“It kind of strips you of any pride that you have. It was very humbling.”
As a care manager, Mary helps patients follow their care plans by coordinating medical visits and community resource referrals, but this was the first time Mary shadowed one of her patients out in the community. At the food bank, Mary watched her patient, who was living with diabetes, receive one box of macaroni along with other canned and shelf-stable food items. A key part of her patient’s care plan included a monitored diet of carbohydrates, but it became clear to Mary that her patient would have difficulty managing her diabetes while depending on the food bank for food security. Seeing firsthand helped Mary understand that the non-medical needs surrounding her patient’s chronic condition would ultimately affect her patient’s ability to comply with care plan recommendations, and this observation informed Mary’s practice:
I try to give as much information as I can to get [providers] to understand what [patients] are going through. [Patients] aren’t intentionally trying to be non-compliant. It’s not like they have this endless money pit to go buy spaghetti squash. They just don’t have that option. They have macaroni. We’re working with macaroni here.
Following Mary’s example, shadowing patients outside of the medical clinic is one strategy providers can use to become more familiar with their patients’ non-medical needs. Directly observing the social and economic barriers patients face may increase providers’ empathy towards challenges that seem mundane but are consequential for health outcomes. Patient shadowing may also facilitate improved communication between providers and their patients — if providers can leverage the insight to better inquire about their patient’s situation. Moreover, providers with a large panel of complex patients can use the shadowing strategy as an opportunity to assess the value, appropriateness, and capacity of their local network of community resources.
A second strategy for improving providers’ understanding of non-medical needs is by simulating patient experiences. In contrast to shadowing, which uses direct observation, simulations use role-played scenarios to elucidate patients’ experiences and challenges outside of the medical clinic. For example, Oregon Health & Science University hosted a role-play simulation for health care professionals, known as the poverty simulation. Participants assumed the roles of low-income family members, while trained volunteers played the roles of various community organizations such as schools, employers, grocery stores, childcare, pawnshops, and social service agencies. The participants’ goal was to keep their families safe, housed, and fed, and the simulation concluded with sessions to reflect on the significance of non-medical needs in patient care. Using the poverty simulation as a training opportunity, one clinic in Oregon sent 200 of its employees to participate. Five years later, the clinic’s chief quality officer continued to reference the simulation as an important lesson emphasizing the impact of non-medical needs:
If a patient is ten minutes late please listen and understand why they’re ten minutes late, and don’t turn them away because they may have taken eight buses to get here…It’s not that they’re late; there’s a whole story underneath why they’re late.
Simulated patient experiences, like the poverty simulation, remind providers that ordinary needs such as transportation, food and housing can be routinely challenging for some patients. By drawing attention to these common non-medical needs, simulations may increase providers’ sensitivity to the social determinants influencing their patients’ health. By sensitizing providers to social determinants of health, simulations may also serve to enhance the patient-provider relationship by engaging providers in more empathetic communication with their patients, thus helping patients feel understood and improving providers’ ability to make holistic medical decisions.
Of course, each approach — shadowing and simulations — has strengths and limitations. While the shadowing strategy illuminates concrete patient experiences within a provider’s panel, the simulations strategy usually covers a standard and hypothetical set of patient experiences (though simulations can also be designed based on actual patients’ experiences). Since it is impossible for providers to shadow every patient, shadowing may be best used in small-scale application with narrow focus. For instance, providers may select patients to shadow based on the most frequently made community resource referrals, or providers may decide to shadow a subset of their most complex patients to better understand these patients’ specific challenges and needs. In contrast, for those wishing to train groups of providers or an entire organization, the simulations strategy may be more practical. Simulations may also be used to promote cultural values and provider competencies, like empathy, and function as a tool for organizations to define a standard of care that recognizes social determinants of health.
While shadowing and simulations are far from the only two strategies for improving providers’ awareness of non-medical needs, they serve as useful examples of how organizations can look to advance patient care — specifically sensitivity to social determinants of health. With an enriched perspective of the daily and structural barriers patients face outside of the medical clinic, these strategies may help providers better respond to their patients’ needs and also challenge implicit assumptions about the causes of non-compliance among patients. By shadowing and simulating their patients’ experiences, providers may not only empathize but perhaps even problem solve with their patients to address the non-medical needs influencing their patients’ health.
Names of respondents are de-identified from interview data collected in 2017 during in-depth site visits with health care organizations.
Joelle Jung is a research project coordinator and Valerie Lewis is an associate professor of health policy, both at the Dartmouth Institute for Health Policy & Clinical Practice.
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