In WVSOM’s student-designed activity, Appalachian stories illustrate the social determinants of health

LEWISBURG, W.Va. – “Raise your hand if this simulation made you feel anxious or stressed,” said Courtney Eleazer, Ph.D., a faculty member at the West Virginia School of Osteopathic Medicine (WVSOM).

A sea of arms went up.

First-year medical students had just completed the first mandatory activity of the academic year — a simulation designed to introduce the concept of the social determinants of health, which encompasses economic stability, access to education and other nonmedical factors that impact a person’s health and quality of life.

In the activity, each student was randomly assigned one of seven characters to portray. There was “Jack,” a widowed coal miner who didn’t complete high school. Some students took the role of “Kiersten,” a young woman with an abusive boyfriend. Others were “Susanne,” a retired grocer raising two grandchildren, and “Hunter,” an unhoused, unemployed man suffering from mental illness and hepatitis C. Students spent a month — condensed into an hour for the purposes of the activity — living the lives of their characters and trying to maintain good health for themselves and their dependents.

Created to mimic some of the health inequities present in rural Appalachia, many of the simulation’s characters had limited income, lack of access to health care and education, poor social support systems, and experienced discrimination based on their social status. According to U.S. Consumer Financial Protection Bureau data, the median household income in rural Appalachia is about $49,000. And the federal government’s National Center for Education Statistics reported that about 66% of adults living in Appalachia read at or below an eighth-grade level.

If the activity made students anxious, it was by design, said Eleazer, who teaches in WVSOM’s Department of Biomedical Sciences and helped lead the activity.

“By placing students in the role of patients, this simulation serves to recreate the chronic stress many rural community members face in response to health inequities,” Eleazer said. “We know social determinants have a direct impact on health quality and outcomes, but they also can have an indirect impact by affecting mental health. Chronic stress is a factor in the development and severity of diseases such as cardiovascular disease, obesity, diabetes and auto-immune disorders.”

The social determinants of health, as defined by the World Health Organization and adopted in the U.S. by the Centers for Disease Control and Prevention, are economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

The simulation’s objectives were to help WVSOM students identify these determinants, recognize their effects on patient health and outcomes, and find strategies for health care workers to address them.

DESIGNED BY A STUDENT

The activity was created by Madison Robinson, a fourth-year WVSOM student. The characters ring true because Robinson based them on people she knew growing up in the Mountain State and patients she interacted with while volunteering at a hospital while earning an undergraduate degree at West Virginia Wesleyan College. A “poverty simulation” she experienced at Wesleyan inspired her to design an activity aimed at educating medical students about the social determinants of health — but the format, rules and goals were Robinson’s alone.

Robinson, a Kanawha County native and lifelong West Virginian, had the idea for the simulation after noticing that many members of her class were from urban areas in other states. She wondered whether those students might be surprised by some of the situations they would encounter during their final two years of medical school, which consists of clinical rotations at sites across the state through WVSOM’s Statewide Campus system.

“I realized early on that I was the only one in my friend group from West Virginia and that there wasn’t a lot of rural representation,” she said. “A lot of my peers were from larger cities, so they weren’t prepared to go into their third year in terms of living in a rural neighborhood. Knowing how to survive in a rural area is one thing, but learning to interact with people who have centuries of ancestry there is another. To take my mind off studying, I got back to graphic design, a hobby of mine, and came up with these characters.”

Besides “Jack,” “Kiersten,” “Susanne” and “Hunter,” the simulation also included “Tamara,” a second-grade teacher who is part of the only black family in town; “Brooke,” a young pregnant woman who is estranged from her family; and “Ashton,” a nonbinary individual who is seeking gender-affirming care.

Each character deals with obstacles that mirror those of the real people Robinson used as models. “Jack,” who is functionally illiterate, is unable to read the materials given to him by emergency room staff. “Hunter,” who was incarcerated following a bar fight, is unable to obtain employment because of his arrest. “Kiersten” has been living with opioid use disorder since incurring a volleyball injury during high school, and she has no transportation, requiring her to walk to many of the locations in the simulation.

