2. 170 MARR ET AL.
INTRODUCTION should be taught in palliative medicine pro-
grams. The purpose of this survey was to assess:
S ERIOUS ILLNESS regularly triggers questions of
a spiritual nature—questions of meaning,
value, and relationships.1 Common spiritual con-
1. How fellowship programs define the domains
of spirituality education;
cerns include, “Is God punishing me?”, “What is 2. What content and teaching formats are utilized
the meaning of my life?”, or “What happens to to teach spirituality;
me after I die?” Thus, palliative medicine clini- 3. Who provides spirituality education; and
cians regularly find themselves in situations that 4. How fellows’ skills, knowledge, and behaviors
require skill in assessing and addressing the spir- in the domain of spirituality are evaluated.
itual needs of their patients and families. Inter-
disciplinary care of patients and their families is
considered a standard of practice in palliative METHODS
care2 and many palliative medicine teams contain
chaplains. The authors carried out a literature review of
The American Board of Hospice and Palliative published articles discussing topics of physician ed-
Medicine (ABHPM) presented Initial Voluntary ucation and spirituality.5–36 Based on this review, a
Program Standards for Residency Education in spiritual education self-assessment survey for pal-
Palliative Medicine in 2003. One of the learning liative medicine fellowship directors was devel-
domains is “spiritual support of patients and oped by the authors. The survey was pilot-tested
families,” including “the assessment and man- and reviewed with one current palliative care fel-
agement of spiritual suffering faced by patients low, three fellowship directors, and two palliative
with life-limiting illnesses and their families.”3 care chaplains. We condensed all the various top-
The document does not specify how this topic ics and themes into thirteen discrete domains
should be taught, what specifically should be within the commonly used attitudes/knowl-
taught, which professional discipline(s) should edge/skills paradigm to categorize education ob-
do the teaching, or how competency should be jectives (Table 1). The final survey contained four
evaluated. With one exception,4 there are no pub- questions: What specific content domains within
lished reports on how palliative medicine fellows the broader title of spirituality are included?, What
are acquiring spirituality education and no guide- teaching methods are used?, Who is providing the
lines exist as to how spiritual assessment and care teaching?, and How are fellows evaluated?.
TABLE 1. WHAT ARE THE DOMAINS THAT ARE COMMONLY INCLUDED IN SPIRITUALITY EDUCATIONa
Yes No Unsure
Knowledge/attitudes
Definitions of spirituality and religion 14 0 0
Common spiritual issues faced by patients at end of life 14 0 0
How different cultures view and address death and dying issues 12 1 1
How different religions view and address death and dying issues 12 1 1
Role of chaplains and clergy 14 0 0
Recognizing spiritual distress (such as “Why me?,” “God is 13 0 1
punishing me,” guilt, etc.)
Rituals for death and dying 12 1 1
“Unusual” (paranormal) patient experiences near time of death 10 2 2
Review of data examining link between spirituality and physical 9 1 4
and mental health
Skills
Completing a spiritual assessment 13 1 0
Responding to spiritual distress (counseling, referral, etc.) 13 1 0
Physician’s ability to self-reflect on personal spiritual issues and 10 0 4
how these affect patient care
Physician self-care 11 0 2
aFrom Palliative Care Fellowship Self-Assessment Questionnaire.
3. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 171
The survey was distributed by e-mail to all 48 training sites.” We used the number of active pro-
palliative medicine fellowship directors listed on grams (or potentially active programs) to calcu-
the American Academy of Hospice and Palliative late the response rate.
Medicine website in June 2004,34 excluding the
three fellowships represented by the authors.
Two e-mail reminders were sent during the 6- RESULTS
week data collection period. On the website, 33
of 48 programs (69%) indicated that their pro- Fourteen fellowship directors completed the
grams were training fellows, while 13 (26%) re- survey, representing 29% of all programs listed
ported they had not yet started to accept fellows. on the website and 42% of those training fellows.
