Feature: Students embed EDI into MD research

By Ashley Rabinovitch

An MD research course at Schulich School of Medicine & Dentistry does more than prepare future physicians to make sense of research and apply it to their field. It also gives them the opportunity to shine a spotlight on those who are pushed to the margins of the healthcare system.

Dr. Amrit Kirpalani, one of the course leaders, says that students have complete freedom to choose the topic they will research during the first two years of their MD program. The current class is particularly passionate about issues of equity, diversity, and inclusion (EDI), which is evident in some of the topics they chose.

“This class gives us a glimpse into what the physicians of the future find important,” says Kirpalani. “Their research is not only good for dismantling social injustice; it’s good science. They are demonstrating that you can examine EDI issues with a scholarly approach.”

Shining a spotlight on hidden homelessness

In early 2020, Grace Lilly was searching for a research topic when she came across the Mental Health Nursing Research Alliance, a team of researchers collecting data on a national scale about Canadians experiencing homelessness. Attracted to the opportunity to contribute to research that drives major policy decisions, Lilly joined the organization’s ongoing project, Homelessness Counts.

“Right now, we have a poor idea of how many Canadians are experiencing homelessness at a given time,” she says. “The overarching goal of the project is to develop an algorithm that quantifies this number and informs movements toward change.” She began her work with the organization by helping with focus groups and sifting through data, hoping to discover an unturned stone that could form the basis of her MD research project.

It didn’t take her long to find what she was looking for. Time and again, the concept of hidden homelessness arose in the focus groups she was analyzing. In contrast to someone experiencing absolute homelessness, which looks like sleeping at an emergency shelter or in the rough, someone experiencing hidden homelessness may be couch surfing or staying at hotels. They may be a woman fleeing domestic violence or an Indigenous person forced to leave a reserve because of overcrowding. While their situation may not always appear dire to onlookers, the absence of true stability puts them at risk of sliding into absolute homelessness.

“A lot of the research I discovered discussed how if we can better identify and support this population, we can help prevent the trauma of absolute homelessness and support better social integration and recovery,” Lilly says.

Lilly is analyzing the data collected from a housing history survey conducted by the larger team. Close to 400 respondents provided information that classified them as housed, absolutely homeless, or hidden homeless. Very few participants identified with hidden homelessness at the time of the survey, but the housing history they provided painted a more nuanced portrait.

In conjunction with housing history, Lilly is also working to analyze data about the public and community services utilized by individuals experiencing hidden homelessness. She aims to publish an article that details her findings within the next year.

“Any comprehensive strategy that tackles inequity in healthcare should consider people experiencing homelessness, but to make real change, decisions have to be backed by research,” Lilly has learned. By shining a spotlight on people experiencing hidden homelessness, she hopes that her research project, “Characterizing Hidden Homelessness,” will inform policy efforts that take these individuals’ interests into account.

Uncovering barriers to gender affirming top surgery

At the start of their first year of medical school, Gavin Raner and Jordan Shapiro became fast friends as two of the class’s few 2SLGBTQ+ students. Together, they decided to study the barriers faced by Canadian patients seeking gender affirming top surgery.

For Gavin Raner, who identifies as transmasculine non-binary, the MD research project is informed by lived experience. In the process of exploring and undergoing top surgery, Raner experienced countless barriers caused by lack of information and accessibility.

Raner and Shapiro formed a partnership with the Gender Clinic at Women’s College Hospital in Toronto, and their project, entitled “Experiences of Binary- and Non-Binary Transgender Patients undergoing gender affirming top surgery,” began to take shape.

They soon confronted a scarcity of research surrounding Canadian patients who were seeking top surgery. The little research that did exist was mostly on the U.S. side, and it was entirely focused on binary transgender patients to the exclusion of non-binary transgender patients.

“One of our primary goals was to illustrate the differences in experience between binary and non-binary transgender patients,” says Shapiro. “A binary and non-binary patient might face the same barrier but have totally different outcomes.”

The research they did discover helped illuminate the barriers experienced by both binary and non-binary transgender patients seeking masculinizing top surgery.

After embracing their identity and deciding to pursue surgery, a patient typically turns to a community healthcare provider for a referral to a surgery center. In that process, many encounter healthcare practitioners who lack fundamental knowledge about transgender healthcare. For nonbinary patients, there is also a lack of clarity on the requirements for surgical referral. Many practitioners mistakenly believe that nonbinary patients do not seek to transition.

For all top surgery patients, only one part of the procedure is covered—the removal of chest tissue. The second part of the surgery, which differentiates “masculinizing top surgery” from mastectomy, involves masculinizing the chest using liposuction. “Unfortunately, liposuction is not covered because its use is considered an ‘aesthetic procedure’ despite it being a crucial part of gender affirming top surgery, which is a ‘medically necessary procedure’,” explains Raner. “That is a major barrier for patients who are unable to pay $3,000 or more to complete their surgery.”

“For these projects and others like them, the science is sound and the subject matter is incredibly significant. Whether or not they go into research, physicians of the future need to learn how to ask and answer meaningful questions.” — Dr. Amrit Kirpalani, Course leader

In partnership with the Gender Clinic at Women’s College Hospital, Raner and Shapiro are in the process of recruiting participants who have engaged with the Clinic to complete a survey about the specific barriers they have faced. Their research aims to provide recommendations for healthcare centres, particularly surgical centres, to alleviate the burden experienced by transgender patients.

While Raner launched the research project with personal knowledge of the topic, the project left more room for reflection on Shapiro’s part. “As a cisgender man, I was aware of top surgery but didn’t understand barriers to access,” Shapiro says. “This research project has shown me that as much as we like to think we engage with EDI issues, we are always most engaged with topics that directly affect us. As physicians, we need to engage at a deeper level to become as inclusive and welcoming as we can be."

Asking the right questions

When reflecting on these two student projects, Kirpalani is pleased that his students have dedicated themselves to diving deep into issues with direct implications for marginalized populations.

“For these projects and others like them, the science is sound and the subject matter is incredibly significant,” he says. “Whether or not they go into research, physicians of the future need to learn how to ask and answer meaningful questions.”

They may not yet have discovered all the answers, but they are certainly on the right track.