Addressing social determinants of health in anaesthesiology: a series of simulation cases for resident trainees

Abstract

Background

Social determinants of health (SDH), non-medical factors that shape health and care access, play a critical role in perioperative safety and surgical outcomes. However, anaesthesiology residency programmes often lack structured training on communicating about and addressing SDH during routine clinical encounters. We developed a simulation-based curriculum to enhance anaesthesiology trainees’ preparedness in recognising and responding to SDH-related challenges in perioperative care.

Methods

An educational intervention consisting of three simulated perioperative case scenarios was integrated into an existing residency training course. Standardised patients were used to recreate realistic social and clinical challenges encountered in preoperative clinic, obstetric and paediatric settings. Sessions were followed by facilitated debriefings including the acting resident, observing peers, and a simulation faculty member to reflect on performance and key learning points. Post-simulation surveys assessed residents’ perceived confidence, communication skills and awareness of institutional support resources related to SDH. Quantitative responses were summarised using descriptive statistics, and open-ended items elicited qualitative feedback.

Results

42 anaesthesiology residents participated in this pilot. Following the intervention, residents reported increased confidence engaging patients and caregivers in discussions about social needs, improved familiarity with resource pathways such as social work and care coordination, and improved preparedness for sensitive conversations. Participants described the scenarios as authentic, relevant to clinical practice and valuable for observing peer communication approaches.

Conclusions

This pilot project suggests that simulation may be a feasible and acceptable approach for introducing SDH-focused communication training in anaesthesiology education. Integrating realistic scenarios into perioperative curricula may help residents develop skills needed to identify social barriers and collaborate with interdisciplinary partners to promote equitable care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Social determinants of health (SDH) significantly influence perioperative outcomes, yet anaesthesiology training programmes often lack structured education on addressing SDH in clinical care.

WHAT THIS STUDY ADDS

• This pilot study demonstrates that a simulation-based curriculum is a feasible and well-received approach to improving anaesthesiology residents’ confidence, communication skills and awareness of institutional resources for addressing SDH.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• These findings support the integration of SDH-focused simulation into anaesthesiology training and highlight the need for further studies evaluating its impact on clinical practice and patient outcomes.

Introduction

Healthcare disparities remain a well-documented and persistent challenge across medicine. In anaesthesiology, consistent evidence has demonstrated racial and ethnic inequities in multiple domains of care, including differential use of general anaesthesia for caesarean delivery, variation in perioperative pain management, and disproportionate postoperative morbidity and mortality in paediatric patients.¹,⁴ These inequities highlight how social and structural factors can influence perioperative outcomes even when clinical care pathways appear standardised.

Recognising and addressing the social determinants of health (SDH), non-medical factors such as socioeconomic status, education, environment and access to care, that contribute to delayed surgical readiness, limited access to perioperative optimisation and adverse recovery is essential for promoting equitable care delivery. However, despite increasing attention to health disparities within the specialty, anaesthesiology residency education rarely provides structured training on addressing SDH in clinical care.⁵,⁷ As a result, trainees often lack experience navigating these complex conversations, particularly in the perioperative setting.

Simulation offers an effective educational strategy for preparing clinicians to address SDH-related challenges in patient care. Growing evidence supports the incorporation of simulation within SDH curricula, with learners frequently reporting greater engagement and satisfaction with interactive experiences compared with lecture-based or self-directed learning.⁸,¹⁰ By allowing residents to rehearse complex communication, navigate system barriers and coordinate care in realistic scenarios, simulation promotes active engagement and strengthens both knowledge retention and skill development.¹¹

To address this training gap, we developed a formative simulation-based curriculum for anaesthesiology residents featuring three specialty-relevant encounters situated in preoperative clinic, obstetric and paediatric perioperative settings. Each case highlighted a distinct SDH-related challenge commonly encountered in practice and emphasised the anaesthesiologist’s role in identifying unmet social needs and activating available institutional resources to support safe and equitable care. This pilot study evaluated the perceived impact of the intervention on resident preparedness and confidence in addressing SDH during perioperative clinical encounters. To our knowledge, there are no published simulations to date that specifically address SDH for anaesthesiology trainees. As the first iteration of this curriculum, this study was primarily designed to evaluate feasibility and educational value.