The start date of two fellowship training pro- Twelve directors who responded were currently
grams was unclear based on their website post- teaching fellows; 2 had programs that had not yet
ing, and they were considered to be “potential accepted fellows but had curricula prepared, thus
TABLE 2. WHAT TEACHING METHODS ARE USED?a
Shadow
Small chaplain or
group Role- other Other
Lecture discussion Supervision play Self-study professional None methods
Knowledge
Definitions of spirituality 10 9 2 0 8 7 0
and religion
Common spiritual issues 9 12 7 0 7 6 0
that occur at the end
of life
How different cultures 7 10 3 0 7 5 0
view and address death
and dying
How different religions 8 10 3 0 7 4 0
view and address death
and dying
Role of chaplains and 8 9 4 0 4 7 0
clergy
Recognizing spiritual 5 10 6 1 6 7 1 1 (conference)
distress (such as “Why
me?,” “God is punishing
me,” guilt, etc.)
Rituals for death and 4 8 4 0 5 6 2
dying
“Unusual” (paranormal) 3 6 5 0 4 3 4
patient experiences near
time of death
Review of data examining 5 5 3 0 7 2 2
link between spirituality
and physical and mental
health
Skills
Completing a spiritual 3 6 7 3 7 7 1
assessment
Responding to spiritual 3 7 5 3 4 8 1
distress
(counseling, referral, etc.)
Physician’s ability to self- 3 9 6 1 5 3 1
reflect on personal
spiritual issues and how
these affect patient care
Physician self-care 4 7 5 1 4 3 0
aFrom Palliative Care Fellowship Self-Assessment Questionnaire.
4. 172 MARR ET AL.
12 of 31 reports (39%) represented teaching in ac- ation was most commonly used for both knowl-
tual training programs. Of the 14 responding pro- edge/attitudes and skills, with little emphasis on
grams, all indicated they taught “spirituality”; 12 more robust methods of evaluation, such as struc-
of 14 had distinct programs for teaching spiritu- tured role-play (Table 4).
ality and two reported they taught spirituality to
their fellows, but integrated spirituality educa-
tion with other content areas, not as a separate DISCUSSION
program.
Spirituality education in medical school,
What are the domains that are commonly residency, and palliative care fellowships
included in spirituality education?
The goal of the project was to understand bet-
All of the respondents are teaching the defini- ter how fellowship directors view the various ed-
tions of spirituality and religion, common spiritual ucational domains that comprise “spirituality”
issues faced by patients at end of life, and the role and, by extension, how they provide that educa-
of chaplains and clergy (Table 1). Most respondents tional content and evaluate trainees. The data
indicated they were teaching the majority of the from this survey can be considered a snapshot of
other domains listed in the survey instrument. how fellowship programs are attempting to meet
the ABHPM training guidelines, as well as their
What teaching methods are used? own goals for training fellows.
Small group discussion, lecture, and self-study The development of spirituality education in
were the most commonly employed teaching palliative care fellowships parallels has followed
formats for spirituality knowledge and attitude a growing interest in spirituality education in
domains (Table 2). Small group discussion, medical school and residency training that began
supervision, shadowing a chaplain or other pro- around 1990. In this section, we look for educa-
fessional, and self-study were the most commonly tional guidance from spirituality teaching pro-
reported methods to enhance spirituality skills. grams in medical schools and residency pro-
Role-play was a rarely used educational technique. grams, and discuss the similarities and
differences between this teaching and the current
Which health professionals provide state of teaching in palliative care fellowships,
spirituality education?
Domains of education
Chaplains and physicians were most com-
monly identified as providing spirituality educa- Many domains, topics, and broad themes have
tion, followed by social workers, nurses and psy- been described as part of “spirituality” in med-
chologists (Table 3). ical schools and residency programs. A summary
of key components in medical school curricula is
How are fellows evaluated? provided by Larson and Puchalski26 and is listed
in Table 5. Some topics commonly included in
Although programs described a variety of eval- spirituality curricula are related to spiritual as-
uation techniques, written or oral faculty evalu- sessment and care, while others, such as break-
ing bad news,7 hospice/palliative care,7,27,30,31
TABLE 3. WHICH HEALTH PROFESSIONALS PROVIDE and self-care14,28 cannot be specifically related to
SPIRITUALITY EDUCATION?a,b spirituality. For the palliative medicine fellow-
ship survey, Respondents to our survey indicated
Chaplain 100% general agreement that the topics we included
Physician 86%
Social worker 64% within the concept of spirituality were appropri-
Nurse 50% ate, and had no suggestions for other topics that
Psychologist 50% were not listed.
