Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Jennifer Mathews: Hello, and welcome to the AMA STEPS Forward® podcast. My name is Jennifer Mathews. My pronouns are she/her and we are going to be talking today about inclusive and equitable health care for LGBTQ+ patients. And I am very happy to welcome as our guest, Dr Kyle Christiason, medical director and family medicine physician at UnityPoint Health in Cedar Falls, Iowa.
Dr Christiason, why don't we start with you just telling the listeners a little bit about yourself and your background?
Kyle P. Christiason, MD, CPE, FAAFP: That sounds great, Jen, it's an honor to be with you today. My name is Kyle Christiason. My pronouns are he/him. I'm married to Jen and we're the proud parents of two children, Ben and Lars. Medically, after my residency in Market, Michigan, I returned to my hometown in Iowa to start my medical career.
My medical practice, family medicine, has been comprehensive doing obstetrics and inpatient medicine and, over the years, numbers of leadership roles. And yes, I'm sure many physicians can attest, my career path has taken a whole number of unpredictable turns, many really good ones. And I'm sure we'll talk about one of those in much more detail today.
Mathews: I suspect we will. Well, thanks for being here. Why don't we start with the main reason that we're here? In 2017, you founded an LGBTQ health care clinic at your practice in Cedar Falls and you had a personal reason for doing this. So why don't we start with how this entire journey began for you and for you and your family?
Dr Christiason: Yes. Would love to. The spark for launching a dedicated LGBTQ+ clinic is our eldest child, Ben. And if it's okay, I'd like to share a little bit about his experience coming out—
Dr Christiason: …Because I think really is foundational to the spark for what we're doing. And I think embodies a bit of the why.
So yes, when our child was born a very good friend and a talented artist made us this full-body mirror and had lots of stained glass around the edges. It was beautiful, this thing. And even before Ben was born, we would kind of dream about dancing in front of the mirror, and our kids then, as they matured, they would love dressing up. They would dance and all their friends would play in front of this full-length mirror in their room for years. So, when our child at the time about sixth grade asked me to take this mirror down, I was confused, but sad as well. And in its place, they asked me to hang this tiny mirror, the size of a postcard. Just big enough to see one's eyes and nothing else. And what we didn't know then was our child was experiencing severe gender dysphoria.
You see our first child was sex-assigned female at birth. And however, thanks to really their diligence, by junior high age, they discovered this true gender identity as being more masculine. So, when getting dressed, if our child happened to kind of glance in the mirror and saw breasts, he would feel dysphoria. Really at the time, again, unbeknownst to us, to the point of suicidal ideation. His body just simply didn't match his gender and the mirror was this source of pain. And so even as Ben was able to share his authentic self with us, his parents, we realized that we were just not very well prepared to support him both as parents, but also as health professionals.
And that was kind of the real “aha” for us. So regarding transgender health, I had next to nothing for training in my medical school curriculum. Connecting with my physician colleagues all around my community they had the same gap and knowledge as did I. So, we called our insurance company and they, as expected, advised us to stay in-network as the first step. Okay, happy to do that, but give us some advice. So, they referred us to a sex therapist who was an hour away from our home. And although the sex therapist was nice and professed to be absolutely fascinated by Ben. She had no experience with transgender clients. So again, another strikeout.
And it was only through a couple of kind of serendipitous connections that we found our way to an academic medical center with a specialty clinic in transgender health. By the way, out of network and four hours from our home.
Dr Christiason: And this led to some really terrific experiences and affirmations, lots of learnings and some amazing new partnerships like with the university of Iowa eventually. But we acknowledged that, gosh, if it took this much effort and it was this difficult really for a couple of years even, for two health professionals who enjoy a large amount of privilege to find safe and competent care, well, we recognized that as absurd. And so, we hope to do something about it and we didn't want another child to feel unseen and didn't want another parent or adult to feel alone in this journey.
Mathews: Four hours. My goodness. How many years did you do that back and forth before you found another alternative or created one?
Dr Christiason: Yeah, so it really took, it took probably three years for us to really settle in and find some great care relatively closer to home that was only an hour and a half away to find culturally humble care.
