An Experiential Community Orientation to Improve Knowledge and Assess Resident Attitudes Toward Poor Patients

As of 2010, 46.2 million Americans live below the federal poverty line. At 15.1% of the population, this is the highest percentage of people living in poverty since 1993.1 Poor health outcomes among people living in poverty are well documented.2,3 

Future physicians may not be prepared for the challenges of caring for poor patients. Overall resident knowledge regarding health access and socioeconomic levels is generally low.4 Residents have reported feeling uncomfortable caring for underserved patients during residency5 and do not view underserved settings as desirable places for practice.6 Residents also have reported that impoverished patients are likely to be more difficult, show up late or miss appointments, care less about their health, and may “take advantage” of the health care system.7 Physicians-in-training do not represent the socioeconomic diversity of the United States' population; more than two-thirds of matriculating medical students each year come from the 2 highest quintiles of family income.8 The discordance in socioeconomic status between physicians and patients may contribute to insufficient knowledge and negative attitudes of physicians toward poor patients.4 Encouraged to provide education in caring for underserved populations,9,10 some residency experiences include caring for vulnerable populations; however, most curricula do not specifically address the needs of poor and underserved patients.11–17 

At the University of Oklahoma School of Community Medicine (OU-SCM), we replaced our traditional resident orientation with an experiential learning activity18 in community medicine to address the gaps in resident knowledge and attitudes regarding the social determinants of health. In our Resident Academy, lectures about professionalism and cultural competence were augmented with experiences to open residents' minds and hearts to the challenges their patients face every day. Academy elements were designed to stimulate learning at a deep personal and professional level and to help residents develop generalized mental models and emotional or moral processes underlying their service commitments.

During June 2010, all 66 incoming postgraduate year (PGY)–1 residents from 8 residency programs (emergency medicine, family medicine, internal medicine, internal medicine–pediatrics, obstetrics and gynecology, pediatrics, psychiatry, and surgery) of the OU-SCM were required to participate in 2 days of orientation, before the start of their PGY-1 year. The Academy schedule and elements are provided as online supplemental material.

We collected data through an anonymous online presurvey and postsurvey of all participants. Surveys included questions on demographics, satisfaction with Academy elements, and a series of open-ended questions that allowed for reflection on what was learned or experienced during the Academy. Satisfaction with programmatic elements was measured by using a Likert scale (1  =  excellent to 5  =  poor). The t tests and descriptive analysis of the quantitative data were conducted with SPSS (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp). Satisfaction scores from the postsurvey respondents for each element of the Academy were organized by residents in primary care programs, compared with residents in nonprimary care programs, using t tests. Researchers reviewed and coded qualitative comments as positive or negative perceptions, discussed and determined themes, and then reached consensus regarding the final themes presented in this article. The University of Oklahoma Institutional Review Board approved this study.

As an ice-breaker activity, “cultural bingo” cards were created by using interesting cultural diversity information from resident personal statements and curricula vitae. Residents asked each other if they had the particular experience or characteristic on the card, and if so, asked about it and collected their signatures in the square. Residents met others in OU-SCM training programs, initiated personal relationships before collaborating on patient care, and set the stage for appreciative inquiry with community interview teams.

Three brief lectures oriented residents to community medicine; to the history and demographics of Tulsa, Oklahoma; the social determinants of health; and cultural competency.

Teams of residents and faculty from the same discipline traveled together to visit 2 community organizations located in lower socioeconomic status neighborhoods. These included social services agencies, community health centers, nursing homes, rehabilitation centers, and hospices. Teams formulated questions designed to understand the barriers physicians and organizations face in providing health care to the poor, and 1 team member was selected to record a summary of the visit.

Teams were challenged to buy a “poverty lunch” in the neighborhoods they visited. Individuals who live below 130% of the federal poverty level in Oklahoma are eligible to receive $200 per month in food assistance through the Supplemental Nutrition Assistance Program.19 Teams received $2.50 per person to purchase lunch and could not spend more than allotted. All purchases had to be at a place of business within city limits. Teams were not allowed to obtain food or drink from anyone's home or apply discounts as a benefit of employment. Lunch could be consumed at the place of purchase or teams could return to campus to prepare and eat their meals.

The poverty simulation is an interactive group learning experience designed to promote greater awareness and understanding of poverty.20 The simulation and debriefing take about 3 hours. Participants assume diverse roles in up to 25 different “family” units. Each low-income “family” must provide basic needs during a simulated month. Participants are challenged to keep their “family” afloat while navigating social service systems and confronting life pressures. The simulation created awareness of the stress of standing in lines, experiencing unhelpful agencies, or taking for granted the importance of credit cards, bank accounts, and reliable transportation.

