stage Description
1 Brainstorming all plausible interventions that can be utilized in GAC
2 Review of the proposed interventions by the coauthors, edits, and finalization of a final survey
3 Dissemination of the first round of surveys to the experts, and analysis of the returned data from the experts
4 Sending second round of surveys to the experts
Figure 1
Figure 1.Delphi study process

Expert Selection

Institutional Review Board protocol #2022P003238 was submitted and approved through Mass General Brigham (MGB). Expert selection was performed in accordance with the outline set forth by Wechsler, which includes formation of a list of potential experts in the field, evaluation of reputation, experience, and publications, and estimation of potential motivation in participating in the study.24 Ten experts, all attending physicians, in the field of GAC were identified within Massachusetts General Hospital and Brigham and Women’s Hospital. Surgical and nonsurgical providers with a dedication and specialization related to GAC were identified and recruited for the study through purposive sampling.25,26 Selected attending physicians were contacted via email and invited to participate in the survey. Out of the ten experts, seven responded affirmatively to participate. Experts represent fields of adult internal medicine, endocrinology, surgery, as well as psychiatry. 85% of the experts have teaching appointments at Harvard Medical School in addition to their primary practice appointments. 100% of the experts have had additional post-graduate training as chief residents and fellows. 100% of the experts have had scholarly involvement in the field of TGD medicine.

Survey Conduction

The initial survey included eleven questions (appendix A). Five questions asked the experts to rate a proposed intervention based on its importance in facilitating care. A rating scale was given to the experts (Table 2). The following five questions were posed to have the experts rank and compare the interventions that are currently being utilized and should be utilized. At the end of the initial survey, there was an open-ended free-response question for experts to share any further recommendations. The experts did not have the opportunity to communicate about the study with one another.

Table 2
Rating Numerical Equivalent Rating Category Description
Utmost importance 6 High importance Care of patients will not be possible without these actions and recommendations
Moderate-high importance 5 High importance These are critical and life-changing recommendations, without which quality of care is significantly impacted
Average importance 4 Moderate importance These tasks are important, though not the highest importance as they can be substituted with other recommendations.
Low importance 3 Low importance These are the recommendations that should only be addressed if the other recommendations have been properly addressed.
No importance 2 Low importance These recommendations should be disregarded as they do not add value to care of patients.
Inappropriate 1 Inappropriate These recommendations have the potential to hurt patient care and should be removed.

For the ranking questions, the responses of the experts from the initial survey were counted as their final answers. Those questions were not asked again on the second survey, and their aggregate results were counted as their consensus answer. Responses with a rating of 1 were labeled as “inappropriate,” ratings of 2 and 3 were labeled “low importance,” a rating of 4 was labeled “moderate importance,” and ratings of 5 and 6 were labeled “high importance.” Aggregating rated results into fewer categories than the initial rating levels (in this case, six rating levels aggregated into four categories) is a reasonable Delphi practice.27 With regard to the first five rating questions, consensus was defined as meeting a threshold at which 70% of respondents selected a score of 5 or 6 for an intervention, similar to the methods utilized by other scholars.28,29 The questions that did not meet the threshold were excluded from the second survey.

The study was conducted between January and April of 2023. The first round of surveys was conducted between February and March of 2023, and the second round of surveys were conducted between March and April of 2023.

Results

The results of the first study are summarized below (Appendix A), and the results of the second round of surveys are summarized below (Appendix B).

General recommendations

The results demonstrate strong endorsement of lectures and didactic opportunities on TGD care, accommodation of trainees for dedicated clinical care for TGD patients, as well as creation of a new standard in medical note writing that takes gender diversity into account in the order of priority stated (Table 3). The panel did not reach consensus with regards to a) mandatory assignment of trainees to dedicated TGD care clinics, or b) hiring a TGD educator to observe patient care to give feedback and recommendations.

