Screening for social determinants of health (SDOH) during medical visits has been recommended by hospital payers and is currently adopted by many health systems. 1–4 Medical education primarily focuses on identification and treatment of disease at the individual level. Thus, generally trainees are ill equipped to address SDOH and are led to believe they are beyond the scope of clinical practice. The Association of American Medical Colleges has acknowledged the importance of training future physicians to address SDOH. 5 Efforts to integrate SDOH education to improve students’ knowledge and attitudes range from single didactic sessions to service learning opportunities. 6–8 There has been little education focused on developing the capabilities of medical students to address SDOH.
Despite evidence supporting the use of interprofessional education (IPE), formal curriculum opportunities for health professions students to learn collaboratively are lacking. 9 Barriers for IPE include logistical problems (location of campuses, scheduling issues, etc.) and challenges to create experiences resembling clinical settings. As a discipline, social work (SW) possesses understanding of the complexity of chronic conditions and the range of determinants of health and is rooted in community engagement and empowerment. 10 Collaborating with social work students may advance medical student preparation to address SDOH and allow SW students to engage in IPE training experiences with medical professionals.
Digital education, the act of learning by means of digital technology such as virtual reality (VR), is an option for addressing some challenges to IPE we described above. VR is a computer-generated representation of a real or artificial environment that allows for a first-person active-learning experience. VR can be used to create opportunities for students across disciplines and geographic locations to practice sensitive scenarios and to increase empathy among team members. 11,12 Immersive VR requires the user to put on a VR headset to feel like they are inside the environment. 13 A study using VR to teach residents how to counsel patients about vaccines was rated as equally effective as standardized patient encounters. 14 VR can elicit emotions, including empathy toward a person experiencing adverse social conditions, comparable to those experienced in real human relationships, and has been shown to promote interprofessional collaboration. 15
Therefore, we hypothesized that an interprofessional learning experience using an immersive VR environment, where students could collaboratively grapple with clinical scenarios addressing SDOH, would serve as a feasible and acceptable method for engaging students in collaborative problem solving with diverse health care professions students to address SDOH.
Students from Boston University health professions education schools participated in the learning experience encompassing web-based video conferences and an immersive VR simulated learning environment (SLE) in January 2020. Participation was voluntary and students self-selected in response to advertising across programs. The Boston University Medical Campus institutional review board determined the study qualified for an exemption.
Web-based video conferences
Students participated in three 60-minute Zoom video conferences facilitated by medical and social work faculty in preparation for the VR SLE. Topics were health equity and the SDOH, health care delivery systems, team-based models of care, and SDOH screening using THRIVE, a screening tool that explores homelessness, housing insecurity, food insecurity, inability to afford medications, lack of transportation to medical appointments, utilities, caregiving, unemployment, and educational aspirations. 2 Sessions involved small-group discussions, role plays, and case examples.
The immersive virtual learning environment
The VR SLE was developed by an interprofessional group of faculty, with financial support from the Digital Learning & Innovation Office at Boston University. The group partnered with a VR company, Immersive Health Group, to build a role-play simulation consisting of 2 virtual environments developed using the Unity Technologies Game Engine.
Student dyads participated in an immersive VR session. During the session, students engaged with 2 virtual environments. The first mirrors an inpatient medical room and served as the location where students interacted with the patient, who was being role played by the faculty. The second mirrors a work room and provided space for students to collaboratively develop a care plan. Students accessed the virtual environments using the Oculus Quest head mounted display. At the start of the exercise, medical degree (MD), physician assistant (PA), and SW students were located at 2 different campuses, 3 miles away.
To begin, students received a handout explaining the goal of the experience, their role (MD, PA, or SW), the case presentation (Box 1), and a brief orientation on using the device. While wearing the headset, students accessed the virtual environment, chose their role and physical characteristics, and entered the simulation.
