This month has been all about my personal practice of gender affirming healthcare. I wanted to take this last blog slot to share some of the things that shape my practice:

• Being queer
• Being femme
• Being in recovery
• Being a patient
• My community
• My family

All of these tie together into a primary force- my family, my community, and myself have experienced discriminatory and poor quality healthcare. That shared experience drives me to do better for my own patients- I want to be the doctor I wish I had. 

I have had many moments accessing healthcare where these intersectional identities have driven interactions that have been incredibly impactful in my practice of medicine. Over the years, I have shared many of these publicly. Today I want to share a few more recent encounters that represent these experiences well.

One of my sweeties had gender affirming top surgery to make their chest more smooth and less curvy. They ended up with a post-op bleed that necessitated a return to the OR. Finally on the way home from the surgery center, they told me they were having pleuritic pain with inspiration. You guessed it- they had a partial pneumothorax. This was during COVID, so I wasn’t allowed in the ED or their hospital room with them. They were placed on the cardiothoracic unit where the staff did not know how to manage their drains nor had access to any of their post op medications. Needless to say it was a rough night. The next day, the cardiothoracic senior resident and intern arrived for rounds. I started off the introductions by telling them myself and my partner are physicians and that my partner really prioritizes informed consent and minimizing interventions. They made a joke about my partner playing the lottery since they had two rare and unrelated complications in surgery. There was also another sarcastic joke that I can’t remember. None of which mirrored the tone of me, anxious, or my partner, exhausted, who had been up all night under medicated and managing their own drains with no post-operative care support. They then proceeded to tell us my partner needed a chest tube and that they were there to get the consent form signed. When we asked about risks and complications rates, they proceeded to tell us all the strategies used to minimize complications- no actual complication rates or other treatment options. I told them we would not be signing a consent, and that they needed to get an attending who could actually have an informed consent conversation with us. 

I used to be those residents. Not cardiothoracic residents, but the ones who had a plan and intention for a doctor-patient interaction that did not take my patient’s plan or goals into account at all. My success in pre-med, medical school, and to some degree residency was entirely dependent on me having the answer, knowing the plan. I needed a certain degree of ego or confidence in these settings to access those answers. I saw that ego in those residents- that “I know what’s wrong with you and I know how to fix it”. That ego that kept me from connecting as a human with another human in the clinical encounter. Culturally humble care requires, “a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.” It is a hard shift to go from having all of the answers to having none of the answers, from being the expert, to being a partner. Those residents had not made that shift yet. I don’t know that I would have made that shift from doctor-patient interaction to human-human partnership if I wasn’t queer, femme, and in recovery. It was not practicing medicine but receiving healthcare, especially as a marginalized and discriminated against person, that really reshaped my framework.

Medical school and residency taught me medicine. Being queer, femme, in recovery, and a patient taught me humility which has been a bigger asset to me as a clinician then the medicine has.

Just to give you the rest of the story, the fellow was well prepared for an informed consent conversation doing much better than the research indicates is average for clinicians. 85% of the time we discuss the benefits of an intervention but we only discuss the risks 35% of the time. My partner’s pneumothorax was right at the cusp of the size where chest tubes are recommended. However, my partner decided to try a period of watchful waiting as they were clinically stable. Their pneumo resolved on its own and they are very happy with their surgery results. 

Culturally humble care is so well suited to gender affirming care because we aren’t treating a pathology, just supporting people being themselves. It is so easy to forget that each patient, each person has bodily autonomy, when we are inundated as clinicians with practice metrics, A1c goals, screening targets, Press Ganey scores, and our own burnout. My new orthopedist and I were discussing treatment interventions for my hip. After I told her I get withdrawal or rebound headaches from NSAIDs- 5 days of a debilitating headache that prevents me from working or engaging with my life, she told me NSAIDs were non-negotiable if I chose to have hip arthroscopy.

Let me be clear- never have I ever said to a patient that something they put in their body is non-negotiable. 

I have offered education on the risk and benefits of different approaches. A tactic which she did not take. I am guessing her non-negotiation stance has something to do with the risk of heterotopic ossification. I had to look that up though- she did not offer me that education. She lost an opportunity to build a therapeutic connection with me. A stepping stone to a healthier therapeutic relationship because instead of understanding and education (shared decision making), she stripped me of my autonomy. 

We pay a lot of lip service to shared decision making in healthcare, but no training I have had as a clinician taught me how to truly practice it. I learned that by being a patient who really wasn’t given autonomy.