Table 3
Proposed Intervention Result
Lectures and didactic opportunities on TGD care Approved by panel of experts (86% consensus as first priority)
Accommodation of trainees for dedicated clinical care for TGD patients Approved by panel of experts (71% consensus as second priority)
Creation of a new standard in medical note writing that takes gender diversity into account Approved by panel of experts (71% consensus as third priority)
Mandatory assignment of trainees to dedicated TGD care clinics Panel did not reach consensus (14% consensus)
Hiring a TGD individual and educator to observe patient care provided by trainees and attendings to give feedback and recommendations Panel did not reach consensus (57 % consensus)

The three approved general recommendations are presented based on Dewey’s Principle of Reflective Learning (Table 4). For reflective learning to take place, students need to first be educated on the foundational concepts of TGD care (first recommendation).30 Once they have been educated on the concepts, the students shall be introduced to patient care and immersed in the clinical aspect of learning (second recommendation). Clinical immersion allows for students to be exposed to their own strengths and weaknesses, as well as their peers’ strengths and weaknesses through communal engagement and comparative thinking.31 Through this process, they have the opportunity to reflect and critically think about the ways they can improve. Furthermore, through writing clinical notes (third recommendation), students are encouraged to think about their use of words and language when accurately describing patient interaction, an opportunity which will inherently allow students to instill reflective thinking to ensure objective and precise clinical documentation.32

Table 4.PlaceholderTable 4: Commentaries on How Dewey’s Process of Reflective Learning Relate to Approved General Recommendations by Panel of Experts
Recommendations from panel of experts
Dewey’s Reflective Learning process steps		 Lectures and didactic opportunities on TGD care Accommodation of trainees to provide care in a dedicated clinical setting for TGD patients Creation of a new standard in medical note writing that takes gender diversity into account
Reflection as a meaning-making process that moves learner from the experience of learning to a deeper understanding of chosen topic Through lectures, lunch-and-learns, chalk-talks, simulation-based exercises, as well as other educational content delivery methods, we can allow the student to start learning about principles of TGD care (with or without patient interaction). For instance, a lecture on the topic of pronouns, and a case study on TGD patient care, may allow learners to not only learn about the correct and incorrect ways of using pronouns, but these educational modalities may also help build intuitive understanding of how and when to ask patients for their pronouns, build a habit of asking patients for their pronouns instead of assuming, and forming routines of checking patient charts to gather as much information as possible on the patient’s self-disclosed pronouns instead of asking patients. By allowing students to gain clinical exposure, the students can apply what they have learned in didactic opportunities to real patient-care scenarios. For example, by allowing trainees to provide clinical care to TGD patients, the trainees will learn the fundamentals of pronouns, sex, gender, and sexuality. In addition to such fundamental knowledge, they will have the opportunity to better understand TGD patients, learn their various stories and challenges, and form a deeper knowledge of the patient population they are treating. It is through clinical immersion that the students will gain a deeper understanding on the topic of TGD care. After clinical immersion, trainees are asked to write a clinical note about the patient encounter. This is an opportunity for the trainees to reflect on what they have learned in the classroom, as well as what they have experienced during the clinical practice, and apply it to a sensitive, clear, and concise clinical note. Through the process of writing, trainees are given the opportunity to reflect on their previous learning and patient experiences and translate them into a meaningful clinical note. The overarching goal is for trainees to write clinical notes in a way that is non-judgmental, objective, and free of connotations. Development of such skill demonstrates a deeper understanding of medical note writing in the context of TGD care.
Reflection is way of thinking that is rooted in inquiry For reflection to take place, trainees should be given the opportunity to ask questions and receive feedback. This opportunity is inherently afforded in a didactic setting. For instance, in a lecture-based exercise, they are given the chance to ask questions along the way. In another instance, in a simulation-based exercise, they are provided the opportunity stop, think, reflect, and ask questions from their instructors and their peers as they move through the exercise. In a clinical situation, a trainee is learning and does not know all the answers. This is why there is a supervising physician to guide the trainee. As students are immersed in a clinical experience and see patients, they are not only encouraged to ask questions, but also are forced to seek guidance of their seniors to ensure that, as trainees, they have all the appropriate information to provide safe and effective patient care. For instance, during a clinical visit with a TGD patient, a patient may ask about interaction of a certain prescribed hormone with their allergy medication. A trainee may not know the correct and complete answer, which will prompt the trainee to inquire about the correct answer with their supervising physician. Writing clinical notes can be challenging, as a trainee attempts to translate all the information they learned about a patient and put the information into clear, concise, and sensitive language. This process is inherently difficult and requires guidance. During the process of creating new standards of medical note taking, space must be created to allow for the students to ask their supervising physicians and peers questions as well as give feedback.
Reflection needs to happen in community with others Trainees should have the opportunity to work with one another to learn, reflect, and improve. Through a variety of learning opportunities, educators can facilitate environments that allow for community and peer learning. For instance, in a lecture-based exercise, they can split students into groups for “breakout sessions” where the students are asked to discuss and reflect on the topic of TGD care. In a simulation-based exercise, they are inherently asked to work with one another and learn in as a group and community. For instance, when working with peers, a colleague may make a mistake with regards to pronoun use. The mistake made by a colleague may prompt another trainee to reflect on their own past mistakes and implicit biases, creating a space for reflection and learning. In a clinical experience, numerous trainees assist in seeing various patients with the supervising physician. Additionally, there are other healthcare professionals, such as nurses and medical assistants, that allow for a larger community in a clinical learning space. Through observing their own performance, as well as the performance of their peers and colleagues, trainees have the chance to reflect on their own knowledge, strengths, and weaknesses, and gain the opportunity to improve. For example, in a dedicated TGD care clinic, a trainee who is shadowing a supervising physician may see a standard example of how to lead a conversation with a TGD patient about their gender-affirmation history. Observing model behavior by the attending physician may create a space for the trainee to reflect on how the trainee can improve. Clinical notes are widely available to peers, supervising physicians, as well as patients. As the visibility is far and wide, it creates a space where the trainee must think and reflect more carefully when finalizing the clinical encounter notes. Furthermore, due to their visibility, it would not be uncommon for the trainees to receive feedback from their peers, seniors, as well as patients. Such feedback and visibility forces students to reflect deeply about what they have learned, and the ways they can improve.
Reflection requires valuing personal and intellectual growth TGD care requires a certain level of compassion and sensitivity. For trainees to undergo various didactic opportunities, the trainees should be reminded of their own personal investment in education, the impact they make in patients’ clinical progress, as well as the impact they make on their professional colleagues through enhancing and furthering their education on this topic. Clinical immersion allows students to learn about patients’ personal stories. Such stories are often filled with struggle, pain, and hope. The impact of these patient encounters has the potential to allow the student to reflect deeply about their own learning and professional development. It would allow the trainees to grow more interested in valuing their personal and intellectual growth, setting them up to be more impactful in the patient care they deliver. Clinical note-writing can be a difficult task. It is made even more challenging when writing about medical topics that can have sensitive connotations. Being tasked with writing notes on patient encounter visits could place the trainee in a reflective space where the trainee might think about the importance of their own personal and intellectual growth, as the words the trainees leave on a patient’s chart will last forever and be impactful in numerous ways.

