As medical students, we’ll find ourselves in the ‘sim lab’ on rotations such as emergency medicine and intensive care, going through different simulations of critically ill patients. Presented with patients in severe sepsis or acute respiratory failure, simulations help us build thought patterns and practice skills with a real world flavor.

But what if we could use simulation to teach trainees about another domain of health – the social determinants of health? Topics such as race, poverty, and food insecurity are touched on in medical school, but often in lectures and small group discussions of articles that struggle to grab the attention of students. At this fall’s National Summit on the Social Determinants of Health organized by Root Cause Coalition, I had a chance to participate in a simulation that made me think about its potential for teaching trainees in medicine about the challenging obstacles that our patients confront.

A fast paced simulation: ‘cost of poverty experience’ (COPE) program

Dubbed the ‘cost of poverty experience’ (COPE) by its creators (an organization called ThinkTank based in Ohio), the simulation immersed its participants in the experiences of families attempting to navigate poverty and health. I became ‘Ken’, a 40 year old African American man on probation with a history of two incarcerations. Work was hard to come by; I was holding down a dishwashing job that paid little. My ‘wife’, Kayla, was 36 weeks pregnant with a restaurant job that paid minimum wage. With our two year old Marissa, Kayla and I experienced a month in the life of a family in poverty, with each week lasting fifteen minutes. In the space of that fifteen minutes, each family attempted to navigate an array of tasks — going to work, getting groceries, making a doctor’s appointment.

Kayla and I quickly ran into multiple hurdles. Owning no car, we both had to wait three minutes (20% of our allotted time each week) before we could go anywhere.  Late to work because of this immobility, I was fired by week two. Attempts to seek social support or further employment were thwarted by the precious time lost in weeks one and three to my probation officer, who kept close vigilance over me. The little money we had went to Kayla’s prenatal care and my medications for hypertension.

With no income, we went hungry. When we went to the social services agency seeking emergency help, we initially received little attention, as other families with access to care coordinators from a local organization cut in line. Later, we were told that my criminal history was disqualifying. By the end of the month, we had two children, no jobs, and no income to pay rent.

Understanding the lived experience of accumulated disadvantage

The simulation effectively taught multiple lessons, a few of which particularly resonated. First: living in poverty produces an intensely emotional experience with implications for mental health. I felt shame for paying attention to my medical care but not leaving enough money aside for food. Anger at losing my job due to my lack of mobility. By week three I felt despair and desperation – the cognitive burden of multiple difficult choices in a context of scarcity. I wanted to give up. Growing evidence illustrates the deleterious impact of poverty on mental health; yet when we treat depression and anxiety, for example, we often fail to consider the wider context that may be producing the patient’s symptoms.

Another lesson: being poor can be costly in terms of time. Without access to mobility, Kayla and I had to pay with our time at the expense of lost wages and employment. Standing in line at the social services agency, with the probation officer, at the busy health clinic further absorbed the little time Kayla and I had. Academics sometimes call this ‘time poverty’ – the scarcity of time required to build assets and resources needed for social mobility. Then think about adding multiple doctor appointments and referrals to that list – a health issue might end up low on a growing list.

Finally, the simulation introduced me to the multiple social determinants of health and how they interact. Financial insecurity – with inconsistent wages and then unemployment – led to eviction and food insecurity. These were shaped by my history of incarceration; being ‘justice involved’ was an ongoing penalty that hurt every attempt at social mobility. Employment, social services, even access to a housing shelter – were blocked by this history. Struggling with these different determinants, participants came to appreciate the ‘structural vulnerability’ that many of our patients experience.

Applications for medical students and residency programs

I could easily imagine COPE in the first or second year of medical school, complimenting other teaching on social determinants of health. For residency programs, (particularly in internal medicine, family medicine, pediatrics, and obstetrics and gynecology) a more advanced version of such a simulation could be also be delivered. As training programs seek ways to teach social determinants, such a simulation has three practical features that are useful for medical education.

First, a simulation brings to life many of the ‘social determinants of health’ that few lectures or readings can. Trainees in medicine are familiar with case-based learning, and a simulation takes it further. Placed briefly in the shoes of a family in poverty, I had to weigh the decisions facing many of my patients and the forces arrayed against them. This practice built greater understanding for my next encounters. Second, simulations create a shared experience among peer learners. This experience produces opportunities for rich dialogue and learning, as students exchange insights and lessons from their own families’ trials. Self-directed learning can grow out of these exchanges. Third, the organizers of COPE run ‘train the trainer’ workshops, which mean medical schools and residency programs can run simulations on an annual basis – ideal for the new generations of trainees that enter their programs each year. This feature makes simulation an affordable strategy over time.

As medical educators experiment with different modalities for teaching social determinants of health, my experience with COPE convinced me that simulation should be an enticing option.

Victor Roy, PhD is a 4th year medical student at Northwestern’s Feinberg School of Medicine. He earned his doctorate in sociology at the University of Cambridge studying the social and political determinants of health. Follow him @victorroy.

References

Neff, Joshua et al. 2016. “Teaching Structure: a Qualitative Evaluation of a Structural Competency Training for Resident Physicians.” Journal of General Internal Medicine. 32(4):430–33.

Bourgois, Philippe, Seth M. Holmes, Kim Sue, and James Quesada. 2017. “Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.” Academic Medicine 92(3):299–307.