1. Spirituality and iVIedicine
A Workshop for Medical Students and Residents
Katherine Gergen Barnett, MS4j Auguste H. Fortin Vi, MD,
'Yale University School of Medicine, New Haven, CT, USA; ^Department ot Medicine, Yaie University School ot Medicine, New Haven, CT,
USA; %aterbury Hospitai, Waterbury, CT, USA.
INTRODUCTION: Governing bodies for medical education recommend tients'^; discomfort''; role uncertainty (e.g., working with
that spirituality and medicine be incorporated into training. chaplains)"; and lack of awareness of the importance of belief
AIM: To pilot a workshop on spirituality and medicine on a conven- to patients.^
ience sample of preclinical medical students and internal medicine To address these concerns, governing bodies for medical
residents and determine whether content was relevant to learners at education, such as the Association of American Medical Gol-
different levels, whether preliminary evaluation was promising, and to leges, have recommended that spirituality and religion be in-
generate hypotheses for future research.
corporated into medical training.'° Gurrently, 80 of the
SETTING: Private medical school and university primary care internal nation's 126 accredited medical schools are offering courses
medicine residency program, both in the Northeast. on spirituality and medicine, up from 1 in 1992." The content
CURRICULUM DESCRIPTION: The authors designed and implemented for these courses has been suggested,'^"''* but few curricula
a required 2-hour workshop for all second-year medical students and a have been reported in the literature, '^ and there has been little
separate required 1.5-hour workshop for all primary care internal med- empirical research on the ideal targeted learners, content, im-
icine house staff. The workshops used multiple educational strategies plementation, and efficacy of such courses.
including lecture, discussion, and role-play to address educational ob- Faced with limited curricular time for new courses, we
jectives.
developed and piloted a brief workshop on spirituality and
PROGRAM EVALUATION: Learners completed optional, anonymous medicine. We sought to determine whether the content was
pre and postworkshop surveys with six 5-point Likert-rated statements relevant to learners at different levels, whether preliminary
and space to cite the most useful part of the curriculum and their re- evaluation was promising, and to generate hypotheses for fu-
maining questions. One hundred and thirty-seven learners participat- ture research.
ed and 100 completed both surveys. Medicai students and residents
had increased (all P<.002): agreement regarding the appropriateness
of inquiring about spiritual and religious beliefs in the medical encoun- CURRICULUM DESCRIPTION
ter, their perceived competence in taking a spiritual history, and their
perceived knowledge of available pastoral care resources. Medical stu- Subjects
dents, but not residents, had an increase in their perceived comfort in
One of us (A.H.F.) had curricular responsibility for second-year
working with hospital chaplains.
medical students and primary care internal medicine interns
DISCUSSION: A brief pilot workshop on spirituality and medicine had and residents, both at a private Northeast university. For ex-
a modest effect in improving attitudes and perceived competence of pediency, we involved these learners in the pilot project.
both medical students and residents.
KEY WORDS: spirituality; curriculum; medical education. Curriculum
DOI; 10.1111/J.1525-1497.2006.00431.X
J GEN INTERN MED 2006; 21;481-485. In 2000, we performed a needs assessment'^ by reviewing the
medical school's preclinical curriculum and the residency pro-
gram's didactic curriculum to determine existing spirituality
and medicine content. None was noted. We informally inter-
viewed residents and found that they had little or no contact
N poll, Americans areaabelief in God or ainUniversal Gallup
orth
91% reported
spiritual people; a 2000
Spirit, with hospital chaplains. We searched the literature for expert
suggestions and reported curricula'^"''*'^ and, based on this
while 83% asserted that, "God is highly important in my life."'
