Down to the Last Dollar: Utilizing a Virtual Budgeting Exercise to Recognize Implicit Bias

Abstract

Introduction:As social determinants of health and implicit bias are recognized as critical components of medical education, there is a need for novel approaches beyond didactics. We developed a small-group budgeting exercise to simulate the impact of poverty. Pediatrics exemplifies the effects of poverty on the family. This exercise allowed students to recognize the effects of food insecurities on health and reflect on biases regarding patients living in poverty. Methods: The virtual interactive budgeting exercise (1.5-2 hours) introduced third-year pediatric clerkship students to the challenges faced by a single parent living in poverty, requiring them to make choices on which budget items were most important. Students attempted to balance budgets within small breakout groups, followed by a group reflection on biases encountered. A faculty facilitator then debriefed with the larger group. Results: Within the first four rotations of the 2020-2021 academic year, 75 students completed the budgeting exercise and reflection, with 61 students completing the postexercise survey evaluation. Between 94% and 98% rated the objectives as met to a moderate, considerable, or very high degree. In addition, 98% of students noted the group discussion heightened their awareness regarding biases, and 95% agreed or strongly agreed the activity was conducted virtually without difficulty. Discussion: This simulated budgeting exercise provides a well-rounded experience for medical students, that can be administered at either the preclerkship or clerkship level, at a minimal cost, with interactive engagement of students in a virtual environment and reflection on biases within a group context.

A systematic scoping review of group reflection in medical education

“…Participants possess some degree of autonomy over reflective content [ 101 , 102 , 105 ] however common reflective themes include • Day to day activities and perspectives [ 18 , 126 ] • Challenges [ 127 , 128 ] • Actual case studies [ 129 ] • Views and experiences on a program [ 119 ] • Suggestions for improvement [ 21 ] • Student-patient interaction [ 68 ] • Professionalism in practice [ 61 ] • Ethical dilemmas [ 99 ] • Psychological supervision and clinical reasoning for practice [ 18 ]. Size of group Less than 7 [ 62 , 126 , 129 – 131 ] More than 7 [ 21 , 119 , 132 ] Frequency Once-off [ 130 ] Weekly [ 18 ] Bi-weekly [ 132 ] Every few months [ 129 , 133 ] 1 h 15 min [ 126 ] 90 min [ 132 ] 2 h 15 min [ 18 ] Modality of reflections In person [ 21 , 61 , 126 , 133 ] Online [ 25 , 128 , 134 ] Video review [ 104 , 106 ] Vignettes [ 61 ] Case studies [ 99 ] ...…”

“…Frequency of these sessions varied between once-off sessions [ 130 ] to regular meetings [ 18 , 132 ]. Group reflective programs utilized different modalities such as in-person meetings [ 21 , 61 , 126 , 133 ] and online meetings [ 25 , 128 , 134 ] which are scaffolded by other activities reviewing video playback [ 104 , 106 ].…”

Integrating the Social Determinants of Health into Graduate Medical Education training: a Scoping Review

“…Another six programs relied on a participatory approach, with community placement and no formal lectures [27,35,36,[43][44][45]. Three programs integrated didactic teaching and a participatory approach with no community engagement [29,37,38]. Another set of four programs included participatory learning only, requiring participant engagement, such as information gathering, group discussions, and activities [22,26,32,39].…”

“…As explained in table 3, the duration of the program relating to SDH varied. A total of twelve programs had longitudinal modules, which spanned between one to three years of the postgraduate medical residency [22][23][24][25][26][27][28][29][30][31][32][33], while ve other programs spanned between two to nine months of postgraduate medical residency [34][35][36][37][38]. Seven programs took between two weeks and six weeks [39-43, 43, 44], while the shortest program involved three online simulations, each simulation is 4 hours (one-half day) and completed during a module on advocacy .…”

“…[45] Table 3 to be inserted here The structure of the programs related to SDH varied across a range of thematic areas. A total of ve courses had a focus on home visits and different community healthcare interventions [23,30,31,40,41], while another set of ten programs were in the form of case-based workshops on a variety of topics such as prison healthcare, housing issues locating pharmacies and follow-up of patients after discharge [24-26, 28, 29, 32, 34, 39, 43, 45] Lastly, nine programs focused on health advocacy topics, such as opportunities to integrate SDH at community health clinics, housing, education and legal issues, integration of health disparities to clinical practices and equity, diversity, and inclusion [22,27,[33][34][35][36][37][38]44].…”