For most people, it may be hard to understand why a mother of a child just diagnosed with diabetes wouldn’t make sure he got his insulin every day. It may be just as hard to imagine being homeless, living in a motel, and not having access to a refrigerator in which to store the insulin.
Narrowing that gap in understanding was the goal of a poverty simulation exercise experienced by about 50 interns starting their residency training at Baystate Medical Center.
(Photo: Residents Osama Kandalaft, MD and Sarah Solano, MD seek social services assistance from Richard Johnson, volunteer from the New North Citizens Council, during the simulation)
This is Not a Game
“Our goal (for the poverty simulation) was to become familiar with the systems that people in poverty interact with, and the resources that are available for assistance,” says Molly Senn-McNally MD, Director, Pediatric Continuity Clinic, who was instrumental in bringing the Community Action Poverty Simulation to Baystate.
Each resident was assigned a role in a family that is struggling financially—perhaps recently deserted by a breadwinner, or disabled and living on Social Security—and asked to provide basic necessities while facing constraints common to those living near the poverty line, such as, being without a car, having no phone, or needing to cash a check without having a bank account.
Participants figure out how to survive for a simulated month (four 15-minute weeks) on an extremely limited income, deciding how to allocate their resources to pay for housing, buy food, get to work, keep their kids in school, pay utilities, and deal with unexpected challenges dealt out by "Luck of the Draw" cards.
They interact with other families in their neighborhood, as well as grocers, pawnbrokers, community services agencies, police officers, and people involved in illegal activities—who are role-played by volunteers, often those who have faced poverty themselves.
A Big Eye-opener for Residents
After the simulation, facilitator Paula Consolini, PhD, director of the Center for Learning in Action at Williams College, led participants in a discussion about their experience and insights.
“You are barely keeping your head above the water and you have to kind of play loose with the rules or break the rules," explained Taylor Koerner MD, internal medicine resident. "We were supposed to have everybody home sick for a week but we sent people to work anyway.”
The residents participated very openly and fully in the simulation, noted Senn-McNally. “It was clear that they were moved by their experience,” she said. “Though this was a simulation, they were able to feel a small measure of the stress, the difficult decisions, and the frustration of working within difficult systems that our patients experience.”
“As the month went on, expenses really started to get away from us and things got more and more overwhelming,” said internal medicine resident Anthony Nicolas MD. “I think the biggest lesson to take away from this is, so many unexpected challenges start popping up.”
Poverty a Powerful Impact on Health
Poverty is a powerful predictor of disease and death. The poorest 1% of people in the U.S. die a decade or more earlier than the richest 1%, according to an April 2016 article in Journal of the American Medical Association.
Poverty is a real issue in the community served by Baystate Medical Center. Poverty rates and reliance on government support programs like Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) is higher than the Massachusetts average.
“We want all of our providers and staff to have empathy and understanding for the patients that they work with. The goal was to generate an understanding of the challenges that people living in poverty face outside of the medical setting, and how those challenges might affect their health and decision making,” says Senn-McNally.
Dealing With the Challenges
This was Baystate’s first poverty simulation. “But we would like to run them for senior residents as well as providers, staff, and administrators across the institution,” says Senn-McNally. "And, we are working on developing community resource lists and partnerships with community members and institutions."
Ultimately, residents will have a better understanding of the complexity and interconnection of the social and economic issues affecting their patients' health.
“It was a big eye opener for all of us,” concluded Dr. Nicolas.