Using a Poverty Simulation in Graduate Medical Education as a Mechanism to Introduce Social Determinants of Health and Cultural Competency

There is a growing body of literature that supports linkages between cultural competency and health care disparities. Race and ethnic differences can lead to health care inequities as highlighted in a 2002 report by the National Academy of Medicine entitled “Unequal Treatment.”¹  In the last decade, we have seen a push to integrate understanding of social determinants of health into medical practice. With this increasing national focus on population health, a key success factor is the early cultural competency training of all health care providers in order to improve patient outcomes.

Christiana Care Health Services (CCHS) participated in Improving Community Health and Health Equity Through Medical Education: National Initiative V of the Alliance of Independent Academic Medical Centers. The goal was the transformation of medical education, with a focus on cultural competency and health equity. We felt that it was paramount to create an experiential educational activity that would both set the tone for, and have a lasting impact on, residents. Furthermore, it was crucial to integrate any activities into the preexisting educational curriculum and capture residents from all specialties offered at CCHS to maximize institutional impact.

To satisfy these mandates, we leveraged 3 hours of postgraduate year 1 orientation to conduct a community-tailored poverty simulation. Utilizing the Missouri Community Action Network (MCAN) poverty simulation kit,²  which for $2,150 inclusively provides comprehensive instructions and reusable materials for up to 88 participants. All 74 new interns participated in a simulation exercise alongside hospital and community volunteers role playing resource providers (eg, school teacher, shelter workers, pawnshop staff, law enforcement). The interns were assigned roles as members of low-income limited-resource families, all facing a variety of challenging, but typical circumstances. The family units were required to complete defined tasks (eg, paying rent or utilities, buying groceries) by interacting with community resource providers, while caring for their families and contending with simulation-determined unexpected events (eg, job loss, illness, expenses). These tasks and events were distributed over 4 consecutive, 15-minute simulation cycles and reflected 4 weeks of life. The simulation takes approximately 1 hour to introduce and organize participants into family units, 1 hour to run the simulation itself, and 1 hour for participant debriefing and conclusion.

Validated surveys are included in the MCAN simulation kit. Every resident who participated voluntarily completed the deidentified surveys, designed to assess opinions on poverty and equity along with the impact of the simulation exercise. As an example, “the community provides effective and efficient services to help families with low income live”²  was assessed as inadequate compared to presimulation responses (χ² = 14.99, P = .002). While preliminary data analysis has not shown all questions to have had a significant pre-post change, the feedback from 29 participants, including free-text responses, were unanimously positive supporting the exercise as a valuable, educational, and well-executed event. Residents were also eager to discuss their experience during the postsimulation debrief and focus group discussions. This yielded supportive reflection and enthusiastic dialogue with community volunteers on challenges faced by low-income families. Similar enthusiasm was shared by the community volunteers and CCHS leaders who observed the event. The inaugural poverty simulation was also publicized in the CCHS internal magazine Focus and received interest across the hospital network, resulting in a groundswell of interest, enthusiasm, and requests to repeat the exercise with leadership to better integrate health equity into our clinical operations and strategies.