Table 3: This table provides a commentary on how the three interventions that met expert panel consensus (columns) are explained, supported, and interpreted by Dewey’s process of reflective learning, which has four major components (rows). The commentary includes possible ways that Dewey’s process can take effect when considering the expert recommendations in real practice.

Educational modalities

The current delivery of education material on TGD care mostly consists of lectures, bedside teaching, and independent study, in that order of priority. The panel recommends delivery modalities to be prioritized in the order of bedside teaching, simulation-based learning, and lecture-based didactics (Table 5; Figures 5.1 and 5.2).

Table 5
Prevalence and Priority Current modalities Recommended/ideal modalities
Highest Lectures Bedside teaching
. Bedside teaching Simulation-based learning
. Independent study Lectures (in person or virtually); can include grand rounds, noon lectures, chief resident talks, etc.
. Research and scholarly activities TGD care conference attendance
. Pre-recorded modules, such as HealthStream Research and scholarly activities
. TGD care conference attendance Pre-recorded modules, such as HealthStream
Lowest Simulation-based learning Independent study and self-learning
Figure 5.1
Figure 5.1.Current educational modalities (top of pyramid has highest prevalence)
Figure 5.2
Figure 5.2.Recommended educational modalities (top of pyramid has highest priority)

Evaluation modalities

The experts recommended case presentations, observed interviews, and objective structured clinical examination (OSCE) as preferred evaluation modalities. With regard to current evaluation modalities, the panel mostly reported that no modalities are being enforced. Some experts stated oral and written exams are being utilized (Table 6; Figures 6.1 and 6.2).

Table 6
Prevalence and Priority Current modalities Recommended/ideal modalities
Highest Oral and/or written exams Case presentation requirement
. Objective Structured Clinical Examination (OSCE) Observed interviews
. Case presentation requirement Objective Structured Clinical Examination (OSCE)
. Patient case requirements (such as surgical logs) Oral and/or written exams
Lowest Observed interviews Patient case requirements (such as surgical logs)
Figure 6.1
Figure 6.1.Current evaluation modalities (top of pyramid has highest prevalence)
Figure 6.2
Figure 6.2.Recommended evaluation modalities (top of pyramid has highest priority)