Methods

This was a prospective study of a simulation-based educational intervention conducted at Duke University Hospital from 2024 to 2025. The curriculum was implemented as a new component of an existing all-day crisis resource management course for anaesthesiology residents. Case topics were developed with input from faculty experienced in addressing SDH and reflected commonly encountered perioperative challenges for diverse patient populations. The Institutional Review Board determined the pilot project to be exempt from formal review as it was an educational study without any patient or participant information involved. All survey data were collected anonymously. Patients and the public were not involved in this study, as it evaluated a simulation-based educational intervention for anaesthesiology residents and did not involve patient care or patient outcomes.

Setting and participants

Participants included post-graduate year 3 (CA-2) anaesthesiology residents enrolled in the simulation course. Each simulation session involved one resident as the primary learner interacting with a standardised patient portraying either a caregiver or patient. Up to 4–5 other residents observed remotely and participated in a debrief session following the case. Simulation faculty facilitated the sessions and were selected based on familiarity with SDH and institutional support resources.

Intervention design

At the start of the day, learners were told that performance during simulations and the related debriefing sessions are confidential to provide a safe learning environment. Each scenario included pre-determined learning objectives to guide discussion and learning (table 1). The facilitation guide used for each simulation, including a scenario summary, standardised patient script and relevant information provided to the learner, can be found in the Extended data. Simulation materials were developed using a standardised simulation template published by MedEdPORTAL, a peer-reviewed repository for medical education resources.¹² Full simulation materials can be found in online supplemental file 1. Encounters lasted approximately 30 min and were broadcast in real time to an adjacent classroom via secure video feed. Observing residents noted key communication strategies and areas of strengths and weaknesses.

Table 1. Case settings and learning objectives.

Case setting	Learning objectives
Preoperative testing clinic	Discuss barriers to receiving care and solutions to obtain necessary medications with patient through comforting and open communication. Engage patient in conversation regarding available resources. Demonstrate empathy for patient’s financial and emotional concerns. Use medical terminology that is appropriate for the patient’s level of understanding.
Obstetrics	Recognise the broad differential diagnosis that exists for headaches in a peripartum patient. Identify the risk factors for intimate partner violence in the peripartum period. Performing a screening for intimate partner violence. Communicate resources available to patients to help in exiting intimate partner violence situations.
Paediatrics	Perform a comprehensive preoperative risk assessment for a paediatric patient with a history of nutritional deficiencies and underlying chronic conditions. Demonstrate effective communication skills with caregivers, addressing cultural, socioeconomic and logistical barriers to care. Recognise the importance of multidisciplinary care in optimising outcomes for medically complex patients. Understand and apply principles of informed consent, including the nuances of obtaining consent from a legal guardian.

The intervention concluded with a large group debrief including the patient actor, resident, observers and a simulation facilitator. Simulation facilitators were provided with a standardised debrief guide (online supplemental file 2) to promote consistency across groups while tailoring resource discussions to each case scenario.

Following the simulation, residents completed a post-implementation survey assessing perceived confidence, preparedness and awareness of SDH-related resources. The survey remained accessible indefinitely after the simulation, and completion was entirely voluntary. The survey included six closed-ended questions using four-point or five-point Likert-type scales written by three faculty members after discussion and consensus, in the absence of a targeted, externally validated assessment tool. Two open-ended questions eliciting qualitative feedback were included in the survey and analysed using descriptive statistics. Qualitative responses to open-ended questions were independently reviewed by three members of the study team using a modified immersion-crystallisation approach.¹³ This process involved independent review of resident responses with close attention to recurrent words, phrases and themes. Each reviewer identified up to six most frequently observed themes and then met together to identify the four most common themes. Afterwards, representative quotes or phrases were extracted to illustrate the underlying perspectives reflected in resident responses.

