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Taking PRIDE in Better Patient Care through Assessment and LGBTQIA+ Representation

The NBOME believes that examinations designed to protect the public should reflect the makeup of the patient population that osteopathic physicians will serve. This means ensuring there is representation for the lesbian, gay, transgender, queer, and asexual (LGBTQIA+) community in the way we write and edit our test items.

The importance of diversity is a Core Value of the NBOME, and rooted in the Master COMLEX-USA blueprint. That document specifies, “The osteopathic physician must demonstrate sensitivity, respect, and responsiveness to a diverse and heterogeneous patient population, including but not limited to diversity in culture, religion, age, gender, sexual orientation, socioeconomic circumstances, mental and physical disabilities, and military personnel and their families.”

Diversity, equity, and inclusion is also one of the themes in the recommendations from the Special Commission on Osteopathic Medical Licensure Assessment.

This emphasis is essential as many in the LGBTQIA+ community have felt discrimination and bias from healthcare providers. According to a 2019 study, roughly 16 percent of LGBTQIA+ adults have reported facing discrimination, and as a result, avoided seeing their provider altogether. In an effort to combat this discrimination, the osteopathic medical profession is using several strategies to foster inclusive care.

One example is the American Osteopathic Foundation’s LGBTQ+ Health Equity and Inclusion Campaign, designed to undertake the work of better understanding and addressing the healthcare needs of the LGBTQIA+ communities. Several colleges of osteopathic medicine are working to emphasize inclusion and allyship in osteopathic medicine as well:


The NBOME is doing its part to combat stigma and discrimination by ensuring that its test questions accurately address the health needs of the LGBTQIA+ population, and are fair and free from bias. The NBOME Item Development Style Guide’s section on LGBTQIA+ terminology offers specific guidance on up-to-date language for editors and item writers.

“This has been a focus of ours for a long time,” explains Marie Fleury, DO, associate vice president for test development. “For each test question, we conduct a review that includes looking for bias and stereotypes related to gender and sexual orientation. We also review candidate comments and flag any that indicate an item has problematic terminology or outdated content.”

The NBOME has also held item writing workshops dedicated to transgender patient care. At these sessions, the NBOME’s National Faculty shared resources, brainstormed exam content, and wrote and reviewed test questions together.

“It is important to address and assess heath care needs of patients from all backgrounds,” said Obstetrics-Gynecology National Faculty Chair, Stephanie Zeszutek, DO. “The LGBTQIA+ population has unique but also overlooked needs that often contribute to health disparities.”

In a recent item writing workshop, Zeszutek added, “The NBOME team was extremely collaborative and supportive in the item writing workshop. We found it helpful to utilize real-life patient-interaction scenarios as a stepping-stone to exam question development. Our goal was to create timely and timeless items that address stigma, increase awareness, and promote wellness.”

Evelyn Ronkowski, associate director for test development also says, “We have referenced the GLMA Provider Directory to find National Faculty members who may be well-suited to write and review topics related to LGBTQIA+ health, but this does remain a high-needs area for us.”

In addition, the NBOME Item Development Style Guide has a section on LGBTQIA+ preferred terminology, which is regularly updated as new guidance emerges on best practices. Two resources for this section include the GLMA Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients and the GLAAD Media Reference Guide.

“Information can change so quickly, so as the organization responsible for assessing if a DO is fit to practice, it’s important that we remain nimble, and continually ask ourselves: ‘What are we doing now? What info do we want to provide item writers and reviewers? What can we change in our items right now? What do we need to remove?’” says Fleury.

If you are interested in writing questions related to LGBTQ health, please email nationalfaculty@nbome.org.