A part of learning to be an effective physician is learning how to have difficult conversations with and about patients. This includes discussing social determinants of health (food insecurity, housing issues, barriers to accessing care, and adverse childhood experiences), which have been shown to be incredibly important factors when caring for patients, particularly children. Associate Program Director Kimberly Collins, MD of Johns Hopkins All Children's Hospital in Saint Petersburg, Florida set out to see how simulating conversations about social determinants of health (as opposed to in-class learning or immersion-based training) affected a resident’s or fellow’s ability to broach and explore these complex, often sensitive, subjects with patients and their parents. Her results are recorded in her poster: Improving Resident Comfort with Discussing Social Determinants of Health through Simulation.
Primary Author: Kimberly Collins, MD
Co-Authors: Sarah Marsicek, MD; Akshata Hopkins, MD; Robert A Dudas, MD; John Morrison, MD, PhD; all from Johns Hopkins All Children's Hospital.
ACGME: Tell us about your academic and professional role.
Collins: I am a pediatric hospitalist and the associate program director for our pediatric hospital medicine fellowship. I also help develop, coordinate, and facilitate some of the pediatric residency program's simulations, which focus on improving communication skills for a variety of potentially challenging situations. This broader simulation curriculum includes the simulations described in our abstract.
ACGME: Can you briefly describe your project for us?
Collins: We developed and piloted simulated patient cases that gave first- and third-year pediatric residents the opportunity to practice and debrief discussions about various social determinants of health, or SDH. We asked residents to complete a brief retrospective pre- and post-simulation survey about their comfort with discussing each of these SDH, their previous experiences with these discussions in the clinical setting, and their feedback about the simulation session.
ACGME: What inspired you to do this project?
Collins: We recognized that not only was it important for residents to learn about social determinants of health and think about them when considering all of the factors that affect our patients' overall well-being, but also to develop that comfort in discussing these factors with patients and families. As we developed a curriculum to use simulation to give residents practice and feedback on these discussions, we wanted to know how effective the curriculum was at improving their comfort with discussing SDH.
ACGME: What did you discover?
Collins: Pediatric residents at our institution don’t often discuss SDH in their clinical practice. Most residents reported that their comfort level with discussing food insecurity, housing issues, barriers to access to care, and adverse childhood experiences improved after the simulations. Simulation-based education with simulated parents is an effective teaching method to practice asking questions about SDH. The simulation experience helped identify simple advocacy tools to integrate into their curriculum, including Advocacy Letters (writing to school on behalf of a patient, writing to community members on behalf of a patient, and writing to your legislators as a pediatric expert).
ACGME: You noted in the abstract that 44 percent of third-year residents reported less than two conversations about food insecurity in a clinical setting. Was this number higher or lower than you were expecting, and why did this seem surprising to you?
Collins: As a part of the resident survey, we also aimed to get a rough estimate of how many times the first- and third-year residents had discussed each specific SDH in the clinical setting. The fact that less than half of third-year residents reported having no more than one conversation about food insecurity was surprising. We would have expected it to be higher, as routine food insecurity screening has been implemented in the continuity clinic.
Although this number did surprise us, there may be a variety of reasons for the small number of conversations, including both provider and patient discomfort with discussing food insecurity, as well as prioritization of acute medical issues or chronic disease management during the visit.
ACGME: What was the main takeaway?
Collins: A short simulation-based activity helped pediatric residents feel more comfortable with discussing social determinants of health.
ACGME: What are your next steps?
Collins: We plan to refine the simulations based on resident feedback. In addition, we plan to look at resident outcomes in terms of communication competency for discussing social determinants of health as well as measure the effect of the curriculum on the number of discussions about SDH that residents have in their clinical practice.