Walking in a Patient's Shoes
By CINDY SANDERS
Social Determinant Simulation Gives Students, Residents Invaluable Insights
So much of medical school and residency is focused on identifying disease and prescribing a course of action to address the diagnosis ... but what happens when the 'right' answer doesn't mesh with the real world?
Helping students and young physicians truly provide patient-centered care was the driving force behind the launch of a unique simulation program created by the University of Tennessee College of Medicine - Chattanooga in cooperation with Erlanger Medical Center. "Walking in our Patient's Shoes" flips the script by having young medical professionals try to follow 'doctor's orders' while navigating a host of issues ranging from a lack of transportation and funds to unsafe environments and food deserts.
Spearheaded by Mukta Panda, MD, MACP, FRCP-London, assistant dean of Medical Student Education and a professor in the Department of Medicine at UT, and facilitated by Erlanger chaplains Greg Daniel, BCC, and Jeremy Lambert, BCC, the popular program started with residents in 2011 and was expanded to include medical students in 2014.
Mukta Panda, MD, MACP, FRCP
"A patient with diabetes: you write a prescription, tell them to eat nutritious foods and get 30 minutes of exercise daily ... but to a patient living on food stamps who has no transportation and lives in a zip code where it's not safe outside of the house, that feels impossible," said Panda. "I found it was really difficult for me to articulate that the patient population we saw really needed a lot more than just writing a prescription or doing a procedure."
Putting providers in patients' shoes drives home the impact social determinants play on compliance in a way that didactic lectures hadn't been able to achieve previously. Many medical students and residents, noted Panda, hadn't personally experienced the types of tough choices faced by a lot of patients seen in clinical practice. The interactive learning experience also helped meet a number of goals for both the university and hospital including fostering holistic, patient-centered care; providing future physicians with enhanced knowledge and tools to improve population health; and addressing key hospital metrics including readmissions and length of stay, which are significantly impacted by adherence to a medical plan.
"We took actual patient scenarios, and we flipped the roles," explained Panda. She added students were given a budget, the exact clinical scenario a de-identified patient presented with prior to admission, and the discharge instructions provided to that patient. Other useful details were found in the patient's social history. "We wanted to teach them a social history taken on a patient is more than just 'Do you smoke or drink? We also talked to them about spiritual support because spiritual support is one of the important components of holistic care," Panda continued.
Working in teams, the students had to navigate the four weeks of time between discharge and the follow-up appointment, while meeting all the requirements of daily life alongside some unexpected surprises. "Do you pay the rent or the babysitter so you can go to work? Do you not take your insulin this month because the car broke down?" Panda said of the real-world scenarios the teams faced.
She explained the interactive exercise was facilitated by discussions about community resources that might be available to help patients address barriers and rethinking how providers could lay out a treatment plan that more realistically mirrored a patient's specific circumstances. Other professionals, including a lawyer from Legal Aid, have been worked into the scenarios over the years, as well. "You do not work alone as a physician," said Panda. "It is truly patient-centered care, and you are the pivot. It's a partnership between you and the patient and the patient's family, nurses, pharmacist, chaplain, social worker and all the other care providers that might be involved in the care," she enumerated.
While the foundational seminars are comprised of 60- to 90-minute sessions, Panda said the lessons learned are applied daily. The teams also meet each weekday for about 15 minutes at the end of their interdisciplinary rounds to discuss action plans and coordinated care. "The learning from this seminar is reinforced every day," said Panda. "It's become a part of the culture."
Not only has the course continuously received overwhelmingly positive responses from participants, but the impact of the seminar also was evident in an informal research format. Using a control group of young medical professionals in Middle Tennessee who had not taken the seminar or had involvement in the interdisciplinary rounds, Panda said the Chattanooga students and residents had significantly higher empathy scores. "They've changed the way they actually see their patients and take their patient's histories," she said of those completing the course.
A vocal advocate for holistic care, Panda said it's equally important to look at a patient's spirituality and how that impacts patient care and satisfaction. When patients are seen as spiritual beings in a human body, she continued, the shift in perception has also been shown to enhance physician engagement while decreasing burnout. "The programs we are talking about are all about the human connection and looking at that person as a human being and not just as a patient with diabetes," Panda said.
"In today's healthcare environment, one of the important aspects of our vocation as healthcare providers is to reignite the joy of medicine ... and that will only happen if we reignite the reason we went into medicine in the first place," she concluded.
The unique University of Tennessee College of Medicine - Chattanooga program was recently featured as part the Tennessee Center for Patient Safety Leadership Summit, which highlighted successful initiatives fostering an organizational culture of excellence, quality and patient safety. The TCPS, a department of the Tennessee Hospital Association, develops and shares hospital and health system success stories and promotes best practices.