But again, we still were seeing this in our day-to-day clinic. So, I was seeing, in my medical practice then, seeing people drive two, four, and six hours away to get access to safer, more welcoming care. That really, again, was the spark for us thinking, “Gosh, somebody ought to be doing something about this.” And as we turned around, we recognized that well, that could be us. That has to be waiting for an urban setting or an academic medical center alone, just to provide safer, more welcoming, and inclusive care.
Mathews: So how did you get from that first epiphany that the help that we're looking for is right here where we are to starting this clinic?
Dr Christiason: Though the spark really is looking at disparities for us. So, we recognize that many marginalized groups, and I hope this is the part that becomes the broader takeaway, and some of the benefits of what we can do in health care transcend the LGBTQ population that we're talking about today.
The principles here are universally applicable. So like many other marginalized groups, health care historically has failed LGBTQ folks. There are lots of studies describing doctors using harsh or abusive language with LGBTQ+ patients or blaming them for their health status, using all this excessive, personal protective equipment when examining or even refusing to touch patients.
In fact, 20% of transgender folks have simply been refused health care because of their identity. And so, it's these types of disparities that truly lead to poorer outcomes. For example, more likely to smoke or use substances, increase depression or anxiety, increased risk of suicide. And again, if your health care experiences have been so poor, then that just leads to just general avoidance unless absolutely necessary.
So that really was what we were trying to bridge, that gap. So, to understand what was possible we sought the voice of the community that we wanted to serve. We convened all kinds of focus groups and tried to collect data on what local needs might be for health care in our community. And that ultimately led to the vision for the clinic, which is to provide primary care and gender-affirming care to those in the LGBTQ+ community in Northeast Iowa.
Mathews: So after you reached out to the community and really tried to identify where the needs were and how you can meet them, who is we, by the way you said we, who at this point, did you have on board that shared your vision for this clinic?
Dr Christiason: We had a wonderful partnership early on with a Title 10 clinic as part of UnityPoint Health that primarily focuses on women's health. And they actually had this experience. When someone who had my voice, let's just kind of say, it sounded like my voice calling into this women's clinic and said, “I need to do some cancer screening.” “Well, tell me more.” “Specifically, I need to have a cervical cancer screen.” And the unfortunate response was making assumptions based on my voice, the sound of the voice. Well, we only treat women here.
So that collided with, again, the experience that we were having in our family and recognized that, listen, we need to pay attention to these opportunities. We need to make sure that we are purposefully creating safe and more welcoming care. And it's those moments that are the missed opportunity and we recognize those were happening all over the place.
So, it was working with this women's clinic and with some other health care leaders in our system, in our region, that we started to develop a business plan to create the clinical case, to create the vision of what this could be to start to gather the troops, so to speak. So, we were actually inviting folks to be part of something that we were still trying to create. But when we stated the vision of we want to close this gap in health care and make health care safer, more accessible. Time after time we had folks say, “Yes, I'm in, let me be part of this.”
Mathews: Well, that's great. I was going to ask what was the response that you got when you started reaching out to colleagues, peers, et cetera. So, it sounds like it was overwhelmingly positive?
Dr Christiason: Very much. Our goal was to, again, try to get as many folks on board that would be able to create a good safer experience. Our goal was to recruit team members, get administrative support and try to support this at a system-wide level. I kept thinking, how on earth are we going to convince pharmacists and physicians, nurses, others, to be part of something that's very different? And by the way, come to this dedicated space after their workdays. So, this was typically in the evening hours for this clinic. And every time we stated the goal, they resoundingly said yes.
In fact, we had one of our nurse practitioners come up to me a few months after we were underway. And she asked me, “Did you know that we get paid to work here?” Again, I think it speaks to the mission that the people were really excited to be part of something.
Mathews: Oh wow. That's amazing. So, I think there's a lot of hesitancy around this in general, because, as you mentioned, this particular patient community has often experienced various levels of medical trauma trying to reach out for care in environments in which they didn't feel welcomed. They didn't feel seen. They didn't feel affirmed to the level that they actually felt attacked. They felt judged, they felt rejected.
