This study examines medical students’ involvement in LGBT healthcare education across multiple centers and, to our knowledge, is the first to assess how demographics, patient exposure, and curricular education influences LGBT preparedness, attitudes, and knowledge. We found that medical students reported very high attitudinal awareness, moderate knowledge, and low clinical preparedness. These findings are similar to prior studies that showed high affirming attitudes and moderate knowledge among medical students [9, 11]. Obedin-Maliver et al.  demonstrated that in 2009–2010 medical schools across the nation delivered a median of five total hours of LGBT-related curricular instruction during four years of medical education. From that research, it was apparent that LGBT-related medical education was not only scant but also highly variable among U.S. medical institutions. Our finding of 2.22 annual hours of LGBT-related education is only a modest improvement from the five total curricular hours reported by Obedin-Maliver et al. nearly 10 years ago.
Importantly, we found that as medical students cared for more LGBT patients and received more LGBT education, they reported higher LGBT-DOCSS scores. This finding is akin to the few studies that have shown that for medical students, LGBT patient contact and curricular education can be effective in increasing comfort , knowledge , and confidence  in caring for the LGBT population. However, to our knowledge, there are no specific recommendations regarding the amount of patient exposure and education that relate to high LGBT cultural competency. As educators and curricular leadership often experience competing demands for increased educational hours on a number of topics, we aimed to quantify the specific patient encounter and curricular hour benchmarks that could be recommended to promote high LGBT cultural competency. By setting a high, yet reasonable, standard for proficiency, we found that medical students with high cultural competency (i.e., those who reported an Overall LGBT-DOCSS score near 6) cared for 35 or more LGBT patients and received 35 or more LGBT total education hours. The effect of LGBT patient exposure and education on cultural competency was most apparent in Clinical Preparedness, which had the largest difference in scores.
Of the 35 curricular hours that higher-competent medical students received, 25 of those hours were extracurricular, suggesting that many medical students may heavily rely on self-directed LGBT education. While this finding could indicate that incorporating 10 LGBT curricular hours may be stimulating enough for medical students to pursue supplementary education to achieve a total of 35 LGBT hours, it is also problematic. Nearly 30% of medical students in this study did not report any extracurricular education and thus relied exclusively on their programs for their LGBT education. As such, a large proportion of medical students may not achieve 35 h if these hours are not provided explicitly by their programs.
To close the current gap of nationally inadequate LGBT cultural competency, medical schools should consider an LGBT educational curriculum that consists of approximately nine annual hours (both 2.5 h of required curricular education and 6.5 h of supplemental education) over the course of the typical four-year medical education timeline. For schools without any or minimal integration of LGBT topics and patients, an LGBT educational curriculum could easily be delivered and required within lectures, case presentations, and small group sessions across different courses and levels of training; additional, supplemental, non-required education could be encouraged through online modules, journal clubs, seminars, conferences, and clinical rotations such as multidisciplinary and sexual and gender minority clinics and electives. An interesting inquiry is how much impact this amount of curricular and supplemental education has on subsequent clinical performance, patient-provider shared decision making, patient satisfaction, and patient outcomes.
With regards to the transgender population, the lowest item mean of the entire LGBT-DOCSS addressed having received adequate clinical training and supervision to work with transgender patients. Additionally, we found a disconnect in medical students’ moderately high reported understanding of transgender-specific knowledge and their very low reported transgender-specific preparedness, especially when compared to their preparedness in treating LGB patients. This discomfort with transgender care specifically has been described in prior studies among medical students [10, 11] and may imply that there is a lack of educational emphasis on transgender-related topics, particularly those that involve clinical preparedness. Dubin et al.  noted curricular time as a barrier to transgender health exposure. Taken together with our findings, not only should LGBT education as a whole be increased, but special attention should be given to transgender-related healthcare topics. As one surveyed student conveyed, “While frequently spoken of as one group, I feel that treating LGB patients and transgender patients are two entirely different experiences.”
Future studies are required to: 1) examine the specific proportion of transgender-specific patient exposure and hours which relate to high transgender cultural competency, 2) examine the long-term effects that increased LGBT patient exposure and curricular education have on LGBT cultural competency, clinical performance, and patient outcomes, and 3) recommend standardized, universal cultural competency training for medical students. Also, given the spectrum of gender identities, sexual orientations, races, and levels of training, this sample population represents a diverse pool of medical students, although with notably more cisgender women and White/Caucasian medical students than the entire medical student population  as well as notably more sexual and gender minorities than the general U.S. population . While not the specific aim of this study, these demographic variables are important attributes to consider in future research, as many were significant predictors of LGBT-DOCSS scores. Future LGBT cultural competency studies should consider incorporating more sexual, gender, and racial minority medical students by direct outreach to diversity student groups as well as diversity and inclusion offices at medical institutions.
Study limitations do exist. Firstly, this study was conducted at only three universities. In addition, reliance on convenience sampling may have caused medical students with biases toward the LGBT population to not participate in this study. Taken together, the degree of generalizability of these results to the national medical student population is unknown. Secondly, the accuracy of the self-reported experiential variables is unknown. Thirdly, self-reported quality of LGBT educational hours was not assessed. Lastly, only 50 medical students were polled in the initial validity analyses of the LGBT-DOCSS , and a broader use of the LGBT-DOCSS within medical student populations has only been presented here.