In another poll of 1,000 U.S. adults, 79% of respondents be- information, developed specific learner objectives (listed in Ta-
ble 1, column 2) and educational strategies to address these
lieved that spiritual faith can help people recover from disease
objectives (Table 1, columns 1 and 4)."^
and 63% felt that physicians should ask patients about their
The medical student workshop was 2 hours long and was
spiritual beliefs.^ Although many patients are hoping for their
presented as part of a required Doctor-Patient Encounter
spiritual and religious beliefs to be addressed by their doctors, course, while the separate resident workshop was one-
most physicians do not ask,^"^ Gited barriers to asking in- and-one-half hours long and was given during a required am-
clude; lack of time; lack of training in taking a spiritual history; bulatory block rotation. Each workshop accommodated
uncertainty about how to identify patients with spiritual approximately 20 learners and was repeated to train all
needs; concern about projecting beliefs onto patients; uncer- 105 second-year students and all 60 primary care residents
tainty about how to manage spiritual issues raised by pa- in the 2000 to 2001 academic year. One of 3 physician in-
Presented in part at ttie Society for General Internal Medicine. New structors presented each student workshop; 1 physician in-
England Region Meeting. 2001. structor presented all the resident workshops. To help
Address correspondence and requests for reprints to Dr. Fortin: Office standardize delivery, instructors attended a training session
of Education. Yale University School of Medicine, 367 Cedar Street, New and used the same PowerPoint presentation and speaker's
Haven. CT 06510-3240 (e-mail: augusteforiin@yale.edu). notes for all workshops (Appendix A),
481

2. 482 Barnett and Fortin, Spirituality and Medicine Workshop JGIM
Learners received a handout covering key concepts including iilness prevention.23.27,28 coping with iilness,^
(Appendix B) and a spiritual assessment pocket card (Appen- and improving illness outcomes.^® Some criticisms of this field
dix C). There were no advance readings. We used several in- of research were also presented.^'
structional strategies in specific sequence to meet the The instructor then facilitated discussions among learn-
educational objectives (Table 1). The workshops began with a ers about the potential harm of patients" religious or spirituai
brief review of the medical interview to provide context for In- beliefs to their health and health care (e.g., religion-motivated
cluding a spiritual assessment as part of the sociai history'® medical neglect, spiritual crlses)^"-^^"^" and the importance of
and care of the whoie person. '^ The instructor continued by professional boundaries when assessing spirituality.^'•^^•''^®^
engaging learners in a discussion of the similarities and dif- To demonstrate how religious beiiefs can affect provision of
ferences between spirituality and religion, as experts stress the medical care, the Instructor presented the exampie of Jeh-
importance of appreciating spirltuaiity's broader context with ovah's Witnesses' proscription against blood transfusions.^®'^®
both religious and nonreligious meanings.^° Learners provid- Learners discussed how physicians' own beiiefs couid impede
ed their definitions, which were written on a blackboard and the doctor-patient relationship.^® They then brainstormed po-
compared with standard définitions from the llterature'^'^""^^ tential barriers that they might have to assessing patients'
to help learners appreciate the multidimensionality of both spirituality in the medical encounter. Reported physician bar-
spirituality and reiigion. riers were also presented.®'^
The demographics of spirituality and religion in America^"* Next, the instructor introduced a mnemonic to guide
and the apparent differences in ievels of spirituality/religiosity spiritual assessment."*" The mnemonic is FICA for Faith and
between the pubiic and physicians^^ were then presented in a beiiefs, their importance to patients, membership in a religious
mini-lecture. This was in order for learners to understand the Community, and how patients wouid like clinicians to further
prevalence and breadth of spirituality among Americans and Address the issue in their health care. Learners used the mne-
possible reasons why Medicine has not addressed this topie monic to take a spiritual assessment of one another in pairs
until recently. and then regrouped to debrief the experience. Those uncom-
To introduce the potential clinical relevance of spirituai- fortabie discussing their own spirituaiity were in'vited to make
ity, the instructor reviewed research showing the importance up answers for this exercise.
