Utilizing an Embedded Critical Ethnography Experience to Help Residents Understand Locally Relevant Social Determinants of Health Open Access

Social determinants of health (SDOH) are defined as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”¹  SDOH are of increasingly recognized importance in neurosurgery, including the graduate medical education stage, where residents are expected to learn about how SDOH relate to their patient populations. However, educating neurosurgery residents about locally relevant SDOH can be challenging, given the centralization of training, a predominance of inpatient exposure, and matriculation of residents from diverse origins without previous firsthand knowledge of the history, culture, and background of their training program’s catchment area and population.

Our team constructed a focused critical ethnography exercise to understand locally relevant SDOH, embedded within a yearly travel experience through the state of West Virginia. We based our learning experience on a driving route associated with our state neurosurgical society meeting attended by residents yearly. This 3.5-hour route encompasses locations with varying rurality, including deeply rural and underserved locations very disparate from the surrounding area of our academic center. This route facilitated a broad and deep exposure to the catchment area and capitalized on an already-existing experience by infusing additional meaning into a trip routinely made by 1 to 2 residents yearly. We constructed guiding questions for consideration during the exercise using SDOH domains and known environmental and care issues in a rural underserved area with significant geographic barriers to care (provided as online supplementary data). The observation questions were given to learners before travel, along with a brief training regarding SDOH and ethnography. After the guided experience, an individual or group debrief was done to discuss observations and lessons learned. Faculty facilitators guided the discussion of the learners’ experiences and placed observations into the additional context of daily patient care.

We have had all residents who attend the yearly state neurosurgical society meeting participate in this learning experience over a period of 2 academic years (2021-2022 and 2022-2023; N=4; total residency size=7).

Because this learning experience was embedded in a preexisting departmental activity (yearly state medical society meeting travel), it incurred no additional cost and ensured that all residents attending the meeting over a 2-year period have participated. The time required to do pre-exposure teaching and post-exposure debriefing included 1 hour for each and was easily incorporated into standard didactic time. Our SDOH domain questions were constructed by our team over several weeks and are included here for adaptation, which may streamline the process for other programs. Personalization of the domain questions and consideration for how to best embed the experience represent the main components requiring alterations to maintain feasibility in other programs. An important caveat is that our residency program is exceedingly small which may impact feasibility for larger programs; however, additional participants in a debriefing would likely only enrich the discussion.

While the small size of our residency precludes meaningful quantitative assessment of acceptability, this learning exercise was well received by learners, incorporates important areas of experiential learning, and addresses important Accreditation Council for Graduate Medical Education mandated goals. Residents indicated improved understanding of the impact of SDOH in our rural underserved state. Residents were engaged in the debriefing discussion and indicated that talking about their experience driving through the state was helpful in putting that experience, which they related as stressful and shocking, into a helpful and useful perspective.

The online supplementary data contains guiding questions for the exercise.