Pretending to Be Poor

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An increasing number of medical schools across the country are using simulation programs to teach aspiring doctors about the hardships of poverty. These programs typically involve fictional scenarios in which residents or medical students are assigned an identity before having to make difficult financial decisions, such as choosing between a needed medication and paying rent. While health care professionals are patting themselves on the back for these exercises in empathy, patients wonder if make-believe poverty does more harm than good.

Last week, The Houston Chronicle reported on a simulation program at Texas Medical Center, which involved 80 students arranged in small groups with a name, family, and circumstance. Groups represented unemployed single mothers, veterans with chronic conditions, individuals battling addiction, homeless persons, and more. All students received an information packet with details on medical conditions, employment status, monthly expenses, and budget. With this information, students had 15 minutes to make decisions about spending priorities while a highly visible clock counted down. (Fifteen minutes constituted one week; and there were four segments to total one month.)

“Panic rises as the number gets smaller,” the author of the piece described. But “organizers warned the students they may begin to feel angry or frustrated with each other.” Participants in this simulation walked away feeling as though they had learned an important lesson about the struggles that patients with financial hardships face. And they vowed to apply this knowledge in future interactions with patients.

In a comparable stimulation at University of Buffalo, participants were similarly optimistic. “I think I began to appreciate the truths of what my patients might experience and felt myself even just today be more considerate and empathetic toward them,” one medical student said. A provider claimed, “I have been clueless to the many struggles that my inner-city patients and families face…but vow to take the time to delve into social barriers to adherence and self-care.”

But for patients like Erin Gilmer who live in poverty or who have experienced poverty in the past, “these performative efforts are not all that helpful and are somewhat offensive.” One problem with simulations is where they take place—in an elite space (the medical school classroom). Another problem is with whom (and without whom) they take place—individuals who presumably have not been touched by poverty, rather than those affected. There is also a temporal constraint. How can an hour-long activity possibly capture what some individuals have experienced over the course of their entire lives?

In a Twitter thread responding to the Houston Chronicle piece, Gilmer (@gilmerhealthlaw), Jennifer Leckie (@BrowofJustice), Gabrielle Peters (@mssinenomine), and others noted that these simulations primarily benefit the egos of participants and not patients in poverty. (In this sense, they resemble the “misery tours” that country clubs and resorts have sponsored under the auspices of allowing dues-paying members to increase social consciousness.)

One danger of these simulations is that they allow participants to think that they “get it.” When participants think that they have “checked off this box,” they may not pursue other, more meaningful opportunities to engage with individuals affected by poverty. Furthermore, by focusing solely on physical circumstances, these simulations miss the opportunity to excavate the cultural attitudes that compound those physical circumstances. Chances are, struggling to make ends meet is only one part of the story; the unemployed mother or chronically ill veteran is likely facing social stigmas and structural barriers—burdens that are not embedded in the simulation.

“I am grateful that I don’t have such a burden” (i.e. “Thank God I am not one of them.”)

There is also the danger of unintended learning. As critics of disability simulations have noted in the past, role-playing games often reinforce stigmas and negative feelings toward those whose experiences they mean to explore. Various studies of disability simulations have found that simulations foster pity toward subjects, rather than a genuine desire to engage. This is evidenced by the frequency with which participants comment, “I am grateful that I don’t have such a burden” (i.e. “Thank God I am not one of them.”) These stigmas are inevitable when simulations cast subjects as helpless and incapable. In reality, individuals have strengths and talents in addition to hardships; and many have found shrewd ways to adapt to their circumstances. These assets can be obscured by simulations’ focus on struggles.

Finally, there is little evidence to support the effectiveness of simulations in teaching empathy and cultural competence other than the glowing praise of participants. Given these limitations, critics suggest, aspiring medical professionals and educators should consider other methods to understand poverty and financial hardship. For instance: simply engage those people in conversations. Invite them to class and listen to their stories. Host a panel in which audience members can ask questions. Better yet, recruit those students into medical school programs and allow them to become part of the culture. No matter what, don’t play games at the expense of a marginalized community.

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About Author

Audrey Farley is the Editor in Chief of Pens and Needles. She recently earned a PhD in English from University of Maryland, College Park, where she studied contemporary American fiction, popular culture, and the medical humanities. She has written for various peer-reviewed journals in the literary fields, as well as outlets such as Public Books, ASAP/J, and Insulin Nation. She lives with chronic migraine and is the parent of a child with Type 1 diabetes. Follow her on Twitter @AudreyCFarley.

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