of spirituaiity to many patients^"^ and brlefiy summarized In the student workshop, a hospital chaplain then intro-
studies associating reiigious beliefs/spirituality and ^^
* duced and discussed the role of pastoral services and pastorai
Table 1. Workshop Topics, Objectives, and Timeline
Workshop Component Leorners' Objectives: By the End of the Workshop, Time instructional Reterenci
Leorners Will be Able Allotted Strategy
"Asking about To describe the context for spiritual assessment Students lOmln Mini-lecture 18, 19
spirituaiity in the social history Residents 5 min
in the social history"
""Spirituality" vs To distinguish spirituality's broader context with both 15 min Discussion, mini- 20
"'religion"' religious and non-religious meanings lecture
""Spirituality and To describe the prevalence of spirituaiity and religion in America 10 min Mini-lecture 24, 25
religion in America"' To understand why Medicine has not addressed this topic
until recently
"Spirituality, health, To rate as vaiuabie the importance of spirituaiity to many 15 min Mini-iecture 2 3 , 26-31
and iilness" patients
To rate spirituai assessment as important"
To describe outcomes of research associating spirituality
and health
To understand some criticisms of this research
"Potentiai health harms To agree that patients' religious beliefs can potentially 10 min Discussion 30. 32-34
of religious beliefs"" harm their health and health care"
""Specific beliefs and To describe how patients' religious beliefs can affect the 10 min Mini-lecture 38, 39
healthcare provision: the provision of health care
example of Jehovah"s
Witnesses""
""Barriers to and To rate as valuable the need for professional boundaries 10 min Brainstorm. 6, 7, 31, 32
boundaries in in assessing patients" spirituality/religion discussion 35-37
addressing spirituality To recognize that physicians' spiritual or religious beliefs
in the doctor-patient can affect their provision of health care*
encounter"' To list physicians' barriers to spiritual assessment
"Spiritual assessment To recite a mnemonic for spirituai assessment 25 min Mini-lecture, role 40
techniques"" To practice a spiritual assessment of a colleague* piay. discussion
"'Pastoral care referral To receive a list of available pastoral care resources Students 15 min Mini-lecture,
resources To express increased comfort in working with hospital Residents 5 min discussion
chaplains*
To rate increased competence in consulting pastoral
care services*
'Objectives assessed.

3. JGIM Barnett and Fortin, Spirituality and Medicine Workshop 483
consultation in the inpatient and outpatient setting. For logistical residents. Pre and postworkshop surveys were completed by
reasons, there was no chaplain present In the resident work- 54 students (68%) and 46 residents (79%); the difference in
shop; instead, the physician instructor briefly discussed chap- response rates was not significant.
lains' roles and handed out an information sheet on obtaining Table 2 shows learners' Likert survey scores and changes
pastoral consultation at the hospitals where the residents rotate. after the workshop. Both medical students and residents in-
creased scores (all P<.002) regarding the appropriateness of
CURRICULUM EVALUATION inquiring about spiritual and religious beliefs in the medical
encounter, perceived competence in taking a spiritual history,
For this pilot, we chose to assess a subset of the curricular and perceived knowledge of available pastoral care resources.
objectives. Learners completed voluntary, anonymous sur- Medical students, but not residents, increased their perceived
veys, approved by the human Investigations committee, both comfort in working with others on the health care team who
immediately before and after the workshop. The surveys con- emphasize patients' spirituality, such as chaplains. This dif-
tained 6 statements on attitudes toward spirituality and med- ference between students and residents approached signifi-
icine, perceived competence in taking a spiritual history, cance (P=.OO5). On the item, "Aphysician's spiritual/religious
perceived knowledge of pastoral care resources, and comfort beliefs can affect his/her ability to communicate with and care
working with hospital chaplains (Table 2, column 1). Learners for patients," the difference in pre to postworkshop scores be-
rated their agreement on a 5-polnt Likert scale (1 =strongly tween students and residents achieved significance.
disagree, 5=strongly agree). In the postworkshop survey, The most useful workshop components cited by learners
there was also a space for learners to cite the most useful were as follows; knowledge gained (I.e., information on pasto-
parts of the curriculum and their remaining questions about ral referral resourees, the spiritual history mnemonic, and
spirituality/religion in health care. Demographic information demographics of spirituality in the United States); the oppor-
was not collected. tunity to discuss and refiect upon this subject in a safe envi-
ronment; and the skill of how to take a spiritual histoiy.
