Charles Lockwood, MD, MHCM participated in a poverty simulation on Monday, April 1, 2019, at the American Legion Seminole Post #111 in Tampa. Some of the objectives of the simulation was to engage USF Health faculty experience struggles faced by low-income families.

Donna Petersen, ScD, MHS, CPH (facing camera, right) participated in a poverty simulation on Monday, April 1, 2019, at the American Legion Seminole Post #111 in Tampa. Some of the objectives of the simulation was to engage USF Health faculty experience struggles faced by low-income families.

Haru Okuda, MD, USF Health CAMLS executive director and USF Health executive director for interprofessional education and practice, took a photo during a poverty simulation on Monday, April 1, 2019, at the American Legion Seminole Post #111 in Tampa. Some of the objectives of the simulation were to engage USF Health faculty experience struggles faced by low-income families.

Multimedia story by Allison Long.

For the first time, the exercise brings together students from all USF Health colleges.

Living in the moment is a way of life that countless people strive to achieve, but for those living in poverty, the concept takes on a much more somber meaning. If someone is struggling to make ends meet, their daily life is so stressful that they’re probably not thinking about or planning for the long term.

Every day, health care professionals come face-to-face with patients in poverty and in order to teach students empathy and an understanding of these barriers, USF Health Morsani College of Medicine Office of Student Diversity and Enrichment hosts poverty simulations. This training is in its sixth year, but this year is the first with an interprofessional mix of athletic training, medical, nursing, public health, pharmacy, physician assistant, and physical therapy students, as well as residents, and fellows. At the end of 10 sessions provided in the 2018-19 academic year, about 840 people will have participated.

The local American Legion Post donated its community hall to accommodate the large groups of students and volunteers.

Based on a simulation activity from Central Missouri Community Action, participants have the opportunity to experience life in the shoes of a fixed, limited-income family.

Shirley B. Smith, MA, Director of the Office of Student Diversity and Enrichment for MCOM, begins the activity by instructing the group to take it seriously because, “these are real people who have lived this experience.”

The students were assigned to fill various family roles, with identities ranging from seniors living alone to single-parents and blended families. Each family struggles with barriers such as unemployment, disabilities, and transportation. Over the course of a simulated four weeks, the families’ priorities are shelter, electricity, food, and keeping the family together.

The assigned identities range from single seniors living alone to single parents and blended families. Some are recently unemployed or struggling with disabilities.

A variety of resources are offered to the families by volunteers stationed around the community center room.  The volunteers simulate the roles of bankers, grocery store clerks, hospital staff, social service workers, and a pawn broker. Over the course of the activity, participants may run out of time or money, or even just forget to pay rent or buy groceries. One family was visited by law enforcement after she forgot to pick up her child from day care. Another family pawned their furniture for extra money. At least three families were evicted.

“This experience gives insight to health care workers, because sometimes we don’t know what is going on in a patient’s life and how it’s affecting their treatment or compliance,” said Brolivia Harvey, an adjunct faculty member in the College of Nursing.

Volunteers staff the resource tables that represent businesses such as banks, groceries, social service agencies, pawn brokers, and quick cash operators.

Participants without private transportation have to budget for public transportation passes needed to get to each resource station.

Just like in real life, when the rent is not paid, families are evicted.

At the end of the interprofessional education simulation, the participants sit down for a debrief. More than half of the students raised their hands when asked if they felt stressed or anxious during the experience. One student shared that she felt a “sense of insecurity” the entire experience and how you don’t realize the mental health strain it’s having on you or your children.

“I think the poverty simulation made everyone more aware of the struggles that people go through. We saw how much had to be accomplished in one day and that someone living in poverty may have to choose to pay rent instead of buy their medication,” said Rumour Piepenbrink, a first-year public health student.

“It was an eye-opening and humbling experience. I felt an array of emotions from frustration to gratitude for what I have,” said Ashley Reed, a fourth-year nursing student.

First-year public health student Rumour Piepenbrink visits the payday advance quick cash station.

Fourth-year nursing student Ashley Reed speaks with the volunteers at the simulated hospital.

During debrief, the group discussed how they can apply the lessons they learned from the poverty simulation to their health care careers:

• Don’t judge your patients.
• You have to consider the situation your patient is coming from to best help them.
• Be aware of local resources to refer a patient in need.
• Besides providing a resource to help a patient right now, empower them for the future.
• Teach patients the importance of long-term health.
• Physician burnout can happen when you do not deal with not being able to help everyone.

“Don’t ever get to the point where you’re numb to the poverty or problems of the people in the community,” said Priscilla Perez, a case manager for Positive Spin, a community-based social service agency that assists children and families to live healthy, and long-time poverty simulation community partner. “Helping a patient is more than just taking care of the reason for their visit,” she added.

Students are not the only ones participating in the poverty simulation. A session in April will include USF Health leadership and faculty.

“At USF Health, we are committed to preparing health professionals who recognize the importance of interprofessional team-based care, not only in the clinical setting but also in working together to address the social determinants of health in the communities we serve. Engaging our faculty in this intensive training will help us be better teachers and encourage us to recognize and emphasize the important role that every member of the team plays, including our patients and our community partners,” said Donna Petersen, ScD, senior associate vice president of USF Health and dean of the College of Public Health.