So, trying to create an inclusive community in a community in which you can care for these individuals in a respectful, welcoming manner, while also acknowledging that past potential trauma that they're carrying with them. What type of training or research did you and the care team do when you first sought out to create this clinic and reach out to this community to make sure that you did not perpetuate that trauma?
Dr Christiason: This really is one of the key principles for the clinic is attention to key moments. We have a lot of mantras that we will speak back to ourselves to keep ourselves motivated. But one of those is do not leave a great experience to chance instead design for it. And as we were designing the clinic from the ground up, redesigning the whole experience from front to finish. We wanted to really pay attention to those key moments, which are in health care, I think often overlooked as inconsequential, but nothing's further from the truth.
For example, that very first call-in. If someone's calling in to schedule a visit with the LGBTQ clinic, we purposefully ask, what name would you like us to use when we are working with you? What pronouns would you like us to use when we call you back in from the waiting area to the examination room?
Those have, it sounds very simple, but those have been historically neglected or even rebuffed in health care. When in fact that is the most essential and foundational part of how we address one another is honoring those basic things.
So key moments, such as that initial check-in or that finish process is as the patient is checking out, those we pay attention to because those are opportunities for creating a much more interesting and loving experience in health care.
Secondly, every single team member has gone through what's called safe zones training. So safe zones is open source de facto sensitivity training resource and something that we continuously embed into our clinic process. Every clinic we begin with a huddle, as I mentioned, we're all coming from our so-called day clinics. And so, we want this re-centering moment to get back to our purpose tonight together in this dedicated LGBTQ clinic. So embedded into that is another nugget of education with regard to safe zones. Otherwise, every team member goes through a couple of hours of training.
Mathews: And so, you did officially open the clinic in 2017, is that correct?
Dr Christiason: It was January 2018.
Mathews: January 2018. Okay. And what sort of lessons have you taken away over the last five years of having the clinic open and what challenges have you potentially had to face and overcome that maybe you hadn't anticipated?
Dr Christiason: We knew that there was a need for something like this. I don't think we recognized how much. So, over the last four years, four and a half years, we've had to increase our access five to sixfold to meet that need. And we continue to try to find creative ways to be accessible and continue to create a good experience across Eastern Iowa.
We have patients driving two to three hours to see us now. And again, it speaks to the need to educate my colleagues so that we can provide this, or equitable care, close to home. We don't need to have expert clinics to provide this type of safer care.
Dr Christiason: We recognize that life's most meaningful milestones, I think, are often anchored around moments in health care. For example, we recall events like before or after the diagnosis or that happened before, around the time of my surgery, or right after so and so became ill.
Those are key moments in life. And I think, we in health care, really have this joyful duty to become a valued guest in the lives of our patients when they go through these events. We've traditionally ignored that in health care. And unfortunately, that has created this lack of trust within health care.
That trust relationship involves patients to us in health care. But I think it even is internal that as a health care provider that I feel like maybe I don't make as much of an impact as I would like. That, I think, is one of the great lessons of this clinic is paying attention to how we can be such an important part of one's wellness by creating this place where you get to be your most authentic self. And we in health care honor that, that is the beginning place.
Mathews: Do you feel like your own relationship to medicine and your practice of medicine has changed at all since you've went on this journey, both as a patient, as a parent supporting your child, and then as a health care provider that has focused on creating this clinic and reaching out to the community. And if so, how?
Dr Christiason: Very much, one of the things that we talk about in our huddle as well is it is connecting to your purpose in medicine. So, the only warlike reference I use anymore in health care, Jen, is this. We have what we call joy bombs in our huddle. We refuse to use other warlike terms anymore. So, in the trenches on the front line, health care is not warfare. So, we don't let, allow that. But we do love the term joy bombs. And this is an opportunity for us to share what connected you to your purpose in health care tonight. What connected you to a patient or to your original reason for being in health care?
This is something that happens regularly in this clinic where folks will tell us about the past poor experiences in health care and now really feeling seen and heard and honored in this health care environment where, for the first time, they might actually be caring about their own health, because we are honoring their most authentic self.
When we connect to those improvements in patients' health and recognize that we get to go full circle with patients in that awesome journey. It really helps us with burnout.
