Program Directors' and Athletic Training Students' Educational Experiences Regarding Patient-Centered Care and Transgender Patient Care

Study Design

We used a cross-sectional study design to explore the research question. The setting for this descriptive study was 2 online surveys (Qualtrics, Inc, Provo, UT) each with their own group of participants, PDs of professional athletic training programs and current students enrolled in professional athletic training programs. To guide the design and quality assessment of the reported data, we used the STROBE statement for cross-sectional studies.³⁷ The Institutional Review Board at the University of South Carolina deemed the study exempt.

Participants

Athletic Training Students

Similarly, we sent recruitment emails to students enrolled in an athletic training program. To do so, we used the National Athletic Trainers' Association (NATA) research database to contact 3548 student members. Of those 578 athletic training students who accessed the instrument (16.3% access rate), we collected 527 responses with 11 participants not consenting to participate, 26 participants not starting the survey after consenting, and 38 participants not completing the study in its entirety. This resulted in 452 responses (78.2% completion rate) included in the data analysis. The athletic training students were 23 \( \pm \) 3 years old (range = 19–44 years old). Table 1 provides demographic variables for both groups of participants.

Table 1 Participant Demographic Information

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Instruments

Instrument Development

To design the instruments, 2 researchers (G.T.S., Z.K.W.) performed a literature search for scientific research studies about transgender health education for health care professionals as well as instructional techniques.^{18,27,38–43} From the search, previous survey questions and findings from the literature were gathered and considered in developing the items for this study. This technique is consistent for establishing construct validity. The goal was to design 2 instruments similar in nature and content for the targeted population. The 2 researchers created the instrument and sent it to a panel of 3 content experts (A.K.C., L.E.E., S.M.R.) on LGBTQ+ health care needs for content validation using a modified Delphi panel technique. The surveys were both edited and revised for clarity, function, and appropriateness to the research question. The review completed by the research team and content experts was proceeded by a discussion on research reflexivity to identify and mitigate potential sources of bias. Each group of participants received a separate survey with the same questions worded based on their role as PD or athletic training student. An overview of the components of the PD (Figure 1) and athletic training student (Figure 2) surveys demonstrate the recruitment methodology and similarities in survey items relative to the topics of PCC and transgender patient care.

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Procedures

All recruitment emails with a link to the survey were sent in March 2020. Once participants opened the survey link, they were presented with an invitation to participate, followed by the instrument respective to their identified role in the athletic training program. The data collection window was open from March 17, 2000, to April 14, 2020, with reminder emails sent once per week for the 4-week window.

Statistical Analysis

We incorporated data from only completed surveys due to the study having 2 target groups with 2 specific foci: PCC and transgender health care needs. The data from both surveys were downloaded and exported into a spreadsheet (Excel 2016; Microsoft Corp, Redmond, WA) and then again into SPSS (Version 26; Armonk, NY) for descriptive statistics to be performed. We analyzed the data by group using measures of central tendency relative to their demographics, comfort, competence, and described educational experience. We used separate χ² analyses to calculate the differences between the athletic training students' comfort and competence regarding specific aspects of transgender patient care between the students who had and those who had not reportedly learned about transgender patient care. The significance value was set at P < .05 a priori.

Patient-Centered Care

Program Directors

Most PDs expressed that PCC was an important concept to teach (n = 73, 98.6%), and accordingly, 95.9% (n = 71) of PDs taught the core competency in their professional athletic training program. Most PDs agreed or strongly agreed that they felt comfortable (n = 73, 98.6%) and competent (n = 70, 94.6%) teaching PCC. The PDs reported athletic training students learned about PCC in class (n = 71, 100%) and during clinical education (n = 59, 83.1%). All the PDs stated the athletic training students practiced PCC during clinical education (n = 71, 100%). The PDs reported using several different instructional strategies, with the most common being class discussions (n = 63, 88.7%) and various assessment methods, with the most common being practical exams (n =53, 74.6%) to teach PCC. The full breakdown of instructional strategies is provided in Table 2.

