If you are not a fish, how can you tell if the fish are happy? Chinese Proverb

Instead of the typical training on Social Determinants of Health – which tends to be about poverty and what patients need for resources – what if health care providers could experience how poverty changes the way they think? What if they could be fish?

This is the inspiration for the game, gettin’ by. The game puts the players into several types of scarcity – time, options, resources – at once. Resources include energy, family support, work flexibility (or rigidity), as well as money, though the game does not focus on budgeting. Players face real-life situations and have to make quick decisions. Unresolved problems pile up and resources dwindle as the game progresses. 

Modeled after social science lab experiments, the game forces players to “tunnel,” to focus their limited energy on the immediate situation. This same phenomenon happens to people living in poverty. The constant demands of life crowd out long-term, cost-benefit analyses. A crowded mental tunnel impairs the brain’s executive functioning and lowers a person’s IQ. 

Instead of teaching about poverty, the game shows students how they themselves would cope with scarcity and its effects on their brain. Each scenario in the game comes from sociologists, health scientists, and ethnographers. Scenarios touch upon everything from housing to health care, food insecurity to transportation. All were developed based upon research of the issues that low-income people face. Thus, players see real situations that patients have faced.

For example, one scenario is receiving a call from an emergency room nurse about recent visits for the child’s asthma. (Asthma is higher prevalence in low-income children than higher income children.) The player can spend the time and energy on the phone explaining why these visits were needed, and why visiting a primary care office was not feasible; this requires the player to have a time and energy asset available. Or, the player can hang up on the call. 

A physician playing the game drew this card and had no time and energy assets left on her game board. Though she could have left the situation “open” and hope she gained a time and energy asset in a future turn, she chose to hang up on the nurse.   

That physician will think differently about her patient who keeps going to the ER for a child’s asthma attacks – because she has seen the situation from an entirely different view. 

Sidebar: What Would You Do?

Your kid has flushed his ADHD medications down the toilet. Without them, he’s not allowed to attend his after-school program.


A) Call the doctor’s office and hope they’ll help you. The nurse has accused you of selling the pills, and this is not going to look good. (lose time/energy)

B) Ask your boss to reduce your hours so you can pick up your kid after school. (lose work/job + lose money/debt)

C) Line up someone else to take care of your kid every day after school until it is time to refill the prescription. (lose home/family)

Note: The founder developed this scenario based upon witnessing it with a homeless family. Research shows higher prevalence of ADHD among low income children. It is also common practice to subject low-income families to pill counts for these drugs, which puts another burden onto the parent (often a single parent).  

After playing the game, a facilitator explains the brain science behind it and how poverty shapes health behaviors and health status. It’s a gratifying aha moment when people then are eager to receive the information on how to approach the complex, unique burdens that each patient faces. 

Players brainstorm how to apply this new insight to their work. Tactics can be as simple as having the medical assistant confirm the patient has a ride to the pharmacy; or as extensive as designing education for parents of ADHD children so that sessions can be missed. 

Most training sessions aim is to have people gain a certain set of knowledge. The outcome of the gettin’ by experience is harder to predict. Who knows what changes people will make after they have been fish? 

Linda K. Riddell, MS, is the founder of gettin’ by.