Eliminated proposed interventions

Two interventions from the initial five rating recommendations were eliminated from the second round of surveys (Appendix B) as the panel did not reach consensus during the first round. Not reaching consensus on topics and interventions is common and expected within Delphi studies,33–35 as the nature of the study aims to propose topics that can be narrowed through expert opinion and knowledge. The first eliminated recommendation proposed mandatory assignment of all residents to 2–4-week rotation blocks at dedicated TGD clinical care settings, for which only 1 expert (14%) rated the proposal as highly important. The second eliminated recommendation proposed hiring a TGD individual and educator to observe patient care provided by trainees and attendings to give feedback and recommendations, and to provide cultural sensitivity training to attendings and trainees, for which four panel members (57%) rated the proposal as highly important.

Discussion

The proposed interventions would potentially allow evidence-based gender-affirming practices to create an environment for trainee education that would facilitate a more inclusive and comprehensive patient care environment.36 Trainee education enhancement in the field of GAC is crucial, as appropriate and adequate patient care is dependent on it. To further ensure trainee exposure and education, scholars in the field of GAC have called for installation of trainee graduation requirements by the Accreditation Council for Graduate Medical Education.37 Some may consider our current educational requirements outdated as GAC is rising in popularity and demand, though our medical and educational standards are not meeting the current demand. There is a lack of sturdy and holistic surgical education in the field, and the majority of trainees feel unprepared to provide quality care for patients interested in GAC. Robust curricula involving didactic, clinical, and competency-based evaluation models are recommended to be designed and implemented in undergraduate and post-graduate training programs.38

TGD patients represent an estimated 0.6 to 3% of the population worldwide.39 Despite the fact that they represent a notable portion of patient population, many healthcare institutions that house trainees do not have any educational initiatives on TGD care. In such institutions, the results suggest initiation of didactic opportunities, such as lectures on foundational concepts, terminology, and sensitive communication. Once a foundational didactic education has been established, creation of opportunities for trainees to shadow providers, and treat TGD patients is highly recommended. With a strong didactic and clinical curriculum, it may be appropriate to set standards in note-taking that involve consideration of gender identity, correct name, legal name, and pronouns. Furthermore, creation of standardized trainee evaluation methods, facilitation of research on TGD care, and attendance of appropriate conferences are recommended.

Though the panel did not reach consensus on two recommendations, it may be worthwhile to take a deeper dive into each proposal. One recommendation that was eliminated through a majority negative vote was mandatory assignment of all residents to dedicated TGD clinical care settings for a brief period. Several comments from experts centered around the mandatory nature of this proposal, as differences in program design, goals, and trainee interests may result in inappropriate, unnecessary, and unwanted educational exposure. Though it is necessary to prepare trainees to taking care of patients of various backgrounds and needs, it may be unwise to instill policies that may require drastic changes that may not be in accordance with program objectives or trainee goals.

The second eliminated proposal was hiring a TGD individual and educator to observe patient care to give feedback and recommendations. This proposal did not meet consensus threshold of 70%, as it only received a 57% vote. As the margin for elimination was rather small, it is remarkable to highlight that a notable proportion of experts deemed this proposal very important. As our educational standards currently lag in the field of TGD care, it is prudent to seek guidance, feedback, and education from the TGD community. The TGD community understands their needs, as well as the deficiencies within the healthcare system. It may be a sensible and crucial strategy to engage the TGD community with our healthcare educational initiatives to be able to address the needs of the patient community in an effective and resourceful way.

Future studies can be performed to further investigate the findings of this study. More specifically, studies shall be proposed that evaluate the effects of instilling the recommendations within healthcare institutions, and evaluating the observed effects on trainee education as well as patient care. Furthermore, based on the results, additional studies can be performed to evaluate what enhancements and modifications can be made to the instilled recommendations.

It is noteworthy to mention that while our intention in expanding educational curricula on the topic of gender-affirming care (GAC) is to normalize transgender and gender-diverse (TGD) patient care, the inherent nature of a targeted module on GAC may result in further separation of TGD patients from the rest of the patient population in eyes of certain providers. In order to minimize this possible inadvertent consequence, educators should maintain intentionality within their curricula through emphasizing the importance of integration of TGD patients within their practices, as well as normalization of TGD patient care. In a study performed by Ruprecht, et al., scholars noted that through maintaining an educational environment that is judgement-free, expressive of personal and shared experiences, and driven by a sense of responsibility to integrate TGD patients in routine clinical care settings, educators would be able to create a space where care of TGD patients are considered more well-incorporated to baseline medical practices, minimizing the possibility of segregating TGD patients.40