Table 2 Patient-Centered Care and Transgender Patient Care Instructional Techniques Used by Program Directors (Select All That Apply)

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Gender Minority Patients

Program Directors

After providing a definition of gender minority patients, which included noncisgender individuals such as transgender, genderqueer, and gender nonconforming, we identified that 50% (n = 37/74) of PDs had transgender patient care in their curriculum with an additional 31.1% (n = 23/74) stating they were planning to integrate in the future. We identified that 50% (n = 37/74) of PDs stated their professional athletic training program included PCC and gender minority content in the curriculum, while others' programs only included PCC (n = 12, 16.2%). Some PDs (n = 22, 29.7%) reported their program was currently working to integrate gender minority patient care into their curriculum. Three participants (4.1%) reported their program does not teach either concept in their curriculum. Most of the programs that were integrating gender minority topics into their curriculum were delivered at the professional master's level (n = 24/37, 63.9%; bachelor's = 13/37, 35.1%).

Of the sample of PDs whose professional athletic training programs were teaching about gender minority patients (n = 37), 97.3% of participants (n = 36/37) believed in and taught athletic training students to treat patients equally, including transgender patients. Most PDs reported their program taught athletic training students how to find resources for transgender patients (n = 32, 86.5%). A smaller sample (n = 13, 35%) created opportunities for engagement with a gender minority patient as part of the athletic training program.

The PDs reported that athletic training students mostly learned about transgender patient care in the classroom (n = 36, 97.3%), with the most common instructional method being class discussions (n = 28, 77.8%) with a far lower percentage having the same opportunities during clinical education (n = 13/36, 35.1%). Table 2 provides a detailed breakdown of all instructional strategies. The PDs reported that they believed athletic training students practiced the skills for gender minority care in the classroom (n = 36/37, 97.2%) and fewer during clinical education (n = 22/37, 59.4%). Finally, most PD respondents (n = 33/37, 89.2%) said they assess students on transgender patient care. Of those who did assess students, the PDs usually used less than 2 assessment mechanisms to assess athletic training students' skills related to gender minority care, with most using either class participation (n = 17/37, 46.0%) or quizzes, tests, and exams (n = 14/37, 37.8%). Table 3 compares PD-reported assessment strategies to what athletic training students reported assessments they experienced for both PCC and gender minority patients.

Table 3 Assessment Strategies Reported Frequency

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Most PDs (n = 65, 87.8%) thought teaching transgender patient care was important, and 58.1% (n = 43) felt comfortable doing so, yet only 37.8% (n = 28) felt competent in their delivery. Interestingly, we had several participants select that they neither agreed nor disagreed they were comfortable (n = 18, 24.3%) or confident (n = 27, 36.5%) with teaching about the care for transgender patients. Lastly, common barriers PDs identified that they or their athletic training program might have faced in teaching, considering, and/or adding the topic of transgender health care needs into their professional athletic training program (Figure 3) included a lack of guidance incorporating the topic (n = 41, 55.4%) and a lack of knowledge regarding transgender health care (n = 38, 51.4%).

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Athletic Training Students

Less than half (n = 195/452, 43.1%) of athletic training student respondents reported learning about transgender patient care. We identified that 42.5% (n = 195/452) learned both PCC and gender minority patient care, while the majority learned about only PCC (n = 245, 54.2%). The athletic training students in professional master's programs learned about gender minorities more often (n = 63/101, 62.4%) than those in a professional bachelor's program (n = 116/318, 36.5%) or a combination bachelor's and master's program (n = 16/33, 48.5%). We identified that most athletic training students (n = 192/195, 98.5%) who learned about gender minority patients believed in treating all patients, including patients who are transgender, equally and that their athletic training program teaches equality for all patients (n = 183/195, 93.8%).

Most athletic training students reported learning about transgender patient care during class (n = 165, 84.6%) as compared with clinical education (n = 52, 26.7%). Nearly half of participants (n = 82, 42.1%) reported never interacting or practicing their skills with a transgender patient. Finally, many athletic training students reported they were not assessed on their knowledge or skills related to transgender patient care (n = 83, 42.6%). Of those who partook in assessments on the topic, many were assessed only with class participation (n = 76, 39%). Table 3 shows all reported assessment strategies used on gender minority patient care.

The survey also included specific questions relative to transgender patients. We identified that most athletic training students said they agreed or strongly agreed (n = 418, 92.5%) that it is important to learn about transgender patients in professional athletic training programs. The athletic training students agreed (n = 379, 83.8%) that considering a patient's gender was essential to provide PCC, yet 5.8% (n = 26) of athletic training students did not feel it was necessary to ask a patient's gender identity. Most athletic training students agreed (n = 354, 78.3%) they felt comfortable providing transgender health care, but less than half agreed (n = 189, 41.8%) they were competent. Table 4 provides results from the athletic training students' comfort and competence with specific areas of transgender patient care. The χ² analyses indicated significant differences between these groups on all measures of comfort and competence, while those who had not learned about transgender patient care still indicated comfort with the tasks but indicated less perceived competence with counseling on hormone replacement therapy, drug screening processes, and collaborating with endocrinologists. Lastly, a lack of guidance was the most reported barrier by the athletic training students (n = 347, 76.8%), affecting their ability to provide care to the mock transgender student-athlete patient. Figure 3 provides a complete list of barriers and their definitions⁴⁴ in the survey that were options for the PDs and athletic training students to select with the data sorted by percentage of those who agreed that it was a barrier for transgender patient care.

