Talley, Jan A. PhD; Magie, Richard DO
Effective communication between the health care provider and the patient has been found to increase positive health outcomes.1 Arora and colleagues,2 for example, found a positive effect on patient outcomes when physicians involved their patients in the decision-making process; the authors described this type of decision making as “participatory.” Puchalski3 also described the benefits of partnering with patients rather than dictating to them, labeling this kind of care “compassionate.”
Effective communication between providers and patients may (and should) include awareness by the provider of the spiritual needs of the patient. Several researchers have previously examined spirituality and medicine. One set of authors, Chiu and colleagues,4 conceptualized spirituality as connectedness with oneself, others, nature, and/or a higher being. In 2002, another investigator reviewed the published literature about spirituality in medicine from the preceding 30 years and defined spirituality as an individual’s search for meaning and purpose in life.5 Tanyi5 further explained spirituality as the structure from which an individual chooses beliefs, values, and behaviors in an effort to understand his or her relationship to a greater meaning. On the basis of his review, Tanyi5 credited spirituality with assisting an individual to accomplish difficult tasks, deal more effectively with negative health outcomes, and experience an increased sense of well-being. Another researcher, Thomson,6 surveyed patients who were admitted to hospice services during a four-month period (using the Functional Assessment of Cancer Therapy scale) and noted similar benefits. An analysis of those data indicated that spiritual well-being (along with five other constructs) significantly contributed to the overall quality of life for those patients.
Larson and Larson7 reviewed several longitudinal studies of populations who were monitored for active spiritual involvement and length of life. Their findings were more ambiguous than those of Thomson and Tanyi. Larson and Larson noted that spiritual involvement had a positive effect on length of life and that spirituality for either medically or mentally ill patients contributed to enhanced pain management, improved surgical outcomes, and decreased rates of depression; however, Larson and Larson also reviewed studies that documented the negative effect on health outcomes when a patient’s spiritual beliefs and health needs were in conflict. They concluded that a patient’s spiritual beliefs may have both positive and negative effects on health outcomes.7
O’Connell and Skevington’s8 analyses of data from the World Health Organization’s Spirituality, Religiousness and Personal Beliefs Field-Test Instrument, which measures the relationship of spirituality to quality of life in health, also did not indicate universally positive results. Spiritual quality of life, but not most other aspects of quality of life, was higher for religious people. These authors found religious beliefs to be a subset of the overarching concept of spirituality.
As a result of the increase in research documenting the importance of the relationship between patient spirituality and health outcomes, Kansas City University of Medicine and Biosciences (KCUMB) has emphasized to its medical students the importance of spirituality as a part of the treatment process. Further, KCUMB is a school of osteopathic medicine, which, according to Still,9 who established the practice of osteopathic medicine in 1908, is based on the premise that healing the patient requires the physician to address the problems of the mind, body, and spirit. The unique focus of osteopathic medical training on the whole person—including the patient’s spirituality and the ability of the human physiology to contribute to the maintenance and improvement of health outcomes—contributed to KCUMB’s receptiveness to participate in the George Washington Institute for Spirituality and Health (GWish) “Spirituality in Medicine” educational initiative.
This article describes the process by which KCUMB used funding from the John Templeton Spirituality and Medicine Curricular Award (provided through GWish) to enhance the curriculum with regard to training medical students in the skills needed to assess and incorporate the spiritual needs of their patients into treatment plans and thereby improve health outcomes.
Developing the Spirituality in Medicine Curriculum
KCUMB leaders felt that the “Spirituality in Medicine” curriculum would meet a need in medical education. Research suggests that the incorporation of spirituality concepts into medical curricula is lacking. The results of one recent survey indicated that only 7% of medical schools in the United States had a course dedicated to spirituality and health.10 Those authors surveyed only MD-granting medical schools, but—given the fact that these represent the majority of medical schools in the United States—their findings show that U.S. medical schools are not training students to attend to their patients’ spiritual needs.
As KCUMB faculty and leaders designed the new curriculum, they considered competencies required by the Association of American Medical Colleges (AAMC) and the qualitative results from surveys of medical school applicants.