It is important to acknowledge the paradox that exists in the educational system of minority health or controversial medical treatments. While we try to normalize such care or treatment, we may cause further inadvertent separation of the population or medical treatment from routine care that is studied and provided. To address such discrepancy and challenge, it is important to attempt to integrate the topic of interest at all educational levels. At a local level, the topic of GAC should be part of the educational curricula of medical schools, the same way topics of hypertension and diabetes are discussed. At a state level, licensure exams should include requirements and qualifications with regards to GAC, such as continuing education credits required for certification. At a more national level, medical boards and qualification examinations should include questions on GAC, same way they include questions on abortion care, nonaccidental trauma, and ethical dilemmas.

Limitations

The study was conducted within Mass General Brigham healthcare system. As this healthcare organization may have different facilities, capabilities, patient population, and provider profiles as compared to other institutions, there may be limitations with regards to generalizability of this study. Furthermore, the consensus committee represents a highly specialized group of physicians, possibly making their recommendations idealistic and difficult to be attained. Experts recruited from different parts of the country may have different opinions as compared to MB physicians. Additionally, the methods used asked closed-ended questions, limiting the ability of the experts to provide, and reach consensus on, new ideas not provided by the coauthors.

To address inherent biases discussed in this study due to the focal sample from MGB, future studies can be proposed to enhance objectivity. A Delphi study that includes experts and physicians from various healthcare systems across the country, in both urban and rural areas, will allow for a higher level of diversity in expert opinion and recommendations. It is an undeniable fact that our environments, educational backgrounds, and patient populations affect our understanding, opinions, and approach. With a diversified pool of expert, future studies may be able to mitigate the limitation of this study. Additionally, more open-ended questions should be included in future surveys to enable the panel to provide new recommendations and suggestions.

Conclusion

The results of this Delphi consensus study demonstrate the importance of establishing a strong didactic-based lesson plan on TGD care, facilitation of voluntary clinical care opportunities and community engagement, and improvement in medical record standards to embrace inclusive language. It is important to consider engaging the TGD community with trainee and staff education. The panel recommends delivery modalities to be prioritized in the order of bedside teaching, simulation-based learning, and lecture-based didactics. The experts recommend case presentations, observed interviews, and objective structured clinical examination (OSCE) as preferred evaluation modalities.

Submitted: September 28, 2024 EDT

Accepted: October 06, 2024 EDT

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Appendix A
Questions 1-5 Responses Decision
  1. Recommended intervention: Lecture on foundational concepts, terminology, and sensitive and effective communication. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 6/7 (86%) responses were ≥5 Moved to next round
  1. Recommended intervention: Mandatory assignment of all residents to 2–4-week rotation blocks at dedicated transgender and gender diverse (TGD) clinical care settings. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 1/7 (14%) responses were ≥5 Eliminated from next round
  1. Recommended intervention: Accommodation for residents interested in voluntary additional experience to have a rotation with a medical provider who specializes in gender-affirming care. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 5/7 (71%) responses were ≥5. Moved to next round
  1. Recommended intervention: Creation of a new standard in note-taking that involves consideration of gender identity, correct name, legal name, and pronouns. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 6/7 (86%) responses were ≥5 Moved to next round
  1. Recommended intervention: Hiring a TGD individual and educator to observe patient care provided by trainees and attendings to give feedback and recommendations, and to provide cultural sensitivity training to attendings and trainees. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 4/7 (57%) responses were ≥5 Eliminated from next round
Question 6:Please rank the following delivery methods of the educational content to trainees, in the order that you believe is currently being utilized most heavily to least frequently. Please place the most frequently used methods at the top.

Responses
Intervention Final Rank Answers Mean SD
Lectures (in person or virtually); can include grand rounds, noon lectures, chief resident talks, etc. 1 1,1,1,1,2,3,3 1.71 0.95
Bedside teaching 2 1,1,2,2,3,3,4 2.29 1.11
Independent study and self-learning 3 2,2,2,2,3,3,4 2.57 0.79
Research and scholarly activities 4 1,4,4,4,4,4,6 3.86 1.46
Pre-recorded modules, such as HealthStream 5 3,5,5,5,5,6,7 5.14 1.21
TGD care conference attendance 6 5,5,6,6,6,7,7 6 0.82
Simulation-based learning 7 5,6,6,7,7,7,7 6.43 0.79
Not applicable--there are no current modalities being utilized at my institution. (If this choice applies, place it at the top and do not rank the rest. If it does not apply, leave it at the bottom.) 8 7,7,7,7,7,7,7 7 0
Question 7:Please rank the following delivery methods of the educational content to trainees, in the order that you believe should be delivered to trainees. Please place the most important one at the top and continue in order of importance.