Other 0%
aFrom Palliative Care Fellowship Self-Assessment Teaching methods for spirituality education
Questionnaire.
bPercent of programs reporting spirituality educator by Spirituality is offered in a variety of medical
discipline. school courses or concentration areas: medical
5. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 173
TABLE 4. HOW ARE FELLOWS EVALUATED?a
Patient Staff
Self- Faculty Faculty and/or survey/
assessment evaluation eval. Role family 360° Chart
Test (written) (written) (oral) play survey eval. audit None
Knowledge/attitudes
Definitions of spirituality 1 1 7 6 0 0 2 1 5
and religion
Common spiritual issues 1 1 6 7 0 0 2 1 4
that occur at the end
of life
How different cultures 1 1 6 5 0 0 2 1 6
view and address death
and dying
How different religions 1 1 7 6 0 0 2 1 5
view and address death
and dying
Role of chaplains and 1 2 6 6 0 0 2 1 4
clergy
Recognizing spiritual 1 2 6 5 0 0 2 1 4
distress (such as “Why
me?,” “God is punishing
me,” guilt, etc.)
Rituals for death and dying 1 1 5 4 0 0 2 1 6
“Unusual” (paranormal) 1 1 4 4 0 0 2 1 9
patient experiences near
time of death
Review of data examining 1 1 5 5 0 0 2 1 6
link between spirituality
and physical and mental
health
Skills
Completing a spiritual 1 1 6 7 0 1 4 4 3
assessment
Responding to spiritual 1 1 7 7 0 1 4 2 2
distress
(counseling, referral, etc.)
Physician’s ability to self- 1 2 7 7 0 0 2 1 3
reflect on personal
spiritual issues and how
these affect patient care
Physician self-care 1 3 6 7 0 0 2 1 3
aFrom Palliative Care Fellowship Self-Assessment Questionnaire.
humanities and/or bioethics8,9,25; end-of-life ed- “verbatim” reports, role playing with standard-
ucation24; self-care curriculum26,28; cultural com- ized patients or fellow learners, and the use of
petency29; humanism and professionalism22; poetry and literature to convey spiritual and ex-
psychiatry clerkship11,19; internal medicine clerk- istential themes26,30 (Table 6). Unfortunately,
ship22; family medicine clerkship19; medical in- many of the published reports lack details about
terviewing18,23; community practice experience31; the curricula. For instance, although “read-
and complementary and alternative medi- ings,”6–10,16,19,25,26,28,32 “lectures,”6,7,10–12,14,17,19,21,
25–27,29,30,32,36 and “experiential exercises”14 on
cine.33,34 Residencies in family medicine,14,15,20,36
internal medicine,7 and psychiatry10,12 also in- “spirituality and medicine” are reported, more
clude spirituality in their curricula. The teaching information about these exercises is not provided.
formats used in the various spirituality curricula The McGill Working Group on Healing and
include didactic sessions, small group discussion, Healthcare38 has proposed training for medical
reflective writing, storytelling, case presentation students consisting of regular small group dis-
and discussion, panel discussions with patients, cussions with a mentor, and keeping a jour-
6. 174 MARR ET AL.