New curriculum goals published by the AAMC in 2009 targeted the following physician competencies: (1) physicians must be altruistic, (2) physicians must be skillful, and (3) physicians must be dutiful.11 The KCUMB faculty addressed all three of these competencies as a part of the 2010 GWish project for curriculum development. The Spirituality in Medicine curriculum became part of the Osteopathic Communication Skills (OCS) curriculum, which was designed so that students would be able to do the following:
* Demonstrate knowledge of the National Healthcare Disparities Report (NHDR),12
* Solicit and develop a spiritual history for patients so as to address their spiritual needs,
* Perform self-assessments of spiritual needs and develop a plan of action for spiritual self-growth,
* Integrate spiritual and cultural issues into medical dialogue and the decision-making process with patients and families, and
* Develop skills to work with chaplains to address patients’ spiritual needs and improve health outcomes.
The need for enhancing the curriculum was also supported by another important KUCMB stakeholder: medical school applicants. KUCMB has routinely administered a written survey to applicants while they are on campus for interviews. A number of those applicants indicated in open-ended questions that they were interested in, specifically, studying spirituality and its effect on the practice of medicine. Much discussion occurred among faculty regarding these comments. Specifically, some faculty members were concerned about the need to differentiate between spirituality and the promotion of a specific form of religious practice. The KCUMB curriculum was previously developed in conjunction with a private religious institution, so faculty were predisposed to include religious leaders and hospital chaplains as part of this Spirituality in Medicine curriculum; however, they wanted to ensure that chaplains of diverse faiths were represented. In addition, currently enrolled medical students who participated in the curriculum gave informal verbal feedback that they would prefer their training in spirituality and treatment to encompass more diverse religious approaches.
The development and incorporation of curricula to train students in skills related to spirituality and its role in the practice of medicine began with a visit by KCUMB faculty members to the GWish study center in 2008. The director of that center realized that the students’ interactions with simulators and standardized patients at the Center for Clinical Competence (CCC) at KCUMB might be a unique way to introduce additions to the curriculum. The director of the KCUMB Spirituality in Medicine curriculum project (R.R.M.), the director of the CCC, and the director of the OCS curriculum began to discuss how introducing spirituality skills and concepts through such interactions might be accomplished. These three faculty members worked together from 2008 to 2010 in a synergistic manner to develop needed additions to a preexisting curriculum (the OCS curriculum) that had been developed with the support of a prior grant.
Instructional Delivery Strategies for Course Content
Once the curriculum was finalized, it was delivered initially to 250 first-year medical students in the 2010–2011 academic year by 10 KCUMB faculty members, 3 residents, 2 KCUMB alumni, 4 local physicians with expertise in end-of-life care, 2 nationally recognized physicians with expertise in spirituality and medicine, several local experts on religion and medicine, and 4 palliative care experts. Collectively, these presenters represented almost 30 years of experience in active involvement in curriculum development at KCUMB.
The curriculum comprises eight hours of contact time with students, dispersed over five learning sessions.
In the first session, first-year medical students participated in a two-hour combination of lecture and small-group role-play. Faculty modeled incorporating questions from the Faith and Belief, Importance, Community, and Address in Care (FICA) Spiritual Assessment Tool13 into information gathering for a routine patient history. Then students practiced while faculty, using a checklist developed by the FICA authors, evaluated the students’ ability to maintain eye contact, record data, and collect important information from the patient using the tool. The curriculum planners selected the FICA tool13 because it most directly addressed the information that faculty decided was relevant to the learning skills addressed by the curriculum.
In the next session, a faculty member used the FICA tool to teach students how to perform a self-assessment of their own spiritual needs. In a one-hour session, the faculty member provided a lecture on the use of the tool, modeled the use of the FICA tool for self-assessment, and then facilitated and evaluated student self-assessment with the tool.13
In a two-hour lecture, faculty used the NHDR12 from the Department of Health and Human Services to teach students about the impact of spirituality on health and on health care outcomes.
During a fourth one-hour session, spiritual leaders from various religious and cultural communities, including the Buddhist and Muslim traditions, modeled different methods of conducting spiritually and culturally appropriate medical dialogue and decision making with patients and families. In another one-hour session following this panel, students practiced the skills taught by panel members through role-playing in small groups. Faculty observed each student as they role-played using situations developed by the spiritual leaders.
