‘I’m Sorry That My Patient Had To Teach Me That Lesson.’

How one interaction with a transgender patient taught this emergency room physician something he hadn’t learned in 23-plus years combined of medical schooling, residency and professional practice.
Dr Mike Lutes in his medical gear
Photo by Romulo Ueda
Dr. Mike Lutes

“Anyone, anything, anytime” — that was the unofficial motto that attracted me to the specialty of emergency medicine while I was in medical school in the late 1990s. In my relatively young and naïve perception of the house of medicine, emergency room doctors were the “truest” of all physicians. It fit my imaginings of what it meant to be a doctor, helping to solve whatever problem the patient presented. I started my residency training at the University of Michigan in 2000. From 2000 to 2004, I worked at the university hospital as well as busy community hospitals in Ann Arbor and Flint. Those experiences fostered a false notion that I was well equipped to care for any patient who walked in or was brought through the door of the ER.

Fast-forward a decade and a half or so and I find myself having a conversation with a young transgender woman. It is not going well. To protect her privacy, I won’t share details. But it’s a little like watching two cars back into each other in the parking lot from afar. You can see it unfolding, you know what is going to happen, but you are seemingly helpless to stop it.

At the time, I thought the patient was being irrational. In retrospect, I was clearly more defensive than I should have been. I failed to approach the situation with humility. I apologized to the patient, but I could have done a better job of that, too. I had offended her on a deep level and failed to establish the trust essential to the physician-patient relationship.

If you see a couple thousand patients per year, some complaints are inevitable. I like to think that I am good at establishing rapport with patients and their families. Treating everyone with respect and dignity is a core value of my practice of medicine. This particular case stuck with me. What went wrong here? Gradually, it dawned on me: In four years of medical school, four years of residency training in emergency medicine and 15-plus years of practice with required education to maintain licensure and board certification, the sum total of my training for transgender patients was zero. Zero. I have spent hours learning about diseases that, statistically speaking, I’ll almost certainly never see. Yet I literally did not know the first thing about how to care for the needs of transgender patients. How could this happen in the specialty that prides itself on taking care of “anyone, anything, anytime”? I’m probably not the right person to answer that question, but I think the short answer is that, in the United States, transgender people are still “othered.” Marginalized.

Mike Lutes

Photo by Romulo Ueda

I made it a priority to educate myself on the care of transgender patients. I was pleased to find that my favorite continuing medical education service had some good resources. I was delighted to learn that the Emergency Medicine Residency Association had created its own guide for the care of transgender patients. It is excellent. The primer includes some telling statistics. At the time of publication in 2018, only one-third of American and Canadian medical schools had curricula related to gender transitioning and gender-affirmation surgeries. Only 26% of U.S. emergency medicine residencies had at least one lecture on LGBTQ health in residency curricula.

I suspect, though, that the lack of training with regard to the care of transgender patients will soon be a thing of the past. An informal poll I conducted in a large social media group of emergency physicians was somewhat encouraging. Respondents reported noticing the lack of training and took it upon themselves to fix it. These efforts were typically the work of one person or a small group of people. One person even organized a panel of transgender patients to speak to their residency about their experiences in the health care system. I’m sure that was eye-opening and spurred many attendees to change their practice.

I’m sorry that my patient had to teach me that lesson. It assails my sense of who I am as a person and how I engage in the practice of medicine to know that I essentially ignored the health care needs of this population for the better part of two decades. I’m grateful for the opportunity to learn and grow as a person and as a physician, but I deeply regret that it came at the cost of what was likely one of many disappointing interactions with the health care system. I’m hopeful that progress is being made and I’m so impressed by the many young physicians who are helping lead the way. There is no asterisk to the “anyone, anything, anytime” motto.

Risk Factors for Transgender Patients

The National Transgender Discrimination Survey performed by the National LGBTQ Task Force and the National Center for Transgender Equality purports to be the most extensive survey of transgender health disparities ever conducted. Those results, detailed in the Emergency Medicine Residents’ Association’s 2018 EMRA Transgender Care Guide, include the following transgender patient risk factors:

  • 4% turn to the emergency department for primary care
  • 21% avoid the emergency department out of fear of discrimination
  • They are 5x more likely to attempt suicide
  • HIV infection rate is 4x higher than the national average
  • Higher rates of drug use, sexual assault, domestic violence and sex work
  • They are 4x more likely to live in extreme poverty
  • They are 2x more likely to be unemployed

Source: EMRA Transgender Care Guide, Copyright 2018, Emergency Medicine Residents’ Association, Irving, Texas.

Dr. Mike Lutes is a practicing board-certified emergency room physician with Madison Emergency Physicians, a married father of five, an avid fly fisherman and a mediocre guitarist. He is a committed lifelong learner and enjoys the regular dose of humility that comes with trying new things.