The VR SLE session began with the MD or PA student entering the first virtual environment (inpatient room). Here, they met the patient and explored social factors impacting their patient’s health (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B294). Then, the student moved to the second environment (work room) where they consulted with the SW student. After discussing the case, they rejoined the patient together (see Supplemental Digital Appendix 2, at https://links.lww.com/ACADMED/B294). The SW student explores the patient’s concerns and psychosocial history in greater depth to understand and address the SDOH. Then, students connect the patient with resources and discuss the care plan and next steps. Subsequently, all students debrief their experiences with a faculty member that uses a semistructured debrief guide (see Supplemental Digital Appendix 3, at https://links.lww.com/ACADMED/B294). A video showing a VR SLE and interactions can be accessed here: https://mymedia.bu.edu/media/+SDOH_2_25_20/1_xxmxzpu3.
To determine the feasibility, acceptability, and perceived impact on students’ learning toward addressing SDOH, we developed and conducted a postsurvey and focus group (see Supplemental Digital Appendix 2, at https://links.lww.com/ACADMED/B294). In addition, we debriefed with students immediately following the sessions.
We sent the voluntary postsurvey, which assessed the educational value of the experience, via email. We coded answers to open-ended questions from the postsurvey and analyzed them thematically. 16
Additionally, all students were invited to participate in a 45-minute Zoom focus group to reflect on the learning experience and how the course impacted thinking about SDOH, their understanding of their own role and roles of other team members in addressing patient’s social needs, and opportunities for future interprofessional collaboration. A neutral facilitator explained the group purpose and administered consent. The facilitator used a semistructured guide to probe participant experiences. We audio-recorded and transcribed the focus group. Thematic analysis, 16 which includes reading the transcript multiple times and developing initial codes, yielded 5 themes.
Eight immersive VR SLE sessions were held, and each session included 1 MD or PA student, 1 SW student, and 1 faculty facilitator. Fifteen students (MD n = 5, PA n = 3, SW n = 7) participated in the learning experience. Of the 15, 10 participated in the focus group and 13 participated in the survey (MD n = 5, PA n = 3, SW n = 5). Themes from the focus groups and survey responses were aligned.
Throughout the student responses, collaboration and the desire to work together in an interprofessional team emerged. SW students talked about the lack of holistic approach in MD and PA training and the importance of collaboration. MD students appreciated the value SW students brought to the team and stated SW students were integral in gathering information MD students had not previously considered when interacting with patients. PA students were interested in how to make the collaboration work on care teams in the real world given the well-documented hierarchy in health care settings. MD and PA students both described collaboration between professions as the most valuable aspect of the experience. Further, MD and PA students alike both mentioned better understanding the role of social work professionals in the health care team. SW students realized that they know more than they give themselves credit for, wanted to collaborate and were surprised by how little training MD and PA students had in practicing medicine considering SDOH. Excerpts illustrating key themes can be seen in Table 1.
Focus group results
Five key themes emerged (see Table 2). First, participating in the VR SLE provided an opportunity for collaboration and mutual support and helped MD, PA, and SW students better understand and appreciate each other’s roles. Second, students appreciated learning from one another. MD and PA students appreciated the depth of SW student assessment questions tailored to the patient’s individual needs and presentation. Third, SW as well as MD and PA students commented on the ease of connecting virtually given the geographic distance between their 2 campuses and noted how the virtual connections emulated real-life encounters. Fourth, students thought longitudinal IPE experiences might be helpful in addressing hierarchies in the medical system, which often inhibit collaboration and shared patient care decision making. Finally, students wanted more interaction, both virtually and in person. They also shared constructive feedback for modifying and expanding the course.
We found an immersive VR simulation was an acceptable format for practicing collaboration and problem solving to address SDOH. The benefits of team-based education in health care settings are well established, 11,17,18 and like others, we found MD, PA, and SW students appreciated the opportunity to collaborate and learn about each discipline’s role and to practice patient engagement and assessment skills.