Table 4 Athletic Training Student Comfort and Competence with Transgender Patient Care (Rate Your Level of Agreement With the Following Statement)

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Patient-Centered Care

Almost all PDs who responded to this survey taught PCC in their athletic training curricula. All but 1 PD agreed they felt comfortable and competent teaching the core competency of PCC. This is imperative since PCC is now required to be taught and assessed by accredited professional athletic training programs.⁷ In the survey, we asked PDs if all patients should be treated equally, to which most PDs agreed. Following social learning theory, students expressed similar beliefs of the PD, as a vast majority of athletic training students reported they believe in equal treatment for all patients. Based on these responses of most PDs and athletic training students, further education about health care equality and equity may be warranted. Equity in health care is the effort to remove health disparities such as those that are faced by individuals who are not cisgender.⁴⁶ Creating equity involves removing obstacles or barriers for these groups.⁴⁶ Removing these extra barriers to care requires more engagement. Therefore, equal treatment will not suffice if the goal is to eliminate health disparities, and transgender patients face both health and health care disparities.³⁴ By working toward equity, athletic trainers will expand access to health care, a PCC principle.³⁰ In a comparison between athletic training practice and primary care, Green and Sauers⁴⁷ report successful primary care delivery outcomes, and one outcome is equity of care. If athletic trainers want to contribute to those care outcomes and reduce health disparities, we must educate students to promote health care equity through their clinical practice.⁴⁷ The PDs may not be perceiving the entirety of PCC, as it also involves practicing equity in health care, cultural competence, and an appreciation of patients' diversity.⁵ A majority of PD and athletic training student respondents do not perceive that some patients require extra help, as alluded to by their responses. Their responses identify a need for athletic training programs to emphasize the influences of health disparities and being a part of a socially disadvantaged group on the provision of PCC.

The PDs who reported teaching PCC in their curricula often used class discussions, lectures, and case-based or problem-based learning as instructional strategies. Lecturing is considered a passive learning method, while discussion and case- and problem-based learning are active.⁴³ These teaching techniques generally follow the constructivism theory of learning since, during class discussion and problem-based learning activities, students are actively conversing, generating questions and hypotheses, and exploring contradictions via social interaction.⁴⁸ A recent systematic review found active learning techniques successfully foster lower- and higher-order cognition.⁴³ Both lower- and higher-order skills developed during active learning experiences could prepare students to render equitable and PCC.⁴³ Active learning techniques that can be used to promote learning of PCC include techniques like concept mapping, jigsaw discussion, inquiry learning, role playing, and simulation.⁴³ To make lectures more interactive, we suggest that PDs and instructors consider incorporating breaks for discussion, demonstrations, think-pair-share activities, or games.⁴³ As for assessment, the PDs reported most often using practical exams and class participation to assess PCC. The literature offers support for assessment strategies used in professional athletic training education,^49,50 and PDs could use these in their professional athletic training programs to assess PCC. Incognito standardized patients or real-time situations during clinical education are supported by authors of various studies for being realistic ways to assess clinical proficiencies, as they are most applicable to prepare athletic training students for the professional practice of athletic training.^49,50

Since PCC is a foundational core competency for athletic training students, implementing intentional learning opportunities for students to learn and practice PCC is vital in improving their ability to provide care.^7,9 Due to the nature of PCC, foundational learning of PCC can occur both in the classroom and with opportunities to learn and practice hands on during clinical education per the theory of constructivism in which learners interact with their physical and social surroundings.⁴⁸ Learning about PCC in professional athletic training education could promote students to use this approach when caring for patients, including transgender patients, which would enhance communication, advance the patient-provider relationship, and improve overall patient satisfaction.^2–4,51