The students portraying these characters must complete activities of day-to-day life such as working, paying bills, shopping for groceries, caring for children and seeking treatment for health issues. Stations are set up representing workplaces, stores, banks, child care centers, hospitals, homeless shelters, police stations and social services agencies. In the simulation presented to first-year medical students, WVSOM employee volunteers took on the roles of workers at each station.

Katie Williams, Ph.D., WVSOM’s director of academic technology, portrayed an employer during the event. As students rushed around the room trying to complete their daily activities in the allotted time, she admonished those who were late: “You barely made it,” or “Why can’t you be here on time?”

“We’re trying to create situations that our students’ future patients might feasibly have encountered,” Williams said. “Some of the characters have very low-wage jobs, and there are stigmas attached to that. It’s a realistic experience in that if you’re late for work, it’s going to cause problems. Or what happens if you can’t come to work multiple weeks in a row? Some patients experience things that require them to prioritize and say, ‘Do I even try to go to work today?’”

The simulation makes aspiring physicians aware of the tradeoffs that are sometimes forced on patients in rural or low-wage areas. At the grocery store, students can choose to buy either “nutritious” food, at a high cost, or “non-nutritious” food, which is less expensive but causes health problems for their children or themselves. Those without transportation might have to shop at the convenience store, which is closer than the grocery store but is more expensive and offers foods that are less healthful.

Each student receives a set of “luck of the draw” cards that can trigger unexpected setbacks in their attempts to complete daily activities. Their car might break down or their child could have an illness, causing them to miss work. Or they might have a health emergency requiring a costly ambulance ride.

Robinson said the activity is intended to immerse students in the lives of patients similar to those they will treat if they become physicians in rural Appalachia.

“The best thing about the simulation is that you’re really able to step into the shoes of these characters. You’re Jack for an hour, and you have to try to make it through life as a coal miner. I hope it’s an eye-opening experience,” she said.

INCLUSION IN THE CURRICULUM

WVSOM’s faculty and administration spent several years developing a new curriculum for first- and second-year osteopathic medical students. The “Finding Health” curriculum — named for a quote by Andrew Taylor Still, D.O., the founder of osteopathic medicine, who once wrote, “To find health should be the object of the doctor; anyone can find disease” — includes a focus on wellness, nutrition, exercise, lifestyle and preventive medicine, while also incorporating a Justice, Equity, Diversity and Inclusion (JEDI) thread.

When the new curriculum was rolled out to WVSOM’s incoming Class of 2028 in late July, Robinson’s simulation was part of it, concluding a week of orientation activities. Robinson, on break from fourth-year rotations in the Elkins and Buckhannon area, returned to the school’s Lewisburg campus to lead the activity with Eleazer. The simulation was funded in part by WVSOM’s Rural Health Initiative program, through a grant from West Virginia’s Higher Education Policy Commission.

Robinson first presented the simulation to her fellow students during an extracurricular event in April 2023 that was sponsored in part by WVSOM’s Center for Rural and Community Health. Eleazer said that after those in charge of the school’s curriculum saw the simulation, they decided it should become a mandatory part of students’ coursework, given that rural primary care is a stated focus of the school’s mission.

“Once we heard about this activity designed by one of our own students, we knew we needed to work with her on incorporating it into the curriculum,” she said. “We believe this experience will set the tone for a lifelong journey of providing high-quality care and empathy to patients from all walks of life.”

WVSOM was already teaching medical students the social determinants of health, but Eleazer said Robinson’s simulation allowed for a firsthand look at some of the challenges some Appalachian patients face.

“We’ve always done a good job of teaching the humanistic aspects of health care, including rural health care and health inequities. But the new curriculum allows us to work together to organize and streamline content to build students’ knowledge and skill set over their four years with us. We’ve always had lectures dedicated to rural communities, but now we are providing even more opportunities for students to learn to address these barriers.” Eleazer said.

