Impact of social pediatrics rotation on residents’ understanding of social determinants of health

Figures & data

Figure 1. Categories Generated.

Table 1. Findings: Saturated Categories from Reflections and Interviews

Categories	Direct quotations from Interviews	Direct quotations from Reflections
Judgment/Bias	‘I did find myself surprised sometimes when all we had was a well baby visit and it was actually a well baby … So I would walk into half these appointments going, “Okay, what’s the catch? What’s the catch?” But sometimes it actually just was a cute, well baby.’ (Interview 2) ‘I think there’s a lot of biases that come out. I, for example, in that teaching session that I had, I went in with this bias that it was going to be hard, because I was coming in with a different colour of skin and a different background and a different language … But all of those things also come from the other side. I think they probably had feelings of, it could be either direction. Like, “Oh she’s going to tell us what to do or think she’s better.” It would also be like, “I’m really nervous, she’s going to judge us.”’ (Interview 6) ‘But there’s so many different things that I think from a bias standpoint that we bring in, that you have to actively work to overcome, which is too bad. I wish, I’m hopeful for one day that that’s not the case. I think there’s a lot of biases that we bring in, probably that they bring in too. But I think as a healthcare provider, it’s your job to be the one who actively takes that role of overcoming this and helping lay the groundwork for them [the patient] to feel comfortable.’ (Interview 6) ‘But I think that experience has just kind of given you that reminder, even when I am frustrated or finding it difficult, to really think about where this patient is at and to kind of try and recognize if there’s a bias for some reason or I’m judging somebody and to take that out of the equation to make sure that they’re getting the care that they should be getting, if that makes sense.’ (Interview 5)	‘I thought that there was no way this mother could cope with life, especially that she was a single mother who did not speak English. I felt sorry for this family and desperate at the same time because I thought that no service or support would help them to manage their life.’ (Reflection 22)
Systemic challenges	‘Yeah, just coming back to X community, the healthcare system is not meeting the needs of that community. I think it’s horribly under-resourced … It’s shocking that there’s two physicians servicing that large population with … high medical needs. I think, absolutely, the healthcare system’s failing on reserves. It’s not even a money problem, sometimes. A lot of it is recruiting.’ (Interview 1) ‘Through this rotation and through getting to know some families with many challenges, I am reminded how difficult it is to access services and how systems are not necessarily set up for people that they are meant to “help”. The bureaucracy and barriers that exist are a tremendously large and often insurmountable hurdle for patients and their families to overcome.’ (Interview 2) ‘I don’t think we do enough to help vulnerable populations, by a long shot. And I think for certain populations, we go out of our way to the point where I think it is harmful. I do think that, I remember having a super cynical thought; we had an Indigenous Awareness Week, a few months ago at the hospital. And as part of that, I remember someone coming around, “Oh here’s a cupcake” … and I was like, “Oh here’s like a bag of candy” or something like, we’re just celebrating and doing this. And I’m like, I remember cynically saying, “Is that all we could do?” Here’s a bag of candy for these patients. That’s not going to change what’s going on in terms of just trying to reverse everything that’s happening ever. Right. You know what I mean? I remember thinking, “What a weird gesture.” I just couldn’t process it. It’s just like, it’s nice, but it’s not enough.’ (Interview 10) ‘But I think for her, she made me view the system a little bit differently. The phrase that she used would be: the system offers “good enough care” as opposed to good care. So as long as it’s better than the situation they were in before, then that’s already a step up. Is that enough for our kids? Are we failing our kids by only saying like “Well it’s good enough,” as opposed to it being actually good? I don’t know the details about the system enough, but there are those kids where you’re like, why are they still … they’ve been here for two years, their parents don’t visit, how are they still the guardians? You have those situations where you feel there’s a bit of a disconnect between what maybe personally you feel should be happening with this child versus what the system is doing for the child.’ (Interview 4)	‘The system is really stacked against marginalized populations. Systemic racism, child protection services that are unable to protect every child, unstable foster homes, kinship arrangements that seem like a compromise to make the child a little bit “safer”. I think my previous assumption was that once you activate the system, good people would come in and make it right, but I now more clearly see that that isn’t always the case.’ (Reflection 19)
