March 22, 2021, 3:49 p.m. David Mitchell — When Andrea Silva, M.D., attended a local college event focused on issues in the transgender community, it didn’t go well. At least, not at first.
“I was the only physician there,” said Silva, a third-year resident at Valley Family Medicine in Modesto, Calif. “It ended up being a doctor-bashing session. People said, ‘We’re being mistreated. We don’t have access to care.’ I thought, ‘This is unbelievable. I’m so glad I’m here.’”
Rather than react negatively to the criticism, Silva saw an opportunity to make a difference.
“The only access to gender health care at the time was San Francisco or UC-Davis, which are both hours away,” she said. “I said, ‘We’re family medicine doctors. We can do this.’”
Program director Kathleen Kearns, M.D.; associate director Anika Godhwani, D.O.; and Silva met with community stakeholders, including an LGBTQ+ collaborative in the county, and the Rainbow Clinic opened in November 2019.
“It’s a conservative area, and we had some pushback,” Silva said. “People told us we would never be able to fill up a clinic with transgender patients. We have it every other Friday. I was there this Friday, and we were booked solid.”
In addition to helping the LGBTQ+ community, the resident-run clinic and a new gender health curriculum, which Silva helped develop, are teaching residents to care for a diverse population. Medical students also rotate through the Rainbow Clinic, which offers primary care with an emphasis on gender-affirming hormone therapy, mental health and substance use treatment.
“We didn’t want residents to just say, ‘Great, now we have a specialty clinic. We’ll send LGBTQ+ patients there.’ It’s a good opportunity for residents to say, ‘Here is a patient who is so different from me but is just looking for care that feels safe. Now I have the experience to treat aspects of their health that demand LGBTQ+ awareness.’ You feel you’re saving lives at the Rainbow Clinic.”
In addition to the gender health curriculum, Silva has helped her program establish a new curriculum on addiction medicine. According to a report last year, Stanislaus County’s drug overdose death rate is higher than California’s state average. Silva was alarmed when she kept seeing the same patients in the hospital.
“I asked myself, ‘Why are these patients coming back?’” she said. “‘Why are they having congestive heart failure exacerbations every month? What is the reason they can’t take care of themselves?’ It was their substance use disorder. I started realizing there are a lot of treatments and harm reduction strategies for substance use disorder, but we weren’t learning enough about them.”
Silva was awarded a Medical Education and Research Foundation scholarship in 2018 to participate in a California Society of Addiction Medicine conference, and last year she received a scholarship to Boston University’s four-day immersion training for chief residents about addiction medicine research. She’s going back to Boston for an addiction medicine fellowship later this year.
“I will have the opportunity to research the relationship between gender dysphoria and substance use,” she said. “I’m excited. Anecdotally, the transgender patients we treat at the Rainbow Clinic report their anxiety and depression decreases while their desire to live increases as soon as we get them on gender-affirming treatment. It’s remarkable.”
After her fellowship, Silva hopes to return to California t work in academic medicine and resume her involvement with the Rainbow Clinic.
“I always saw myself working with underserved populations, particularly LGBTQ+ individuals, a group of which I am a member, “ she said. “Some of the most vulnerable patients with multiple social determinants of health include transgender people of color with substance use disorder. These patients are stigmatized and face significant barriers to health care.”
Addiction medicine is personal for Silva, who witnessed a family member struggle with addiction for years.
“I think that’s why I’m able to be so empathic,” she said. “People say, ‘You have so much patience with these complex patients,’ and I think, ‘Well, my loved one was in the same position struggling with substance use.’ It gives me a lot of insight and motivation to help others.”
According to the American Board of Medical Specialties, there are only about 3,000 U.S. physicians who are either certified in addiction medicine or are qualified to practice addiction psychiatry.
“I’ve had residents tell me, ‘I would prescribe medicine for substance use disorder, but I don’t know anything about it,’” she said. “When I can give residents that toolbox and say, ‘Here are some ways you can help patients in the outpatient setting,’ they really like that. It’s been fun to educate fellow residents so they can get better jobs, do this when they graduate and help more people, because addiction medicine specialists are hard to find.”
More than 20 million Americans have substance use disorder, but the vast majority go untreated. Family physicians can help, Silva said.
“What I’ve learned over the last three years is that family physicians are jacks-of-all-trades, and we can do everything,” she said. “We deliver babies. We care for terminally ill patients in hospice. We can do sports medicine, pediatrics, inpatient medicine, and HIV care. We are able to do so much for patients because we’re in this unique specialty that allows us to see patients over time, and they trust us.”
Those relationships are invaluable to Silva, who briefly worked as an emergency medical technician before medical school.
“As much as I liked it, we would drop patients off at the hospital and never see them again,” she said. “I always wanted to know what ultimately happened to the patient. That was eye-opening for me. I knew I needed to be a physician who cared for patients over time.”
Silva was one of 16 recipients of the AAFP Award for Excellence in Graduate Medical Education in 2020. This year’s honorees will receive a $1,000 scholarship and complimentary registration for the virtual Family Medicine Experience, which is scheduled for Sept. 28-Oct 2. The application deadline for the 2021 awards is June 8.