Responses
Intervention Final Rank Answers Mean SD
Bedside teaching 1 1,1,1,1,1,2,5 1.71 1.50
Simulation-based learning 2 1,2,2,2,3,4,7 3 2
Lectures (in person or virtually); can include grand rounds, noon lectures, chief resident talks, etc. 3 1,3,3,3,3,5,6 3.43 1.62
TGD care conference attendance 4 3,4,4,4,4,4,6 4.14 0.90
Research and scholarly activities 5 2,2,5,5,6,7,7 4.86 2.12
Pre-recorded modules, such as HealthStream 6 2,4,6,6,6,6,7 5.29 1.70
Independent study and self-learning 7 1,5,5,5,7,7,7 5.29 2.13
Question 8:Please rank the following evaluation modalities trainees undergo, in the order that you believe is currently being utilized most heavily to least frequently. Please place the most frequently used evaluation methods at the top.

Responses
Intervention Final Rank Answers Mean SD
Not applicable--there are no current trainee evaluation modalities being utilized at my institution. (If this choice applies, place it at the top and do not rank the rest. If it does not apply, leave it at the bottom.) 1 1,1,1,1,1,2,2 1.29 0.48
Oral and/or written exams 2 1,1,2,2,2,2,2 1.71 0.48
Objective Structured Clinical Examination (OSCE) 3 3,3,3,4,4,4,1 3.14 1.07
Case presentation requirement 4 2,2,3,4,5,5,5 3.71 1.38
Patient case requirements (such as surgical logs) 5 4,4,4,5,5,5,1 4 1.41
Observed interviews 6 3,3,3,6,6,6,6 4.71 1.60
Question 9:Please rank the evaluation modalities trainees should undergo, in the order that you believe are most effective for education on TGD care. The choices at the top should be utilized most frequently.

Responses
Intervention Final Rank Answers Mean SD
Case presentation requirement 1 1,1,1,2,3,3,3 2 1
Observed interviews 2 1,1,2,2,3,3,5 2.43 1.40
Objective Structured Clinical Examination (OSCE) 3 1,1,2,3,3,4,5 2.71 1.50
Oral and/or written exams 4 2,2,4,4,4,5,5 3.71 1.25
Patient case requirements (such as surgical logs) 6 1,4,4,4,5,5,5 4 1.41
Question 10:Please rank the top five recommendations for an institution with no current initiatives. The recommendation at the top is the one of highest importance in your opinion, with lower importance in descending order.

Responses
Intervention Final Rank Answers Mean SD
Lecture on foundational concepts, terminology, and sensitive and effective communication. 1 1,1,1,1,3,4 1.83 1.33
Creation of opportunities for trainees to shadow and work with medical provider who specializes in gender-affirming care. 2 1,2,2,2,3,5 2.5 1.38
Creation of a new standard in note-taking that involves consideration gender identity, correct name, legal name, and pronouns. 3 2,3,3,3,3,5 3.17 0.98
Hiring a TGD individual and educator to observe patient care provided by trainees and attendings to give feedback and recommendations, and to provide cultural sensitivity training to attendings and trainees. 4 1,4,4,4,5,7 4.17 1.94
Creation of research and scholarly requirements in TGD care. 5 2,2,5,5,6,7 4.5 2.07
Creation of standardized trainee evaluation methods. 6 4,5,6,6,6,7 5.67 1.03
Creation of funding opportunities for TGD care conference attendance. 7 4,6,6,7,7,7 6.17 1.17

Question 11: Please provide any additional comments/feedback/suggestions you may have.

Appendix B
Questions 1-3 Responses
  1. Recommended intervention: Lecture on foundational concepts, terminology, and sensitive and effective communication. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 6/7 (86%) responses were ≥5
  1. Recommended intervention: Accommodation for residents interested in voluntary additional experience to have a rotation with a medical provider who specializes in gender-affirming care. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 5/7 (71%) responses were ≥5.
  1. Recommended intervention: Creation of a new standard in note-taking that involves consideration of gender identity, correct name, legal name, and pronouns. Based on the ranking key above, please rate this recommendation with regards to necessity and importance.
 5/7 (71%) responses were ≥5