In addition to teaching PCC in the classroom, all PDs in this study stated they believed that students in their program learn and practice PCC during clinical education. Concerningly, of the athletic training student participants, only 12.4% said they practiced PCC during clinical education even though all athletic training students agreed that PCC was important and said they were comfortable providing it. In a previous study, Cavallario et al⁹ identified that PCC was the most likely reported core competency by students during patient encounters at their clinical education sites, while in our study, it was barely reported. The authors also reported that students who assisted during a patient encounter and whose clinical site was a secondary school generated the most frequent reports of PCC.⁹ Competencies such as PCC need to be intentionally and comprehensively implemented into clinical education, as found in peer health care professions such as medical and nursing education.^52,53 In another study on core competency inclusion by athletic training students, 363 students from 12 different professional athletic training programs reported their use of PCC by recording if they performed professional behaviors related to PCC during patient encounters at their clinical education sites.⁸ Patient-centered care behaviors tracked were the use of goal setting with the patient, patient-reported outcome measures, and clinician-rated outcomes.⁸ The authors reported finding that 36.6% of students used 1 behavior, 12.2% of students used 2 behaviors, and 7.7% used all 3 PCC behaviors.⁸ The findings from previous literature yield higher implementation of PCC by professional athletic training students than our study, as 1 study reported 90.9% of students said they implement PCC during patient encounters, the previously mentioned study found 56.5% of students implemented at least 1 of 3 possible PCC behaviors, while the present study found 12.4% of students practice PCC during clinical education.^8,9 We believe the reasons for the incongruence between the PD and student perception of practicing PCC in clinical education is multifaceted but begins with different definitions of PCC among the athletic training students, PDs, other educators, and the clinical preceptors. Previous researchers have identified that patients and athletic trainers have a distinct viewpoint of PCC which is usually based off dignity, respect, and the best available care.^54,55 However, PCC is multidimensional and needs to consider the support system, information delivery, and sociocultural factors that play a role in the care provided.

Professional athletic training PDs, core faculty, instructors, and clinical preceptors must make additional progress to teach, model, and allow students to practice PCC behaviors during didactic and clinical education, as it is required by the CAATE standards in addition to potentially facilitating improved patient-provider communication, environmental safety, and quality of health care.^4,5,51 Currently, there is a lack of faculty presence observing athletic training students in their clinical practice. Educators may believe PCC is being practiced, but this tendency is linked back to the false consensus effect, which is a cognitive bias that leads to an overestimate of others' behaviors or attitudes aligning with their own. Administrators of professional athletic training programs should implement preceptor training on PCC and encourage preceptors to explicitly identify to the athletic training student when they are providing PCC. The process should also include evidence-based assessments of PCC that are delivered. Unclear evaluation techniques from clinical preceptors may be shared with PDs, suggesting that the practice is occurring in clinical practice; however, the student may not recognize their application of these behaviors at that instance. It is imperative to note that these data do not suggest athletic training students are not patient centered during clinical education. It does note that they are either not practicing it or not cognizant of these behaviors, which could be the root cause of the analysis.

In addition, PDs can consider the type of clinical site, patient populations at clinical sites, and general core competency education as efforts to increase athletic training students' provision of PCC during clinical education. The opportunities at the clinical site also affect core competency use.¹⁰ Particularly for PCC, athletic training students who performed orthopaedic evaluation, manual therapy, and therapeutic rehabilitation were 3.6, 2.6, and 1.9 times, respectively, more likely to implement PCC.¹⁰ Program directors who want their athletic training students to gain clinical experience in performing PCC should encourage clinical preceptors to provide athletic training students these specific opportunities to incorporate not only clinical skills but PCC skills at their clinical sites.¹⁰ Lastly, to mitigate the incongruence identified in our results, we suggest that instructional techniques such as direct observation, standardized patient exams with live actors, bug-in-ear technology, and video modeling of previous patient interactions be used to promote self-reflection and future practice habit changes that integrate PCC principles.^56–58

