Christiana Care Health System, Newark-Wilmington, DE
“A-HA!” Advancing Health Advocacy Through Resident Education

Background: Christiana Care Health System (CCHS) provides the clinical learning environment for more than 280 residents in 13 residency programs. CCHS residency program directors confirmed that there is currently no standardized method of educating trainees on issues of health disparities and limited opportunities for busy residents to interact with the local community. Our NI V initiative consisted of a multitiered educational curriculum utilizing preexisting resident group activities to develop experiential and didactic learning.

Methods: Using the Community Action Poverty Simulation (CAPS) kit, a structured event was integrated into our multispecialty intern orientation on June 23, 2016. The 74 residents experienced what it might be like to be part of a typical low-income family and were tasked to use a variety of hospital-based and community resources. Representatives of hospital-based resources and volunteer community organizations were recruited to participate in the immersion experience. Validated pre- and postsimulation surveys (included in the CAPS kit) were administered before and after the experience to evaluate any changes in attitudes regarding poverty. The program directors of 7 core residency programs agreed to substitute a relevant, specialty-specific health equity article into their existing, mandatory journal clubs. Faculty champions and resident trainees were enlisted to conduct dual-purpose journal clubs to include community resource tools (for practical execution of local patient advocacy) along with the article. A GME-wide Health Equity – Resident Survey was developed and disseminated electronically to all our residency programs. Residents were invited to complete a brief self-assessment about their confidence with engaging patients in conversations about social determinants of health.

Results: There were important differences between the pre- and postsurvey response of “strongly or somewhat reflect what I believe” for the following statements: “People with low income do not have to work as hard because of all the services available to them” (from pre 13.89% [10/72] to post 4.05% [3/74]; P = 0.04); “People are generally responsible for whether they are poor—they get what they have earned or deserve” (from pre 16.67% [12/72] to post 6.76% [5/74]; P = 0.06); “People with low income could get ahead/improve their situation if they could just apply themselves differently” (from pre 44.44% [32/72] to post 30.14% [22/73]; P = 0.08); “People with low income have low self-esteem” (from pre 34.72% [25/72] to post 50.00% [37/74]; P = 0.06). Overall, residents reported that they were less than competent in their ability to engage patients in conversations about housing conditions, public benefits, food security, and domestic violence/public safety. The response rate was high (72%).

Conclusion: Poverty simulation is an innovative modality to engage and educate residents on the topic of health equity and is now part of our annual orientation. The resident surveys, health equity journal club topics, and poverty simulation event are customizable, allowing for targeted learner discussions on health equity topics. Data collected from surveying the entire resident population about their attitudes and knowledge of social determinants of health can be used to tailor future journal club topics.