Mathews: Oh yeah, I imagine so, definitely. So, in the time the clinic's been open, how has it grown, evolved? What plans for the future do you possibly have? You referenced that you experienced patients now coming to see you that are driving three, four hours to get to you. So, there's obviously still a need in your larger area. Do you have any plans to try to fill that?
Dr Christiason: About a year and a half after we opened the clinic in Cedar Falls, we opened a second clinic of UnityPoint Health in Des Moines. And although the pandemic has gotten in the way a little bit, we are working to continue to advance the education and opportunities across the entire footprint of UnityPoint Health, which is three states serving three million people. And at least in Iowa, providing a care to more than a third of Iowans.
So, we believe that the opportunity is really great. We've done that a couple of ways. One is we've advanced education, some very basic terminology with regards to LGBTQ care, and some very mild safe zone things, but we've got that to 30,000 of our employees. So that's one of the great successes is continuing to elevate that conversation.
We continue to nurture relationships with my colleagues that are specialists that we work with on a regular basis. Other front-door access points to health care, such as the emergency department and urgent care again, are trying to equip each other with the skills and tools to create the safer, more welcoming experience.
I really believe that most of my colleagues want to create a safer, more welcoming experience. They may just not feel equipped. So, we continue to provide those tools, that education, and how to do that.
Mathews: Yeah, we spoke a few weeks ago with the medical director of an LGBT center in Los Angeles. And she said that that was a challenge that they were experiencing there is that they were providing primary care to their patients, but if they needed to be referred for specialist care, there was often a disconnect there that they were having some negative experiences with certain specialists that weren't as inclusive and welcoming. That was a hurdle that they were trying to get over. Have you experienced that at all at your clinic?
Dr Christiason: That's a great example of a key moment, an opportunity for a misstep. So that handoff in health care is always a vulnerable experience, no matter what we're talking about. And so that's a great example of how we want to purposefully coordinate that and communicate that in a way that is affirming.
So that's a great example of what we try to pay attention to is those moments that are often just assumed as somewhat transactional, that's also where the good stuff can happen. That's where we can really create a great experience in health care.
Mathews: Yeah. Yeah. Well, this has been wonderful. Are there any other pearls of wisdom you'd like to leave our listeners with?
Dr Christiason: Yeah, I'd love to, if we could just finish with a story about, I think, consistent with what we were just talking about, how do we do this in health care create the safer experience? So, a couple of years ago we were seeing a young gentleman, 20-something-year-old in our LGBTQ clinic. And as I was doing some chart review and prepare for the visit, I noticed that this patient had been cared for by a PCP since childhood. So gosh, 15, 20 years perhaps. And I commented, “I'm really glad you're with us. It's terrific you're with us, but I would you mind sharing why, since I know your PCP is still actively working.” And he said he liked his PCP, but didn't want to tell him that he was gay because he didn't want to, “Disappoint him.”
And I think that this story really hit me hard because I don't really believe this PCP was necessarily homophobic, but I do know that this other physician did not make it clear, create a space that invited this person to be authentic in this office.
And so, let's, in health care, not make those assumptions that patients know that we're loving and know that we are caring. Let's be very visible and purposeful about how we do that.
So those examples of introducing yourself with your pronouns, those examples of having visible cues, that this is a safer place, such as a rainbow, or having your pronouns on your name badge. Those are very important and meaningful ways that we can convey something to a patient. So, let's not make assumptions about anybody. Let's be very purposeful, intentional about creating a safer place for our patients.
Mathews: Well, thank you. Thank you so much for being with us today. It's been so wonderful talking to you and I congratulate you on your great work and hope that you continue to thrive and what an inspiration. I can't imagine how Ben must feel. I would imagine he would feel pretty darn proud of everything that you've accomplished. That was instigated by, however many years ago, his bravery and speaking up about his truth.
Dr Christiason: Of course, Ben is the spark for all of this, and we couldn't be more proud and really grateful for the journey that we've been on with Ben. And Ben, by the way, is 24. He's thriving, living in Chicago. And again, we just love what his journey has led to.
Speaker: Thank you for listening to this episode from the AMA's STEPS Forward® podcast series, AMA's STEPS Forward® program is open access and free to all at STEPSForward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA's STEPS Forward® podcast series. STEPSForward.org
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