Students also participated in a four-hour shadowing experience. Each student spent time one-on-one with a hospital chaplain to learn how to access and use the chaplain services as part of quality, patient-centered health care. Observing the chaplains gave the students firsthand information about the specific situations and settings chaplains are trained to deal with.
Evaluation of the Curriculum
At the beginning of the 2010–2011 school year, faculty administered a survey titled “Spirituality in Medicine” to the 250 first-year KCUMB students who took part in the Spirituality in Medicine curriculum. The curriculum planners intended for this instrument, adapted with permission from an instrument developed by Chibnall and colleagues,14 to measure changes in students’ opinions about their spirituality. The survey comprised 31 questions: 23 questions used Likert-type scales, 2 questions were forced-choice questions using discrete categories for responses, and 6 questions addressed demographic information (e.g., age, gender, caregiving and marital status, and religious affiliation; see Table 1 for these demographic data).
Other methods used to measure student outcomes for this curriculum were as follows:
* Correctly answering five written test questions, included on the final exam, that address the NHDR,12
* Successfully completing the in-class role-playing exercises focused on spiritually and culturally appropriate patient communication
* Successfully completing the FICA tool13 to evaluate patient and physician (i.e., their own) spirituality needs, and
* Shadowing a chaplain and writing a reflection paper on that experience.
Student outcomes for the Spirituality and Health Competency curriculum for medical students at KCUMB during the 2010–2011 school year were recorded and analyzed for the purpose of the curriculum evaluation.
The vast majority of the students (95.6%, n = 239) answered all five of the NHDR12 questions correctly. All 250 of the participating students wrote a report on an ethical issue about patient care as a part of the chaplain reflection paper, and all of them successfully completed both a verbal and a written assessment of a patient’s spiritual needs using the FICA tool.13 Most of the students (80.8%, n = 202) successfully completed a spiritual self-assessment using that same tool. All of the students attended the session during which spiritual leaders demonstrated methods of conducting spiritually and culturally appropriate medical dialogue and then successfully completed the in-class role-play exercises to demonstrate mastery of that skill (100%, n = 250).
A total of 249 students (99.6%) completed the shadowing experience with a chaplain, and these students’ written reflections demonstrated that they acquired skills in accessing and using the chaplain services as part of providing high-quality, patient-centered health care.
Challenges and Modifications to the Curriculum
One barrier to curriculum implementation resulted from the downturn in the economy in 2008. Budget cutbacks led to a reduction in the number of chaplains available in many hospitals in the Kansas City area, so fewer chaplains were available to train the students than was expected during curriculum development. By 2010, chaplains had experienced a noticeable increase in responsibilities, but the time committed to train the medical students remained the same. More chaplains have been needed in subsequent years of curriculum implementation to alleviate the stress and burnout that the participating chaplains experienced during the first year.
The faculty members who were involved in teaching the curriculum originally had agreements with 5 hospitals. The number of sites has grown from 5 to 10. Those additional hospitals have agreed to allow their chaplains to train students, thus alleviating the stress for chaplains caused by so many student training hours.
Since 2010, additional modifications have been made to the curriculum as a result of both student feedback (in the form of evaluation surveys) and participating faculty feedback (gleaned from informal discussions). Curriculum planners have made the length of time for shadowing a chaplain more flexible—now, varying from two to four hours—to respond to the amount of patient contact that is actually available. In addition, faculty noted that alternative training tools had to be available if no patient contact was possible, so curriculum planners introduced a video about a woman with breast cancer to serve that purpose.
The results of a student survey administered to medical students who participated in the curriculum during its first year of implementation indicated a preference for training by religious leaders from as many different backgrounds as possible. This specific request—for training in various spiritual approaches to medical practice—came from enrolled students after the second year of implementation as well; thus, in subsequent years, diverse religious leaders have given lectures during the regular presentation of the curriculum.
Originally, the reflective paper about the medical student’s rotation experience with the chaplain was to be completed by April of the second year of medical school. The students informed the faculty that this due date conflicted with their need to study for board exams; thus, faculty changed the due date for the paper to the end of the fall semester of the second year for the next group of students. Although, initially, the only criterion for earning credit for the paper was for students to complete it, faculty have since, using the completed papers as a guide, developed more stringent criteria. Those new criteria require that the paper be three pages long.