Data Analysis Research associating spirituality/religion and health was least
cited as useful.
standard frequencies and means were calculated for individ-
ual variables. Because the data were not normally distributed, The most common questions remaining for learners after
we used nonparametric tests for comparisons. Changes in the workshop concerned appropriateness (e.g., "Is it a physi-
survey responses before and after the workshops were analy- cian's role?" "For which patients it is appropriate?") and spir-
zed with the WUcoxon rank-sum test for paired data. Differ- itual history-taking (e.g., when to ask, the extent to ask, and
ences between students' and residents' responses were how to ask so that the patient is comfortable).
analyzed using the Mann-Whitney U test. Applying the Bon-
ferronl correction to account for correlated responses set sig-
nificance at P<.003. In order to analyze learners' citations of DISCUSSION
the most useful parts of the workshop and their remaining
questions, we used the constant comparative method of qual- Overall, the results from this pilot study of a brief workshop in
itative data analysis,'" whereby themes were generated and spirituality and medicine indicate a modest effect on medical
repeatedly assessed until a mutually exclusive set of themes students' and primary care residents' attitudes regarding the
was derived and the interrater agreement was 100%. appropriateness of taking a spiritual history, perceived knowl-
edge about aecessing pastoral care resources, and perceived
eompetence in asking patients about their spiritual or religious
Results beliefs. These pilot results are encouraging as already crowded
The workshops were attended by 79 of 105 medical students curricula can make more extensive courses difficult to imple-
(75%) and 58 of 60 (97%) primary care medical interns and ment.
Table 2. Pre and Postworkshop Survey Scores of Students and Residents
Item Precourse Postcourse Mean
Mean (SD) Mean (SD) Change (.P)
1. "Asicing about a patient's spiritual or religious beliefs is an appropriate Students 3.8 (0.9) 4.1 (1.0) -1-0.4 (.002)
part of patient care" Residents 3.8 (0.9) 4.3 (0.6) -H0.6(<.001)
2. "A patient's spiritual/religious beliefs can impact his or her health" Students 4.4 (0.7) 4.3(1.0) - 0 . 1 (.38)
Residents 4.6 (0.5) 4.6 (0.5) 0(.7)
3. "A physician's spiritual/religious beliefs can affeet his/her ability to Students 3.5 (1.3) 3.3(1.3) - 0 . 4 (.03)*
communicate with and care for patients" Residents 3.9 (0.8) 4.1 (0.7) -F0.2 (.02)
4. "I am comfortable working with people in other fields who emphasize Students 3.7 (1.0) 4.1 (0.9) +0.5 (.001)
caring for patients' spirituality, sueh as hospital chaplains" Residents 4.0 (0.8) 4.0 (0.8) 0(.8)
5. "I feel eompetent taking a patient's spiritual history" Students 2.7(1.0) 3.7 (0.9) + 1.0 (<. 001)
Residents 3.2 (0.8) 3.9 (0.7) + 0.7 (<. 001)
6. "i know to whom to refer a patient with a spiritual or religious question, Students 2.8 (1.2) 4.2 (0.8) + 1.5(<. 001)
concern, or crisis" Residents 3.0 (1.2) 4.1 (0.8) + 1.2 (<. 001)
1. strongly disagree to 5, strongly agree scale.
*P =.002 Jor difference between students and residents.

4. 484 Barnett and Fortin, Spirituality and Medicine Workshop JGIM
Identiiying appropriate content for curricula in spiritual- able to differences in the intervention rather than differences
ity and medicine may aid future curriculum developers. Our between the groups. For example, a chaplain participated only
learners already arrived at the workshop tending to agree that in the students' workshops. The students' workshops were led
spiritual assessment was appropriate and that patients' beliefs by 3 different instructors, while the residents' workshops had
could impact health; workshop time could perhaps have been the same instructor. The instructors received identical training
spent on other content. Conversely, the most frequent ques- and used the same curricular material, but individual presen-
tion remaining for learners after the workshop related to issues tation styles or delivery may have affected survey responses.
of appropriateness. This needs further research. Learners We did not use dated surveys so we could not assess for such
most valued receiving information (the demographics of spir- an effect.
