Can simulations help residents uncover social needs affecting health?

Timothy M. Smith , Contributing News Writer

The COVID-19 pandemic has shed new light on the relationship between patients’ unmet social needs and physician burnout. An intervention designed by one of Illinois’ busiest emergency departments seeks to answer questions about the changes health care organizations ought to seek when training physicians in social determinants of health inequity.

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“Use of Social Simulation to Improve Physician Well-Being and Patient Care,” a workshop at the inaugural AMA GME Innovations Summit, outlined an intervention designed by Advocate Christ Medical Center, in Chicago, featuring a simulation to help identify—and streamline protocols for addressing—social needs commonly encountered in its emergency department.

Perceived disempowerment has a well-documented effect on physician burnout, and it is particularly visible in the field of emergency medicine, where patients often present with complex health care needs that are largely influenced by socioeconomic factors.

“Our hospital … had the greatest number of COVID-19 cases in the state of Illinois,” said Tehreem Rehman, MD, an emergency medicine resident at Advocate Christ Medical Center. “Already one of the busiest Level I trauma centers in Chicago, we saw a greater number of patients also coming in with gunshot wounds, as well as self-inflicted wounds.”

In one case, she noted, a patient distressed by the pandemic’s effect on his livelihood tried to cut his throat with a circular saw.

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"He kept screaming that he wanted to die,” she said. “Once his wife arrived at bedside, he broke down crying, fearful about how they were going to financially survive as their income relied on their now-closed small business. This onslaught of sickness and despair took a big toll on us and physicians everywhere.”

Despite the clear need for physicians to better understand structural determinants of health inequity in clinical encounters, there is a dearth of formal training on the subject, Dr. Rehman said.

“In response, we designed an intervention that integrates simulation learning and developed cases in social needs commonly encountered in our emergency department,” she said, adding that the effort includes interdisciplinary stakeholders, including care managers, community health workers and social workers. “For each case, we established objectives, a patient identity card, a guided script, debrief questions and teaching points.”

Implementation of the simulation has been delayed by the pandemic, but it is expected to start in November. The cases will focus on six factors: language barriers, poverty, racism, housing insecurity, incarceration and human trafficking, each featuring a five-minute simulation. Residents will be randomly assigned to six groups and rotate through all the cases. Facilitators will then moderate a debrief session after each case.

The intervention’s effectiveness will be measured by way of responses to a questionnaire with the following statements, which might be used by other organizations as touchstones in creating their own interventions to boost physicians’ ability to discern and address social determinants of health inequity:

  • “I can identify my patients' social needs.”
  • “I understand the impact of social needs on my patients’ presentation in the emergency department.”
  • “I understand how social needs can serve as barriers to my patients’ ability to access health care.”
  • “I understand how social needs can serve as barriers to my patients’ ability to complete recommended treatment.”
  • “I can differentiate between the roles of interdisciplinary staff members—social worker, care manager or community health worker, for instance—in our hospital.”
  • "I know how to work with interdisciplinary staff members to optimize the care and management of my patients.”
  • “I am able to identify different hospital resources that I can refer my patients to.”

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This pandemic is not going anywhere—an increasing number of people will become unemployed and uninsured,” Dr. Rehman said. “Now more than ever, physicians will need to become better equipped to navigate limited resources with interdisciplinary partners.”

The GME Innovations Summit also featured workshops on enhancing clinical reasoning skills, improving holistic residency applicant screening and eliminating workforce shortages.