USF Health students, residents, and fellows debrief after the poverty simulation.

-Multimedia story by Torie Doll.

Every physician will have patients who struggle so much with their day-to-day lives that following physicians recommendations, getting prescriptions filled, and even getting to appointments are huge endeavors.

To better prepare future doctors help patients in poverty and identify signs of struggle, the USF Health Morsani College of Medicine offers its medical students a poverty simulation activity, an exercise that allows students to walk a mile in their future patients’ shoes, said Vinita Kiluk, MD, assistant professor of pediatrics, co-course director for Doctoring III section of medical curriculum, and co-director for the primary care clerkship.

“An experience like this will help our students to have more empathy for patients,” Dr. Kiluk said. “We hope that through this simulation, the students will have a better understanding of the barriers faced by patients when having to make decisions between paying bills and filling the prescriptions we prescribe.”

The message of empathy can really make the difference for providing holistic care to patients, said Bryan A. Bognar, MD, MPH, FACP, professor of medicine and vice dean for MCOM Office of Educational Affairs.

“We know that a number of factors beyond medical care combine to affect the health of individuals and communities,” Dr. Bognar said. “Every one of our students will have patients who struggle with poverty, and we know that poverty impacts health in several ways, from an inability to get to resources for help and support to an inability to comply with physician recommendations. This simulation is just one example of how our curriculum provides experiences to help our students become better, more compassionate physicians. By immersing our students into situations that reflect real life, we are offering them an opportunity to have a better understanding of the true reality that many of their future patients face every day.”

The personal, hands-on experience aims to have a lasting impact, said Shirley B. Smith, MA, director of the Office of Student Diversity and Enrichment for MCOM, who initiated the activity at USF MCOM.

“The exercise offers medical students an opportunity to experience what many of their patients – more than they realize – will be going through,” Smith said. “They learn that, as a physician, treating and helping a patient get to optimum health takes more than just what’s within the four walls of a clinic.”

Based on a simulation activity from Central Missouri Community Action, the USF MCOM activity is customized to be more health care centric and has been incorporated into their curriculum, making it required by all students, Smith said. The local American Legion Post donated its community hall to accommodate the large groups of students and volunteers. For the simulation, medical students are grouped into their new “families” and take on those families’ identities, physical ailments, employment statuses and economic situation. The time across a morning is translated into four weeks of experiences in poverty.

“Some are single seniors living alone, some are single parents, some are blended families, some who are recently unemployed, some struggling with disabilties – in essence, it’s about people who are struggling from day to day,” she said.

At the sound of a whistle, these families make their way around the multitude of resources at tables on the periphery, such as banks, groceries and social service agencies, but also pawn brokers and quick cash operators. To get to these places, families must use tickets that represent transportation – which they bought with their allotment of money – but these “errands” can only happen after they take children to school and go to work.

“This exercise, which uses real life scenarios, helps validate patient stories and efforts,” Smith said. “The medical students are provided with only a general sense of their ‘itinerary’ and issues they are facing, causing many to forget they need to pay rent. They also frequently forget to buy groceries.”

 Listen to Shirley Smith, MA, director of the Office of Student Diversity for MCOM, who initiated the project at USF MCOM

Just like real life, there are consequences for forgetting. Not paying rent results in warnings being placed on chairs that represent home. Missing another rent payment results in eviction and the chairs are turned upside down, representing no access to home.

And just like real life, there are unexpected events.

“We have Luck of the Draw cards that one of our volunteers delivers randomly to family members, like losing a job or having the electricity turned off, but also, because of our focus, there are health care issues – suddenly getting ill,” Smith said.

 Listen to David McNeely, a volunteer representing a pawn broker, who has helped with the simulation multiple times.

 Listen to Carol Vanrossen, representing a mortgage and rental agency.

 Listen to Jigar Chauhan, a student playing a disabled person who just got evicted.

The medical students take on these roles with gusto and the scenarios have impact. Second-year medical student Mackenzi Frost is playing a mother with a significant other who is out of a job right now because he has pneumonia, and she has a 1-year-old baby.

“I’m just literally going week to week trying to figure out how to survive,” Frost said “It’s really challenging to get all of the necessities for life covered. We’re all struggling to make ends meet. This project definitely helps make me more empathetic. They say the next best thing to living something is to simulate something, and this helps us feel, at a very small degree, what they are going through.”

The empathy central to this activity carries over to issues of health care.

“The goal of this exercise would be to show us, as medical students, some of the circumstances out of people’s control that contribute to how they approach health care, health spending, and whether they get treatment or don’t get treatment,” said Gilbert Murimwa, a second-year medical student. “It shows how people prioritize their needs. You may not be able to get health care if you have to feed your family or pay for medicine or have an unexpected trip to the emergency room.”

 Listen to MCOM student Gilbert Murimwa. 

 Listen to MCOM student Mackenzi Frost.

The real takeaway is the stress of living day-to-day. One of the biggest struggles for these students, Smith said, is prioritizing. With limited time and resources, when everything they need to accomplish is a must – rent, utilities, food, and juggling all of the agencies associated with those – getting them all done in the allotted time with the allotted money is nearly impossible.

Photos by Sandra C. Roa, USF Health Office of Communications