Need for advocacy	‘And then the day-to-day things that you can do as well are making sure that you advocate for your patients. So if they need services, that you don’t think they’re getting, then we have a powerful position to write letters on their behalf, talk to schools on their behalf, attend meetings on their behalf and work in a collaborative environment so that everyone’s on the same page.’ (Interview 9) ‘I think the thing that I really took away is that you can really make a big difference with advocacy, but then there were sometimes where no matter how much you advocated, the system wasn’t set up to be responsive to that, so you couldn’t necessarily make the changes that you want. But it’s still, unless you advocate, nothing is going to change.’ (Interview 4)	‘I realized that the interaction with this patient, or with any patient for that matter is not about my goals but about listening to the patient and their needs.’ (Reflection 16) ‘We must advocate for our patients by preventing trauma, treating trauma, ensuring food security, ensuring stable housing, etc. We need to actively work towards identifying those at risk and building resiliency in these patients. For me, this is my goal and commitment to my patients going forward.’ (Reflection 27)
Everyone is doing their best	‘I think there comes a point where you have to accept you’ve done everything you can and you set up follow-up and you do all these things to try and make the environment as safe as possible. But part of it, that’s where social peds comes in. Just because things are going to be different and not the way you want them to be, or expect them to be in every place. And so part of that is just the nature of this whole experience. So managing that as best as you possibly can.’ (Interview 6)	‘Though she had issues of her own, she was making strong efforts to prioritize the health of her child … She was providing consistent care for her child and, based on the child-mother interactions observed, they had a strong and loving bond.’ (Reflection 14)
Increased exposure and knowledge of specific populations and locations	‘I think a lot of us in the hospital, we’re so lucky to have all these people to help us figuring out resources, but not everyone is so privileged. And probably in those smaller communities, they might not have … we’re kind of right in the centre. Like we’re in a big city where if we needed things, it would probably be much easier than if you’re remote. I do think that part of this rotation, it’s really helpful to go to one of the smaller communities. Even just doing a trip to, I think they’re day trips to Cold Lake, but I really liked getting that time in High Level to realize these outreach clinics are kind of what a lot of people are depending on for their care.’ (Interview 4) ‘And seeing so many traumatized kids and so many kids in foster care coming in through that clinic as a proportion of the clinic was also really eye opening.’ (Interview 2) ‘Yeah, by giving us access to those clinics that we would never have seen. And then by being in those contexts, we get access to patients that we may never have seen in other clinics as well.’ (Interview 4) ‘And I know sometimes in clinics we skip over the, do they have coverage for medications, or for some First Nations kids, do they have treaty status? Are they covered by NIHB? But it makes such a huge difference if you can get them covered for Tylenol, Advil, get them put on an antibiotic that’s appropriate, that’s also covered. Get them put on a puffer that’s actually covered. So, that experience really made me think of that and go that extra step for my patients on CTUs (clinical teaching units), especially. Today, I learned how to write a prescription for Pampers. Who knew? But you can apparently get that covered as well.’ (Interview 2) “As I transition into practice, it’s more about being able to navigate resources and what’s out there that you can offer to these families and hopefully helping them improve their current conditions. And I think now the other thing I’ve learned is when you’re looking for resources, not just looking at the one that you think would be good for them, but having backup options. And saying, ‘if there’s three that they’re eligible for, I’m actually going to refer them to all three and whichever one comes first. And then you can cancel the other referrals.’ (Interview 7)
Increased understanding of SDoH on overall health	‘We talk about the living situation of patients in hospital a lot, and in pediatric clinic, but I think going to see it in person and getting to, not that it wasn’t real, but it makes it more … You can see the true extremes of how people live. So I think for me it was eye opening in the sense that I was like, how do people actually live like this, and have a sustainable life? How does this reflect other aspects of their life if they can’t even really take care of their home.’ (Interview 4) ‘Just the nature of it, unfortunately, the result of lots of systemic racism and drug abuse and multi-generational abuse and trauma that really does lead to kids having all of these blocks ahead of them that they have to overcome before they can even look at furthering some of their basic needs and their basic health.’ (Interview 8) ‘I think in general, anytime you work with anyone who has any barriers or notices any of the social determinants of health impacting their care, it reinforces that there are a lot of populations within Alberta that do have a lot of disparities and there is a kind of hierarchy. So we just have to be very mindful of ensuring that we can provide as equitable care as possible for our patients.’ (Interview 9)	‘You can read about the social determinants of health and see the list of ten things, but until you talk to a family and hear that they’re going back into hospital because they couldn’t afford $73.11, just really imprinted differently on your brain. So, taking that forward is about looking at each individual family, not just as a problem that I can look up on UpToDate, it’s a whole family is something that you need to find a treatment plan for.’ (Reflection 2)