One of the most striking impacts of poverty is the way it changes the brain. While some curricula incorporate simulated scenarios that revolve around SDoH related to poverty, none simulate the brain changes. Linda K. Riddell, an epidemiologist who specializes in low-income people, has developed a game that puts the players’ brains through changes that happen to a person living in poverty.  Games inspires attention and active learning in health professions education.  Especially since a growing number of students are accustomed to technology, games are being used more frequently for learning. (Gorbanev, 2018)

Drawing upon social epidemiology and brain science, The Gettin’ By game creates a first-hand experience of poverty’s impact on the brain. In the Gettin’ By game, each player has a board with 12 assets, divided into four types of social and person capital. The player spends or gains assets as he draws cards and faces different situations. Each card presents a true-to-life situation taken from published literature from sociologists, ethnographers, or Riddell’s own professional experience. The card offers different options for action. “Chance” cards present events where no decision is called for. (See sidebar.)

The player has 30 seconds to deal with each situation, creating a time scarcity. If the player runs out of time, the situation stays “open”. Players can also choose to leave a situation open if they do not have the asset to make the choice they prefer. However, open situations present themselves at the player’s next turn, reducing the amount of time he has to deal with the next situation.

After 15 to 20 minutes of playing, students start making choices they do not prefer or leaving situations open. They may run out of assets entirely, but they continue playing. The game ends after 45 minutes.

Students then discuss what they experienced. Many will be surprised at how their decision-making changed when their brains were “crowded” with competing demands. Players who are themselves physicians may hang up on the Emergency Room nurse who called about ED visits for a child’s asthma. Students who would never consider breaking the law may lie on job applications or buy food stamps. Rarely do we have a student spend a time and energy asset to attend a routine physical.

Gettin’ By is not “walking a mile in their shoes.” It’s actually changing how your brain works.

The session goes on to explain the brain science and what the students experienced as they played Gettin’ By. Because the game exposes players to a wide range of health, work, housing, food, and family situations, they see many different aspects of low-income life and how basic survival competes with basic survival for priority.

Students then learn how scarcity causes the brain to tunnel, and to push aside long-term, cost-benefit thinking. Whatever is not immediate and urgent is irrelevant when a person’s mental capacity is overloaded. Dealing with constant demands also impairs executive function and lowers fluid intelligence. Thus, a person facing chronic demands is less able to weigh the best actions.

The new perspective on decision-making helps students understand health behaviors in a new way. For example, health programs try to motivate people to stop smoking by highlighting future benefits. Future-oriented thinking is crowded out of the brain by the overwhelming present. Thus, benefits of a smoke-free life lose out against having a calming ritual today.

The session gives students tools to gauge the cognitive demands that their services place on the low-income people. For example, a six-week parenting course makes high demands on personal and cognitive resources. To complete the course, a person must have reliable transportation (if in person) or a quiet place, working computer and internet access (if online), a predictable schedule, and no illness or other surprise from him or his family. And all of this has to happen six times.

By understanding how scarcity impairs the brain, students can make their work with low-income people more effective and successful.

Sidebar: Sample Decision Card

Your kid flushed his ADHD medication down the toilet again. Without them, he’s not allowed to attend his after-school program.


  • Call the doctor’s office and hope they’ll help you. The nurse has accused you of selling the pills before and this is not going to look good. Lose 1 Time/Energy asset
  • Ask your boss to reduce your hours so you can pick up your kid after school every day. Lose 1 Work/ Job asset + 1 Money/Debt asset
  • Line up someone to take care of your kid every day after school until it is time to refill the prescription. Lose 1 Home/Family asset

Sample Chance Card

While chasing a squirrel out of your apartment, you damage a wall. Lose 1 Home/ Family asset

–Linda K. Riddell, MS is an epidemiologist and poverty educator based in Maine. The Gettin’ By game has been played at national and regional conferences, and in online training sessions. She can be reached at or on Twitter  @l_riddell.


Gorbanev, I. e. (2018). A systematic review of serious games in medical education: quality of evidence and pedagogical strategy. Medical Education Online , vol 23 (1) 1438718

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