Gender Minority Care

Exactly half of the PDs reported their athletic training program taught about gender minority patients, which includes individuals who are transgender. This finding is like what athletic training students who participated in our study reported; 43.1% said they learned about gender minority patients in their athletic training program. This is an improvement from previously reported data, where a majority of athletic trainers in the collegiate setting said they had received no formal education about the needs of LGBTQ+ patients.³² However, there is still room to increase the number of athletic training students who receive professional education on gender minority patients, especially because PCC is a core competency in the CAATE standards, and knowledge about the gender minority population and their health care needs are inherently a part of PCC.⁷ By educating students on the subject, it could improve transgender care and address inequities.^31,34 Part of why the transgender population face health inequities is because transgender health care education is sometimes not included in health care students' curricula.¹⁸ In 1 study on medical students, 74% of participants reported they had 2 hours of education or less regarding transgender patients, and authors of another study found medical schools spent 5 hours total on LGBTQ+ health.^12,40 Authors of a study on baccalaureate prelicense nursing programs described that median time spent teaching about LGBTQ+ health topics and concerns was 2.12 hours total.⁵⁹ Authors of another study on a pediatric residency program evaluated outcomes of a longitudinal intervention of a curriculum related to LGBTQ+ content, which was based on the results of a needs assessment of providers.⁶⁰ After a year-long intervention, the participants' comfort level in soliciting patient information such as gender identity, sexual activity, or screening questions increased in addition to an increase in knowledge.⁶⁰

Authors of these studies suggest that increasing the time and content relative to the topic yields knowledge and skill improvement which ultimately should improve patient care. The PDs of professional athletic training programs can improve their curricula by incorporating gender minority and transgender specific health care education seamlessly throughout their course of study. We have provided a sample in Table 5 of how educators could integrate and scaffold the topics of gender minority care throughout the program, which could influence knowledge and behavior changes on the subject for future health care providers. Further, there is support for adding gender minority health content into health care curricula, as it has been shown to improve students' preparation to manage gender minority health concerns.³⁶

Table 5 Transgender Patient Care Scaffolding Curriculum

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Of the PDs who reported their program taught about gender minority patient care, the most reported teaching methods used to teach students how to care for transgender patients were the same as PCC, class discussion, case-based and problem-based learning, and lecturing. Class discussion and case-based learning techniques are active learning approaches that can help students develop crucial skills for successful clinical practice, such as evaluation, creativity, and analysis.⁴³ By having athletic training students participate in these active learning activities, PDs and instructors foster students' self-confidence and communication and collaboration skills.⁴³ As for the assessment of transgender patient care, there was a discrepancy between PD and student responses. Almost 90% of PDs said their professional athletic training program assessed students on transgender patient care, whereas 60% of students reported they were assessed on the subject. Assessing students on a topic and the weight of the assessment are vital as they motivate students to learn a subject.⁶¹ Further, assessments given at multiple time points can enhance the retention of information.^62,63 Based on this research, PDs should assess students on transgender patient care and, more importantly, notify the students that they will be assessed on the topic.

Many students who both learned and did not learn about transgender patient care reported they were comfortable caring for the transgender population. Fewer students reported they felt competent with specific aspects of transgender patient care, such as policies for hormone replacement therapy and sport participation, drug screening, and interprofessional collaboration with an endocrinologist. Nye et al³² reported similar findings that credentialed athletic trainers felt comfortable caring for patients who are transgender but reported less competence with certain aspects of care. Berry et al's research on athletic trainers in the collegiate and university setting regarding transgender patient care identified the following aspects of care in which athletic trainers felt incompetent: using appropriate terminology, the effects of hormone replacement therapy on sport participation, counseling on mental health concerns, and working with an endocrinologist.³⁴ The lack of competence reported in our study and by professional athletic trainers in other studies may support that, even though some students are educated on transgender patient care, PDs and instructors should consider making changes to their instructional content or teaching methods to better prepare students to provide care for these patients in their reported deficiency areas.

To address this lack of competence, PDs should include education on these specific areas of care in ways that could increase students' feelings of competence. The 2020 CAATE standards include Standard 74, requiring athletic training programs to teach about pharmacology, so PDs and instructors can use this opportunity to teach students about hormone replacement therapy, which is needed because, using a 2015 survey, researchers reported that 71% of transgender men and women were more likely to have used hormone replacement therapy.^7,24 Educational efforts that have demonstrated the ability to increase the competency of students in other health care fields support the use of active learning, particularly problem-based learning and high-fidelity simulation.^64,65 We suggest that PDs could incorporate more active learning techniques such as game-based learning, problem-based learning, case-based learning, team-based learning, and or flipped classroom to enhance athletic training students' perceived competence with these specific aspects of transgender care.⁶⁶