Results

A total of 42 residents participated in the study. To maintain respondent anonymity, no demographic information was collected. All residents were CA-2 level anaesthesiology residents at Duke University Hospital. Each of the three simulation cases—paediatrics, obstetrics and pre-anaesthesia testing clinic—was run three separate times during a protected simulation education day for CA-2 anaesthesiology residents, focused on challenging clinical and interpersonal situations. Three faculty members were involved in facilitating sessions, each leading one simulation case. In advance of the sessions, faculty were provided with comprehensive case materials, including simulation case summaries and debriefing guides. These resources supported consistent facilitation and enabled faculty to guide case-specific discussions around communication, informed consent and social complexity. While these cases have not yet been used at other institutions, they were designed to be broadly generalisable and easily adapted to other residency programmes.

Post-implementation surveys were completed by all 42 participants, and assessed learner reactions and perceived gains in knowledge and communication skills related to SDH. All respondents either ‘somewhat’ or ‘strongly agreed’ that SDH are relevant to anaesthesiology, influence the way they care for patients and that additional training would make them better anaesthesiologists (figure 1). Learners reported feeling more prepared to speak with patients about SDH and more familiar with institutional resources at their institution, such as care coordination services and social work support for preoperative optimisation and intimate partner violence support. Free-text responses emphasised gains in empathy, confidence initiating difficult conversations and the value of observing peer communication strategies. Representative comments included: “I learned how to talk about financial concerns with patients while being empathetic and neutral,” and “I learned effective ways to communicate and appreciate social determinants and ways to navigate through them from the anesthesia standpoint” (table 2). Learners also expressed interest in additional scenarios and noted that the inclusion of realistic institutional resources improved the applicability of the simulation.

Figure 1. Post-simulation resident perspective survey data. SDH, social determinants of health.

Table 2. Representative resident quotes from post-simulation survey.

Theme	Representative quote
Resource awareness & empowerment	“I learned how I can access resources for my patient through Duke via DukeWell* to help them in the peri-op space and beyond. I wasn’t sure how to access these resources before this simulation.”
	“I learned about social work resources available in the Duke system via DukeWell and the PASS† clinic social worker.”
	“(I learned))About the resources available at Duke for patients under financial constraints (eg, Duke Well).”
	“(I learned))Specific local resources for domestic violence.”
	“Continue to make residents aware of resources Duke has to offer so we can be empowered to help patients in different SDH situations.”
Communication in difficult conversations	“(I learned))how to talk specifically about financial concerns with patients while being empathetic and neutral.”
	“(I learned))phrases to bring up a sensitive topic in a nonjudgmental way.”
	“The phrases provided in the pamphlet are helpful guides on how to approach difficult conversations.”
	“Watching one of my colleagues model some difficult conversations helped me learn new techniques for my future difficult conversations.”
	“Provide instruction or examples on how to navigate difficult conversations regarding race/culture/ethnicity.”
Empathy & self-reflection	“It’s easy to be focused on turnover and being efficient with cases, but it’s important to listen to patients and hear what they truly want to communicate.”
	“(I learned))the importance of asking open ended questions to gain a better understanding of each patient’s social and home situation to better understand their goals and concerns.”
	“Not being afraid to bring up hard conversations and topics, not making assumptions about a patient’s background.”
	“Things are always deeper than appear on surface.”
	“Social determinants greatly influence the care we provide.”
Practical application and curriculum development	“I think more scenarios relevant to anesthesia outside of PASS clinic is useful — navigating language barriers with interpreters, talking to people with poor health literacy about epidurals or anesthesia in general, etc.”
	“Continue to show us different SDOH scenarios!”
	“Including more sessions, and scenarios so that we are more comfortable and experienced with approaching them.”
	“It would be helpful to have our real-life patient interactions observed by third parties with feedback after.”
	“Give us a link to resources we can provide to patients.”