TABLE 5. DOMAINS OF SPIRITUALITY EDUCATION and spirituality training in a palliative medicine
fellowship. As part of their curriculum, they of-
Communication of bad news7,26
Concepts of suffering and spiritual distress30 fer an optional 6-month, 1-day-per-week training
Data of the link between spirituality and/or religion in clinical pastoral education, working with non-
and health outcomes10,14,26,27,32,35 chaplain and chaplain trainees. One article out-
Difference between spirituality and religion21,35 lines a spiritual care training program for pro-
The doctor–patient relationship, and how spiritual and
cultural factors influence it29,32 fessionals working in palliative care.44 Among
Exploration of views of the world’s religions, such as the palliative medicine programs in our survey,
Judeo-Christian, Hindu, Buddhist, etc.7,10,26 the most commonly reported method for teach-
Historical relationship between medicine and ing knowledge and attitude domains was small
religion10,27
Meditation and/or the relaxation response10,14,34 group discussion, followed by lecture and self-
Palliative care, end-of-life care (pain management, study. Small group discussion was also named
palliation, advanced directives, ethical issues) and commonly when teaching spirituality skills, fol-
coping with cancer7,24,27,30,31 lowed by supervision, and shadowing a chaplain
Psychic functions of spiritual/religious beliefs, as well
as transference, countertransference and boundary or other professional. Based on recommendations
issues relating to spiritual inquiry 10 from medical school and residency programs, ex-
Role of the chaplain, and how the chaplain functions as periential training should be mandatory in pal-
part of the health care team10,14,21,26,30,35 liative medicine fellowships. Other strong rec-
Self-care14,28,35
Taking a spiritual history and addressing spiritual ommendations from the literature include
needs, including the skills of compassion, presence training that incorporates time for personal re-
and listening7,10,11,14,18,21,24,26,27,29,30,32,34 flection and feedback and discussion of transfer-
Spiritual considerations in bereavement care14 ential dynamics that arise in the care of the dy-
Understand how your (the trainee’s) spiritual beliefs
affect patient care9,14,21,26,29–32 ing, similar to that found in the training of
Understand the spiritual beliefs of patients, including chaplains.40
those from different spiritual/religious or cultural
backgrounds (including how they affect their health,
medical decisions, affect the doctor-patient
relationship, help cope, etc.)7,11,14,18,21,26,29,30,32 TABLE 6. SPIRITUALITY EDUCATION
METHODS—LITERATURE REVIEW
Case presentation and discussion10,11,12,26,27,29–31
nal/portfolio documenting emotional reactions, Combining students in CPE with medical students27
Essay, reflective writing or discussion, or story-
insights and questions relating to their evolving telling9,17,21,23,24,26,30,31,35
clinical experience, similar to that proposed by Experiential exercises on self care and well-being14,31
Rita Charon.39 Lecture6,7,10,11,12,14,17,19,21,25,26,27,29,30,32,34,35
There are no data to suggest what formats are Panel of invited discussants for question/answer
sessions10,19,29,30
most effective. Several prefellowship spirituality- Rounds with a mentor who “emphasizes the spiritual
training programs ask for written and verbal aspects of patient care and faith based resources in
feedback about effectiveness of their curricula. the hospital and community” (modeling by
Some course directors have reported that an ex- physician)7,19,21,36
Self-study (readings)6–10,16,18,19,22 (gives a list),23 (spirit
periential approach to spirituality (such as shad- catches you),25,26,28,32
owing a chaplain), writing ones own spiritual his- Shadowing a chaplain7,14,21,35,36
tory, and/or interactive tutorials are powerful Small group discussion/seminar6,9,10,11,14,17,19,22–24,26,28,
30,32,34,35,36
teaching methods7,14,21,35; lectures are not as well
Retreat14
received.32 Others have reported positive feed- Senior physician sharing own spiritual journey, and/or
back from small group discussions and senior interactions with patients on spiritual issues21,32
physicians’ sharing personal experiences with Taking a spiritual history on a fellow student, family
spiritual issues in patient care, and patient’s per- member, standardized patient (role play) or actual
patient7,10,11,14,17–23,24,26,29,30,31,35
sonal stories.32 Taking a spiritual history on oneself21
In the palliative medicine literature, the only Verbatim27
report of spirituality education for fellows is from Watch a video on patient and physician experiences
the program at Massachusetts General Hospital,4 with spiritual coping during illness32
Working with a hospice team7,17,31
which described their approach to psychosocial
7. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 175
Spirituality education faculty Evaluation of competency
Various learner evaluation tools have been re-
Educators from many different professional
ported in medical school and residency programs
backgrounds are involved with medical school
including: reflective essay,9,17,21,24,26,30,31 question-
and residency spirituality education.10,14,27,29,32,34
naire regarding satisfaction and self-reported
Such programs have noted that inclusion of fac-
changes in attitude or knowledge,18,19,22,28,32 craft-
ulty from diverse backgrounds (race, gender,
ing a spiritual history on a patient,11 a
faith, and/or health care profession) is a useful
pretest/posttest questionnaire,11 writing one’s
educational strategy, as is recognizing the diverse
own spiritual history,21 videotaping of an end-of-
spiritual and religious background of the
curriculum standardized patient interview on
trainees. Three groups report training-the-train-
end-of-life care and spirituality,18 oral presenta-
ers in “spirituality” before a program in spiritu-
tion,31 and a written exam question.18 In our sur-
ality education.11,23,32 There is no data on the rel-
vey, a written evaluation by the faculty was the
ative effectiveness of individuals from different
most common method of competency evaluation,
backgrounds in the teaching of spirituality con-
while some programs reported no specific evalu-
cepts, or on the effectiveness of faculty develop-
ation for spirituality knowledge or skills. Given
ment programs for this domain.