Residents met in groups of 6 with a faculty facilitator to reflect on their community interview experiences with other residents who visited different organizations. This allowed residents to share what they learned from the interviews, providing a vicarious experience of 12 different community agencies for everyone. It also allowed residents to consolidate both the facts and the emotional impact of the visit and how they imagine poverty impacts the health outcomes of their patients.

Forty-seven of 66 residents (71%) completed the presurvey and 28 residents (42%) completed the postsurvey. Residents reported demographics, self-identified political affiliation, training program, previous poverty experience, and future plans for working with poor patients pre survey and post survey. Residents entering primary care programs had significantly higher levels of satisfaction for most elements of the Academy than did nonprimary care residents (table 1).

The community interviews were the highest rated activity with 75% of postsurvey respondents rating the interviews as “very good” or “excellent.” The qualitative data also amplified the satisfaction with the community interviews. Residents were asked to describe their thoughts and feelings about the community visits, whether the visits improved their knowledge about community resources for their patients, and whether they felt that these resources improve the health of the community (table 2). The positive responses indicated that there was an increase in community knowledge, especially for residents who did not grow up in the Tulsa area. Some respondents noted that the community visits connected their practice and their patients. The negative responses focused on a critique of social services available and the need for more information about how to incorporate these services into practice.

Residents were asked to reflect upon the poverty simulation, specifically whether the simulation helped them appreciate the daily difficulties of poor people (table 3). Many noted that the simulation provided them with new perspectives into patient challenges, broadened their understanding of the wide impact of poverty, and created opportunities for self-reflection and discussion. Negative comments focused on the perception that the simulation offered only a superficial or artificial experience of poverty and that it would not change physicians' practices or biases.

To capture the salient themes from the Academy, residents answered the question, “In your opinion, what is the greatest barrier that poor people face when it comes to receiving quality health care?” Themes emerged related to access and quality of health care, financial resources, the importance of education, and life circumstances (table 4).

Meals cost $2342.50, including $193.56 to feed 83 total participants during the poverty lunch. Supplies for name badges, bingo cards, and notetaking material cost $200. The book titled Wrong Place, Wrong Time21 was purchased for each resident for $1272. The poverty simulation required a total of 20 volunteers, consisting of staff and students, to help the faculty facilitator for 3 hours, along with $1995 to purchase the kit, which can be reused indefinitely for future simulations. The 16 faculty members (approximately 1 faculty member for every 4 residents) who led the community interviews and debriefing sessions for 4 hours were all previous participants in 4 hours of similar faculty development activities required by the dean's office at the OU-SCM.

In this article, we describe a novel experiential orientation to educate incoming residents at the OU-SCM about their patients and their community. Residents demonstrated improved awareness, knowledge, and attitudes toward the challenges poor patients experience in navigating complex health care and social systems. Overall resident satisfaction for the Academy was very good or excellent; however, most elements of the Academy were more favorably rated by residents in primary care training programs than by residents in nonprimary care programs.

Some residency programs have content curricula on community engagement, health disparities, and underserved populations during residency training.22,23 However, the Resident Academy at the OU-SCM is unique in that it provides education and experience in these areas before the first day of residency and allows new residents, who have yet to be influenced by the hidden curriculum of residency training, to learn about the community and patients they will care for during training. For future Academies, residents suggested meeting and talking with actual patients who live in poverty to help them better understand the challenges these patients face in obtaining high-quality health care.

Our study is limited by the low response rate to the postsurvey. In addition, 68% of respondents were from primary care training programs and 47% had at least some experience living in poverty, both of which could have led to higher satisfaction scores for the Academy. Although curricula during residency training have been shown to influence resident career choice toward serving the underserved,22 the impact and outcomes of this curriculum before the start of residency on resident career choice and long-term attitudes toward the poor have not been established. Costs for the Academy were modest; however, institutions may be challenged to find time before the start of internship and faculty who are available from every department to work and travel with each resident team for a half day.

The Resident Academy orientation improved knowledge and attitudes of new residents before the start of residency, and residents were satisfied with the experience. Because residency programs are heterogeneous in the numbers of residents, faculty, and patients, and availability of community resources, it is important that each institution develop its own specific experience that will teach residents about the unique aspects of their patient population and community. Institutional leadership's commitment is essential for success.