Sustainability of the Program
In 2011, the National Board of Osteopathic Medical Examiners (NBOME) issued the Fundamental Osteopathic Medical Competency Domains,15 which outline the seven core competencies for the practice of osteopathic medicine. The NBOME goals that directly addressed the OCS curriculum at KCUMB in 2011 served as a directive to retain and incorporate as a permanent part of our curriculum the following competencies already addressed in the OCS curriculum: (1) exploring a patient’s beliefs, including his or her spirituality, by using interpersonal and communication skills to understand his or her perspective; (2) identifying the impact of social factors that are determinants of health outcomes by using knowledge of the behavioral and social sciences; (3) providing empathy and support for other members of the interprofessional collaborative team; (4) encouraging the patient to be involved in decision making; and (5) identifying the impact of social factors that are determinants of health outcomes.
The initial incorporation of spirituality into the academic curriculum has led to some other permanent changes in the curriculum. KCUMB has incorporated learning how to use the FICA spirituality tool13 into health assessment skills training so that students use it to determine the spiritual status of patients. Also, as mentioned, second-year students are now required to submit a reflective, three-page paper about their shadowing experience with a chaplain. This paper focuses the student’s learning on the skills necessary to be a more compassionate health care team member and on his or her ability to use the chaplain services more effectively for patients.
In addition, as described above (in Instructional Delivery Strategies for Course Content), first- and second-year students are exposed to eight hours of formal lectures from physicians, chaplains, and ethicists about what chaplains are trained to do to improve patient and family health outcomes by addressing their spiritual needs. Community chaplains in the Kansas City area have been integral to the development and delivery of this curriculum. Those chaplains have also received strong support from their administrators to provide time to train KCUMB medical students.
The introduction of the OCS Spirituality in Medicine curriculum has served as a catalyst for change in other educational processes at KCUMB. Additions to the 2013–2014 curriculum have been implemented as the result of the implementation of the Spirituality in Medicine curriculum. First, a new elective in palliative care has been offered for third- and fourth-year students beginning in 2013. Second, a one-month rotation in palliative care was offered at one of four hospitals in the Kansas City area in the spring of 2013. Finally, the third- and fourth-year students (n = 25) who are a part of KCUMB’s formal, international outreach program that sends students to Guatemala (DOCARE) have been asked to assess the effects that serving the underserved has had on their professional development. These same students were asked to describe how their views changed about their peers who served on the mission trip with them.
Some unintended benefits have resulted from the John Templeton Spirituality and Medicine Curricular Award to GWish. KCUMB has formed partnerships with diverse local and national organizations, hospitals, and schools including the Center for Practical Bioethics, St. Benedict’s Abbey and Mount St. Scholastica, Kansas City Hospice, and Commonweal Institute in California. Although unplanned, these partnerships have improved the quality of the training our medical students experience in the Spirituality in Medicine curriculum here at KCUMB.
Further, the curriculum has gained academic and media attention. Information about the curriculum, including outcomes from prior years, has been highlighted at the KCUMB Research Symposium (an event held annually and attended by at least 200 people), by the KCUMB-Communicator (a monthly publication that is distributed to all alumni and friends of the university [about 9,000 people]) and a local periodical, the Kansas City Business Journal.
Future plans include the possibility of obtaining funding for repeated longitudinal studies (again using the survey developed by Chibnall and colleagues14) to track changes in the students’ attitudes toward spirituality and patient care. Specifically, faculty may administer the survey in the third and fourth years of medical school as well as the first and second, and KCUMB may collaborate with two other medical schools in the Kansas City area to compare changes in medical student attitudes toward spirituality and patient care. Key informant interviews will capture qualitative data about how these curriculum changes have affected students.
This project has led to many changes in the curriculum at KCUMB over the last three years. The changes have been made possible by the funding opportunity, but also by the KCUMB faculty who served as the leaders in the development of the curriculum. The creativity and dedication shown by these individuals made the end result possible. As a result of their dedication, medical students will be prepared to assess and use patients’ spiritual beliefs to develop an active physician–patient care model.
Acknowledgments: The authors wish to thank Dr. Seft Hunter for the development of the questions about student demographics, and to Andrea Hanson for providing part of the data analyses.