THE STUDENT EXPERIENCE

Following the activity, Eleazer and Robinson led a debriefing session in which students described what they’d just experienced. One student said the simulation pointed out how inaccessible social services can be to people who are in need of help.

“My character was racing to the bank to pay bills after work, and it made me think about when I was applying for Medicaid, which is something I had to do in real life. I had to call them before 5 p.m., but many days I wasn’t free until after five, so it was hard to find 10 minutes to call. The simulation reminded me that even though services might be available, you may not be able to get them because you’re struggling with time limitations,” he said.

Another student, in the role of “Kiersten,” the young opioid user whose abusive boyfriend kept her in the throes of addiction, said he learned how easy it is to spiral down a path that offers little hope of a way out.

“You’d get sick and then you couldn’t go to work, so you’d have to go the homeless shelter because you couldn’t afford your home anymore. You had to steal food just to survive. It snowballed quickly, because once you’re in a place of economic disadvantage, it’s hard to get out,” the student said.

Dana Engram, a student who recently arrived at WVSOM from Brooklyn, N.Y., portrayed “Susanne,” the retiree forced to raise two grandchildren because her daughter is suffering from heroin addiction.

“It was a great experience, because it made me see some of the difficulties and challenges residents of rural areas have to deal with,” Engram said. “Playing the role of someone who’s worried about paying bills and trying to maintain the welfare of children made it feel real. I learned that you have to make impossible choices.Sometimes you end up overlooking your own health to take care of your family,” he said.

In his rush to complete more required activities than time allowed, Engram could be seen racing around the room carrying Susanne’s grandchildren — dolls, for the purposes of the simulation — by their feet. Child protective services eventually removed the infants from his custody.

“I was hustling to get them to day care on time, and I did the wrong thing by carrying them upside down,” Engram said. “They’re in the foster care system now, but I’m going to get them back.”

A PROVEN TEACHING METHOD

Robinson has presented research showing that her simulation is beneficial in communicating the social determinants of health at the West Virginia Rural Health Association Conference and the American Association of Colleges of Osteopathic Medicine Educating Leaders Conference. Her research is based on data from pre-activity and post-activity surveys that asked students to recall specific pieces of information they’d learned.

In addition to quantitative research, Robinson collected anecdotal data from medical students who experienced the simulation. One student wrote, anonymously, “I have always known that I want to stay within the state to work as a physician, but this has empowered me even more to work harder so I can be the doctor the people of Appalachia deserve.”

Rebecca Thacker, who helped implement the activity as program director of WVSOM’s Rural Health Initiative, pointed out that the simulation is not meant to paint Appalachians in a negative light, and that not all residents of the region are living with the circumstances the activity uses as examples of potential patients.

“These characters are not intended to stereotype Appalachians or West Virginians. Instead, they highlight the impact of social determinants on health care outcomes,” Thacker said. “Our goal is to cultivate providers who are aware of how social factors influence health and access to care, enabling them to deliver more compassionate and equitable care to diverse populations.”

Still, Robinson said it’s important for WVSOM’s medical students to learn to pay attention to the stories behind the illnesses they see in patients. It’s part of the “whole person” philosophy that underpins osteopathic medicine.

“Once we’re working in the hospital, we aren’t seeing somebody who has diabetes or cardiovascular disease. We’re seeing Tom, who can’t afford his medications or has trouble cooking healthy meals. And that’s why I chose osteopathic medicine, because osteopathic physicians have been thinking that way forever — treating the person, not just the disease,” she said.

As she begins her final year of medical school, Robinson said she’s proud of the legacy she’s leaving in playing a role in the way WVSOM instructs students on the social determinants of health.

“This simulation is my baby,” she said. “Now that it’s part of the curriculum, I’m excited it’s going to live on past me after I graduate and go off to residency.”

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