ituality in the Unites States, local pastoral referral resources), Our evaluation method also had weaknesses. Instructors
learning and practicing the spiritual history mnemonic and and students were not blinded. It is possible that social desir-
being able to discuss the topic in a safe environment. ability bias or a wish to please the investigators affected learn-
One of the workshop objectives was for learners to recog- ers' survey responses. This is mitigated somewhat by the
nize how physicians' spiritual or religious beliefs can affect anonymity of the surveys. Learners completed the postwork-
their provision of health care. In fact, students remained near- shop survey immediately after the workshop concluded,
ly neutral in their agreement with this statement compared whereas testing i to 3 months afterward may have allowed
with residents, despite discussing examples of physicians for initial "decay" of itnowledge, skills, and attitudes and may
proselytizing patients or being judgmental on religious have represented a more stable change. Thirty-two percent of
grounds. We hypothesize that a more positive attitude toward students and 2 i % of residents did not contribute data to the
the topic of spiritualiiy and medicine after the workshop may analyses; because the surveys were anonymous, we cannot
have led them to feel that they could exhibit appropriate pro- determine how nonresponders differed from responders, or
fessionalism. Preclinical students lack the clinical context and how the loss of sample may impact our results. We evaluated
experience of residents, so the discussion may have been more only a subset of our educational objectives. While we presented
theoretical for them. Finally, the wording of the survey item #3 both potential salutary and harmful effects of patients' spirit-
was ambiguous because "affect" has both positive and nega- ual/religious belief, the wording of survey question #2 assess-
tive connotations. ing learners' attitude on these items did not discriminate
Medical students, but not residents, signiflcantly in- beneflciai from deleterious effects. Finally, our outcome meas-
creased their perceived comfort in working with hospital chap- ures relied on self-reports rather than actual behavior change.
lains; thus may represent an unintended training effect Further research is needed to determine whether im-
because of the involvement of a hospital chaplain in only the provements in attitudes, perceived knowledge, and perceived
students' workshops'*^ or a ceiling effect among the residents, skills persist over time; whether medical students and resi-
although students' and residents' perceived comfort did not dents who complete such a workshop are more likely to per-
differ signiflcantly before the workshop. form spiritual assessments with their patients and request
The workshop content appears to have been relevant to pastoral care consultations; and how best to integrate this
both medical students and residents, suggesting that such topic into the larger medieal schooi and residency curriculum.
curricula may be appropriate to introduce in both medical As more medical schools offer training in this area, needs of
school and residency. While residents may have a more im- future residents will likely change. Learners' questions about
mediate need, if students are not exposed to this information the appropriateness of spiritual assessment may be best an-
before they start clinical rotations, they may miss opportuni- swered by introducing the ethic of discourse about ultimate
ties to assess spirituality in their new patients. Students also human concerns.'*
have more time than others on the team to elicit a social history
and thus may be better able to uncover a patient's spiritual or
religious crisis or concern. The authors thank Margaret Bia, MD, for her vision arid guid-
Our workshop had several limitations. Although it was ance during the development and implementation of fhis cur-
required, 25% of medical students did not attend. This rate did riculum, Andre Sofair, MD, MPH, for helping fo teach fhe
not differ signiflcantly from attendance at other sessions in the workshop. Rev. Margaret Lewis for helping fo feach fhe work-
doctor-patient encounter course but, as we did not collect de- shop and assisfing wifh fhe qualifafive analysis, Michael Green,
MD, MSc, for sfafisfleal assisfance, and Pafrick O'Connor, MD,
mographic data on participants versus nonparticipants, we MPH, and Robert Smifh, MD, ScM, for reading earlier drafts of
Ccinnot comment on how their absence impacted our results. fhis paper. We also fhank fhe Yale Universify School of Medicine
There was no eomparison group, although the immediate post- class of 2003 and fhe Yale Primary Care residenfs for fheir ad-
test makes it unlikely that any other intervention could have venfuresome spirifs and honesf feedback. This projecf was sup-
ported in parf by a John Templefon Foundafion Granf for
accounted for the observed changes. The workshop was of- Curricula on Spirifualify, Culfure and End-af-Life Care. The fund-
fered only once to learners; lasting change in knowledge, skills, ing organizafion had no role in fhe design and canducf of fhe
and attitudes may be more likely if a topic is integrated into the sfudy, in fhe collecfion, analysis, and inferprefafian of fhe da-
larger curriculum and introduced repeatedly.''^ Our workshop fa, or in fhe preparafion, review, or approval of fhe manuscripf.
was only studied m i private medical school preclinical class
and i university primary care internal medicine residency pro-
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Supplementary Material
The following supplementary material is available for this
artiele online at www.blaekwell-synergy.com
Appendix A. PowerPoint Presentation.
Appendix B. Handout.
Appendix C. FICA Pocket Card.