Students appreciated being able to connect across different campuses and immerse themselves in the safety of the virtual environment. Herrera and colleagues 19 and Kuehn 12 speak to the freedom students often experience in virtual settings where they can develop their sense of professional self and adopt new perspectives while addressing patients’ needs in the structure of the virtual setting. 12,19
SW and MD students also appreciated learning from each other and observing how each discipline approached patient care. Previous research addresses the power structures and dynamics in medical settings that can leave social work professionals feeling devalued and impede meaningful collaboration among team members in patient care. 20,21 However, in our study, students across disciplines were navigating the patient interaction together and the collaboration in the virtual environment helped to level these existing power hierarchies. SW students felt both valued and appreciated by their peers and assumed a leadership role modeling complex and nuanced assessment skills used to explore patients’ SDOH needs and available community resources.
MD and PA students recognized that further expanding SW skills and topics would have a positive impact on interprofessional collaboration. Future iterations should include more information about how to identify patients with social needs.
Although we did not experience challenges associated with technological literacy, delays due to software glitches were present. However, they did not impede implementation of the pilot. Our experience with few barriers may be the direct result of partnering with the information technology department, which provided assistance to students and faculty during the sessions. VR accessibility in terms of development cost and hardware varies and can represent a limiting factor. For this pilot, the total budget to develop the VR SLE was $21,000 and the Oculus headsets and accessories totaled $5,000. It is important to note that the cost of development can vary significantly depending on the company, software being used, or opportunities to partner with the companies developing the software. Additionally, the increase in adoption of VR during the COVID-19 pandemic has resulted in VR head mounted displays becoming more inexpensive, allowing for increasing equity and access to education across institutions with less financial resources. 22
This pilot study was not without limitations. There were limited opportunities for participants to practice with the VR headsets and debrief with faculty about the VR experience. Because students self-selected into the study, bias was likely introduced and the small sample impacted the generalizability of our findings. We did not evaluate presence of implicit bias during the learning experience and the long-term impact of the study is unknown. Nonetheless, this pilot was an important step toward understanding the acceptability and feasibility of VR and interprofessional learning. Future research might seek to examine the cost-effectiveness of VR SLE while further exploring the acceptability, feasibility, and learning outcomes.
VR SLE can connect students across programmatic and geographic boundaries and provide a live platform to teach applied SDOH content. VR SLE created a slower, less pressured learning environment for students to collaborate and learn from one another while honing patient engagement and SODH assessment skills. SW, PA, and MD students developed collaborative working relationships and an appreciation for the unique skills, training, and knowledge each discipline brings to patient care.
Box 1 Patient Summary Used in a Virtual Reality Simulated Learning Environment Exercise to Teach Social Determinants of Health Content to Interprofessional Students, Boston University, 2020
A middle-aged patient with a history of hypertension, coronary artery disease, and heart failure with reduced ejection fraction presents to the emergency department with headache and shortness of breath. The patient is diagnosed with hypertensive emergency and acute heart failure exacerbation. The patient is started back on antihypertensive medications and intravenous diuresis is initiated. The patient is admitted to the inpatient general internal medicine unit to continue the management of hypertension and heart failure. Further history obtained by the inpatient team during rounds indicates that the patient has been unable to take his medications at home, and this has likely led to the current admission for heart failure exacerbation in the setting of uncontrolled hypertension. The social work and medical providers want to better understand the reasons behind the difficulty getting medications, and therefore decide to explore contextual factors that could be having an impact on health. To start the conversation, you as the medical or social work provider will build rapport with the patient by sharing that sometimes there are things beyond our control that get in the way of our ability to be well. You will use the THRIVE screening tool to screen the patient for adverse social factors so that you can then help link the patient to resources that will support health and well-being.
Abbreviation: THRIVE, a screening tool that explores homelessness, housing insecurity, food insecurity, inability to afford medications, lack of transportation to medical appointments, utilities, caregiving, unemployment, and educational aspirations [not an acronym].
The authors wish to thank participating students for their openness to engaging in the course and with each other as well as for their candid feedback.
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