the importance of spirituality education in pallia-
In our survey, respondents noted that chap-
tive care, a standardized and rigorous approach
lains were utilized in all programs to provide
to trainee evaluation should be adopted. Because
spirituality education; other team members were
spirituality education includes key attitudes, a
also involved, indicating the potential for inter-
core of knowledge, and testable skills and behav-
disciplinary spiritual care education. We do not
ior, the optimal evaluation will need to be multi-
know what kinds of attitudes, knowledge, and
dimensional, moving beyond the standard writ-
skills any of these trainers bring to spirituality ed-
ten faculty evaluation to include measures such
ucation, or whether they themselves have under-
as recommended by the Accreditation Council for
gone specific training on the topic of spirituality.
Graduate Medical Education (ACGME), for ex-
It should be noted that chaplains with formal
ample, 360-degree evaluation, portfolios, and
Clinical Pastoral Education (CPE) receive a spe-
standardized patient evaluations.40
cialized form of instruction that may make them
This study has methodological limitations.
uniquely qualified to be involved in spirituality
Most importantly, only 29% of program directors
education.40 CPE students are specifically trained
responded. Therefore, this data may not be re-
to understand how their attitudes, values as-
flective of all current fellowship programs. Sec-
sumptions, strengths and weaknesses affect their
ond, a self-assessment report from fellowship di-
pastoral care. They participate in reflective exer-
rectors may not reflect actual practice, with
cises of patient interactions with a chaplain su-
program directors possibly over- or under-re-
pervisor in an effort to understand the theologi-
porting actual educational activities. A concur-
cal, psychological and social issues arising in
rent survey of fellows might have helped assess
these interactions. CPE includes regularly sched-
the reliability of the information. Finally, al-
uled one-on-one meetings with a supervisor to
though the survey was adopted from the current
discuss issues that arise in patient care, and the
literature on physician spirituality education, we
emotions that work triggers. A common educa-
may have missed topics of importance that are
tional tool in CPE training is a narrative verba-
unique to palliative medicine fellowship training.
tim, where pastoral students record from mem-
ory their conversations with patients that focus
on spiritual issues, and then analyze the text from
a medical, psychological, theological, and ethical CONCLUSION
framework with the assistance of a supervisor. AND RECOMMENDATIONS
Most physician, nurses, and social workers pro-
viding training to palliative care fellows have not Training in spirituality involves developing
had this type of educational experience or train- fundamental knowledge, skills, and attitudes
ing, although one program has adapted CPE for about this realm of human existence and clinical
nonchaplains.45 practice, and touches on issues of professional
8. 176 MARR ET AL.
role boundaries, personal competency and self- care can be invited to participate in spiritual-
confidence in intense interpersonal encounters, ity education. Individual programs will need
and cross-cultural care, all in the context of a po- to decide how specific content areas are pro-
tentially highly charged emotional atmosphere vided to fellows in a manner that respects the
surrounding end-of-life care. Fellows should; discipline-specific strengths of each team
have the skills to complete a spiritual assessment; member.
know their limitations in providing spiritual care • Trainee evaluation in spirituality must provide
and how to work with others more skilled in the sufficient depth to gauge the learner’s atti-
work; have the ability to self reflect and under- tudes, knowledge, skills and clinical practice
stand their own spiritual history and how this af- behavior. We support the learner evaluation
fects their care of patients; be prepared to criti- methods endorsed by the ACGME that go be-
cally evaluate the literature; and be familiar with yond the standard written faculty evaluation
the skills of chaplain, psychologists and others tool.41,43
who can assist patients in their spiritual journey.
At the same time, palliative care physicians will
not obtain the full skill set of a CPE-trained chap-
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Lisa Marr, M.D.
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29. Deloney LA, Graham CJ, Erwin DO: Presenting cul- Department of Palliative Medicine
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