^*DukeWell is a Duke University programme providing care coordination and support services for medical and social needs, including preventive wellness, pharmacy support, care transitions and assistance with health-related social needs.

^†PASS Clinic, Preoperative Anesthesia and Surgical Screening Clinic.

SDH, social determinants of health.

Pilot implementation revealed minimal logistical challenges. Some learners expressed a desire for additional clinical and social context regarding the patient’s background prior to entering the simulation. In response, we updated the pre-encounter materials to include a more detailed case summary and relevant history, which helped better orient learners and support more focused and effective encounters. Other learners suggested incorporating time constraints to better reflect clinic environments and increasing background context for certain scenarios.

Discussion

This pilot simulation curriculum successfully provided anaesthesiology residents with structured opportunities to practice identifying and addressing SDH during routine perioperative encounters. Learners reported increased confidence communicating with patients and caregivers about social needs and recognised the relevance of SDH to anaesthetic planning and perioperative risk. Qualitative feedback particularly valued that the scenarios were realistic and useful for translating conceptual knowledge into clinical practice. These findings align with prior research showing that simulation-based learning enhances communication and collaboration skills relevant to patient care.¹⁴

Key design elements contributed to the educational value of the curriculum. The use of standardised patients allowed for controlled yet emotionally complex interactions and facilitated debriefing supported reflection on communication strategies and resource activation. Learner feedback highlighted the benefit of institutional resource awareness and affirmed the educational value of SDH integration into anaesthesiology training. This simulation series was designed to complement an existing self-directed health equity curriculum implemented during the chronic pain rotation for anaesthesiology residents at our institution. That parallel curriculum focuses on foundational concepts through readings, bias assessments and reflection. The simulation adds an active learning component, allowing residents to apply those concepts in real-time clinical encounters that provides an opportunity for further independent learning.

This study has several limitations. As a pilot feasibility study, its primary aim was to evaluate need and practicality, rather than to provide a comprehensive outcomes-based assessment of the intervention. Evaluation relied on learner perceptions and self-reported learning and did not assess a change in resident behaviour or patient outcomes. The post-intervention survey was not externally validated; however, items were developed through iterative discussion among faculty, providing a degree of internal validity. Additionally, the study design did not collect pre-intervention attitudes or confidence measures, which limits the ability to quantify changes attributable to the curriculum. While verbal faculty feedback was provided to residents following each simulation, more formal written assessment of both learner performance and the intervention should be incorporated in future studies. Further, resident performance may have been influenced by the awareness of observation by faculty and peers during the simulation, reflecting a potential Hawthorne effect. The study attempted to mitigate this by emphasising the non-evaluative, educational nature of the simulation. The intervention was implemented at a single institution with a small sample size (n=42), which may affect generalisability. As standardised patient simulations are resource-intensive, scalability may be limited to programmes with sufficient infrastructure to sustain such a curriculum. Finally, local resource knowledge may not directly translate to other settings; however, the core communication frameworks and ethical decision-making strategies are broadly applicable.

Future work should expand assessment strategies to include observation-based measures and longitudinal follow-up to determine whether skills practised in simulation translate into improved clinical performance and patient experience. More rigorous evaluation approaches, including the use of validated survey instruments and more formal faculty evaluation, should be incorporated to better assess the effectiveness of the intervention. In response to feedback, future studies will plan to refine scenario complexity, simulate real-world time pressures and add diversity in cases including expanded topics such as language barriers, health literacy and immigration-related stressors. We are also developing a comprehensive list of patient support resources—available both online and in print—for distribution at key sites where anaesthesiology residents work such as the pre-anaesthesia testing clinic, pain clinic and perioperative areas. As departments increasingly seek to address disparities in surgical care, this simulation model offers a feasible and adaptable approach for integrating SDH education into anaesthesiology training.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.