Future doctors learn about poverty while training in Houston
Aug. 02, 2018
HOUSTON (AP) — In a stuffy conference room, tucked deep in the Texas Medical Center, dozens of well-heeled future doctors nervously await the start of poverty.
The Houston Chronicle reports in truth they will face only make-believe hardship, a few hours of stress as they play-act the life and hard choices that flow from never having quite enough money to make ends meet.
But the hope behind this mandatory exercise is to make it feel real enough for the third-year medical students that one day they will think twice before criticizing poor patients for not heeding advice, refilling prescriptions or putting health care last on the priority list.
"Portions of today can feel like a game. After all, we are using fake money and props. But I want to emphasize that this is not a game," warns Rebecca Lunstroth, associate director of the McGovern Center for Humanities and Ethics at the University of Texas Health McGovern Medical School, in her stark opening remarks.
"Over your careers some 80 percent of your patients will have struggled buying food, paying their rent or their mortgage or acquiring transportation," she says. It was a statistic chosen for maximum impact.
The sessions, called poverty simulation, are borne out of Lunstroth's frustration as she watched students go through four years of training, starting idealistic and then, too often, becoming irritated and judgmental when they moved from classroom to the real world of poor patients who don't always follow doctors' orders.
She modeled the program after one she heard of in Missouri designed to impart empathy in social services workers. She thought it would work nicely for medical students, too.
"Poverty is highly concentrated in Houston. Neighborhoods are increasingly economically polarized," she tells the crowd. Then she drops a universal truth.
"Those of us from higher incomes can largely escape seeing how the poor live."
In short order chaos descends.
The 80 or so students are separated into small clusters and each are assigned a name, a family and a circumstance. There are single mothers who lost their jobs. Veterans with chronic illnesses or people battling addictions. There are grandparents raising grandchildren because of vanished parents. Still other students take on the role of the homeless or those on the verge. Then there are the handful who have no family. They are elderly and alone.
Each student is given a packet of information about their lives including how much money they have for the month juggled against their expenses. They are also assigned employment status as well as medical conditions or other obstacles.
They must figure out how to navigate it all, including budgeting meager pay or benefits to pay rent and utilities and food while keeping their families safe. Each are also given a set number of transportation vouchers — the key to everything, organizers say — which can spell the difference between getting to work, to school, to day care drop-off and pickup, to a job interview or not.
Each segment is 15 minutes, representing one week. There are four segments to total one month, with slight breaks in between to refigure budgets and priorities. At the front of the room is a screen with enormous numbers that counts down the time. A whistle blows when time runs out. Panic rises as the number gets smaller.
Organizers warn the students they may begin to feel angry or frustrated with each other.
In the center of the room an argument breaks out.
"You need to go to the store," shouts one student.
"I need to pick up the kids," another shouts back.
Four minutes to go.
Lining the room are tables populated with faculty members and volunteers. They, too, have assigned identities.
Each table represents the various services students will need over the course of a month. The trick is they can't access the services without first giving up one of their transportation vouchers. There is a grocer, a banker, a child care center, a homeless shelter, the police station, the utility company, a school, among others.
There are also payday lenders and a pawn shop to fill in the gaps. And there are almost always gaps
Dr. Rodeo Abrencillo, an assistant professor for critical care, pulmonary and sleep medicine at the medical school, has become the owner of Big Dave's Pawn Shop, a role he takes seriously and without mercy.
A student glumly approaches. "Hi, I would like to pawn all four of these," he says as he hands over four cards with pictures on them. Three TVs and a camera.
"I have to tell you I'm not into electronics," the pawnshop owner replies with the slightest of smirks. He offers $35 for all. The student accepts without hesitation. Abrencillo reminds his customer that he can buy the items back later — at 50 percent interest.
Taylor Daileda, a 25-year-old medical student from Houston, is now a 52-year-old disabled veteran whose wife is the main breadwinner. He and his wife are raising two grandchildren while their mother is in jail. One of the children needs ADHD medication. It costs $350 per month.
Daileda stands in line at the payday lender table to cash a disability check to buy more bus vouchers. The lender takes a $50 cut out of the $500 check.
"Our first thing we gave up was our prescriptions because we were trying to pay utilities, rent and food," she says later.
The health care table is the one with the fewest visitors during poverty simulations.
"I think it's pervasive in society that if you are in a bad circumstance it must be your own fault," said Conner Patrick, a 25-year-old medical school student. He hopes when he becomes a doctor he will always remember how powerless he felt on this day.
He grew up in middle-class suburban comfort in Cypress. Today, though, he is a 19-year-old unemployed single mother with a toddler, trying to find a job while at the same time moving through the maze of social services. In his pretend family there is a boyfriend who helps with the bills but there is never enough. Health care, unless a dire emergency, is not even a consideration.
Patrick is shortchanged by a store clerk during the simulation. He tried to argue but soon realizes it is fruitless. "It was my word against his. Who is going to believe me?"
It's now been six weeks since the poverty simulation. The students have moved into the next phase of their training. They now see real patients.
Alyssa Kahl, a 23-year-old medical student from Kingwood, says there is little doubt that the lesson stuck. Before, thinking about a patient's life outside the exam room didn't much occur to her, she said.
"As medical students we are trained so much to see what a disease looks like, what are the symptoms. But the piece of how that patient experiences disease in their everyday life and how they prioritize it is missing," Kahl said.
On a recent morning she and three other medical students who also went through the simulation are on rounds at UTHealth Harris County Psychiatric Center. Dr. J. Chase Findley, an assistant professor of psychiatry and behavioral sciences at McGovern Medical School, is shepherding them.
When talk turns to a discussion on the potential toxicities of lithium, medication typically used to treat manic episodes of bipolar disorder, the lessons of the simulation are not far from the surface.
Findley explains that some psychiatric drugs can cost $1,000 while others can be had for $4. "There's no point of prescribing a medication if they're not going to take it when they get out," he says.
He also cautions that it is important to be mindful of things such as if a medication can be taken just once a day rather than twice, and whether the patient will have help or family emotional support.
Doctors also need to consider that the bureaucracy of health care can be difficult for patients, especially those with mental illness. So too are everyday barriers like a lack of public transportation in Houston or even the weather.
"When you think about treatments there (are) scientific evidence-based textbook answers, but there's also the practical answer," Findley said. He, too, took part in the simulation exercise, taking on the role of a grocery store owner.
"Even if they try really hard at the end of the day they still can't succeed," said Mohmmad Syed, a 24-year-old medical student from the Clear Lake area. The simulation taught him that. It also taught him that, almost always, there is more to a patient's story.
Information from: Houston Chronicle, http://www.houstonchronicle.com