Hands-on for health equity: simulation and spaced reflection in graduate medical education

To advance health equity, residents need preparation to address structural contributors to disparities and mitigate bias in clinical decision-making. Experiential learning around health equity, however, is lacking, and specialty-specific interventions often fail to reflect the interdisciplinary nature of clinical practice. This report describes an institution-wide longitudinal simulation-based health equity educational intervention for first-year residents, comprising experiential education on structural determinants of health (SDOH) and spaced reflection opportunities.

In 2024, first-year residents from all specialties at one academic medical center participated in two simulated encounters with standardized patients (SPs), followed by SP feedback, individual narrative reflection, and group debriefing, which leveraged visual arts-based exercises to generate dialogue. Three to six months later, residents reviewed recordings of their encounters and completed a semi-structured metacognitive activity. Surveys conducted before, immediately after, and 3-6 months after the simulations captured self-reported impacts on decision-making and communication in clinical encounters, understanding SDOH, and performance on the Multidimensional Cultural Humility Scale, which measures dimensions of intercultural interactions (eg, openness, self-awareness).

Of 235 eligible residents, 216 participated. One hundred sixty-four, 116, and 130 consented to have their pre-, immediate post-, and interval- (3-6 months post) responses included for analysis. 99.1% (115) found programming quality to be high. Immediately after simulation experiences, there was a statistically significant improvement in participants' cultural humility and confidence in addressing stigmatizing language, bias, and SDOH during patient encounters; communicating with diverse patients; and advocating for patients. At interval follow-up, most improvements were sustained; nearly 70% (89) found the experience had impacted their patient interactions.

Next steps include offering advanced iterations of this experience to senior residents. Other institutions may replicate this activity with cases tailored to site-specific patient populations to give learners opportunities to practice equity-focused skills and signal organizational commitment to meeting their patient populations' needs.