However, taking an upstream approach to the athletic training students' lack of competence begins with PDs who may teach this content to the athletic training students. Less than half of PD participants reported feeling competent teaching the background information and skills necessary to care for a transgender patient. Additionally, PD respondents expressed a lack of guidance as the most significant barrier in including or teaching transgender health care needs in their athletic training program curriculum. Similarly, athletic training students also felt a lack of guidance would affect their comfort in providing care to a transgender patient. Additional education for both PDs and athletic training students on transgender health care and health care provision could help address this general feeling of lack of guidance. Furthermore, according to the CAATE, it is the PDs' responsibility to have “contemporary expertise in athletic training,” so PDs who do not feel competent with knowledge and skills needed to provide quality health care to patients who are transgender should ensure someone from their core faculty has content knowledge on the topic and/or seek out personal continuing professional development.⁷ There are educational resources provided by the NATA LGBTQ+ Advisory Committee available online that can help PDs, other educators, and athletic training students with how to care for transgender patients.⁶⁷ In addition, many college and university campuses, as well as the communities, have resources that can be used for inclusion training, gender minority health care clinics, and safe space support groups, which may benefit a program to use rather than developing these resources themselves. Widespread social change and promotion of health equity by the athletic training profession must occur on all levels in a professional athletic training program. We encourage PDs to be leaders who engage in difficult conversations, question, and change noninclusive practices, and foster an inclusive work environment for staff and an inclusive learning environment.⁶⁸ Actively working toward an inclusive athletic training program could promote a downstream effect of positive changes for the inclusion and health equity for transgender people.

Although half of the PDs who participated in this study include education about gender minority patients in their professional athletic training curricula, an additional 30% of participants said they were planning to integrate the content in the future; however, many PDs reported a lack of guidance to include gender minority content into their curricula. Areas for professional athletic training program curricula expansion related to gender minority patients have been found in the literature involve asking for a patient's pronouns, fostering a safe environment in the health care facility, listening to the patient, making shared decisions, maintaining patient privacy, using inclusive language, avoid homonegativity and heteronormativity, awareness of mental health needs, and being knowledgeable about local resources for inclusive health care providers.^{31,33,34,69,70} Specifically for transgender patients, it is essential that professional athletic training curricula additionally incorporate the definition of transgender, misconceptions about advantages in sport, sport participation policies, health care disparities, barriers to care, gender-affirming language, preventative health care needs, mental health needs including gender dysphoria, gender-affirming care, and the long-term effects of various interventions.^31,34,39,69 When students are learning about health risks faced by the transgender population, they need to understand that an underlying cause of the health risks is not necessarily being transgender, but living as a transgender person in a homophobic society.⁷¹ We suggest that PDs use the literature to guide how and what gender minority and transgender health care content to add to their curricula.

Limitations and Future Research

Our study was limited to PDs of athletic training programs and did not include other faculty or other instructors from the professional athletic training programs. Although PDs develop and implement the program curriculum, they may be unaware of the experiences of other instructors or the specific content of each course leading to a reporting bias of the PD. Additionally, the 2020 CAATE Standards were made effective on July 1, 2020. The time of this study was March to April 2020, meaning that it was not a professional obligation of professional athletic training programs to include PCC in the curricula.

In addition, we identified that most participants felt comfortable with transgender patient care. It may be assumed that this was due to selection bias for individuals that had a particular interest or concern with the transgender community. However, we feel it is important to note that the research team was mindful of this potential bias before the onset of the study. To negate the selection bias, the research team used general terminology specific to PCC to recruit both the PDs and athletic training students. We believe limiting the word transgender in all recruitment materials and consent forms helped to remove the potential that those reporting comfort in transgender patient care was only due to participants having an interest in the topic. Therefore, we believe our recruitment strategies helped to mitigate the selection bias typically identified in LGBTQ+ research. Moreover, there were some limitations to note from the survey itself. One item in the survey asked the participants if they believed in and taught athletic training students to treat patients equally. With the ever-changing landscape of social justice terminology, we feel it is important to note that the word choice of equally may be a limitation for this question, as equitable care is more conducive when discussing patient care. We suggest future researchers explore the differences in equal versus equitable PCC delivered by athletic trainers.

With this study, we provide support for the future development of educational resources for PDs of professional athletic training programs in both PCC and gender minority patient care. Even though PCC is core health care competency, it does not guarantee that all PDs are knowledgeable about the scope of PCC and the link that education of PCC necessitates education on gender minority patients. Future researchers should explore the clinical preceptors' comfort, education, and clinical experience in providing PCC and treating transgender patients in addition to educational resources. This would help identify specific areas to advance professional development education for the clinical education component of the professional athletic training program. Lastly, research into the use of standardized patients to teach and assess athletic training students' knowledge and practice capabilities of PCC and transgender patient care is warranted as a more active opportunity to practice and evaluate these verbal and nonverbal health care skills.