Research Report
Assessing Third-Year Medical Students’ Ability to Address a Patient’s Spiritual Distress Using an OSCE Case Mimi McEvoy, MA, NP, Sheira Schlair, MD, MS, Zsuzsanna Sidlo, PhD, William Burton, PhD, and Felise Milan, MD
Abstract Purpose To inform curricular development by assessing the ability of third-year medical students to address a patient’s spiritual distress during an acute medical crisis in the context of an objective structured clinical examination (OSCE) case. Method During March and April 2010, 170 third-year medical students completed an eight-station videotaped OSCE at Albert Einstein College of Medicine of Yeshiva University. One of the standardized patients (SPs) was a 65-year-old man with acute chest pain who mentioned his religious affiliation and fear of dying.
S
tudies suggest that many patients welcome inquiry from their physicians about their spiritual or religious beliefs,1,2 yet in another study,3 45% of physicians said it is inappropriate to initiate discussions of patients’ religion or spirituality during clinical encounters. Ms. McEvoy is associate professor of family and social medicine and assistant professor of pediatrics, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Schlair is assistant professor, Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Sidlo is a fourth-year medical student, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Burton is associate professor, Family and Social Medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Milan is professor of clinical medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Correspondence should be addressed to Ms. McEvoy, Albert Einstein College of Medicine, 1300 Morris Park Ave., Van Etten Building, RLG Clinical Skills Center, 2A30, Bronx, NY 10461; telephone: (718) 862-1778; fax: (718) 862-1797; e-mail: mimi. [email protected]. Acad Med. 2014;89:66–70. First published online November 25, 2013 doi: 10.1097/ACM.0000000000000061
66
If prompted, he revealed his desire to speak with a chaplain. The SP assessed students’ history taking, physical examination, and communication skills. In a postencounter written exercise, students reported their responses to the patient’s distress via four open-ended questions. Analysis of the postencounter notes was conducted by three coders for emergent themes. Clinical skills performance was compared between students who reported making chaplain referral and those who did not. Results A total of 108 students (64%) reported making a chaplain referral; 4 (2%) directly
Two primary reasons for this omission are thought to be physicians’ discomfort addressing the topic and a lack of targeted training.4,5 Broadly defined, spirituality can be understood as a “search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives.”6 Religion is a formal belief system that provides meaning to life through a common or shared set of beliefs, tenets, rituals, and practices.7 In this report, we use the term spiritual distress—defined as a disturbance of one’s belief system8—to convey the crisis that can occur when one’s meaning and purpose of life is threatened. Although discussions of spirituality or religion are not uniformly thought to be within the realm of a physician’s role, there is general agreement that meaningful doctor–patient relationships thrive on the doctor’s ability to understand and respond sensitively to the patient’s distress, whether it is of a medical, emotional, or spiritual nature. And although chaplains are available in many health care settings, physicians may sometimes need to engage patients in an initial discussion of spirituality
addressed the patient’s religious/spiritual beliefs. Students’ clinical performance scores showed no significant association with whether they made a chaplain referral. Conclusions Findings suggest that the majority of medical students without robust training in addressing patients’ spiritual needs can make a chaplain referral when faced with a patient in spiritual crisis. Yet, few students explicitly engaged the patient in a discussion of his beliefs. Thus, future studies are needed to develop more precise assessment measures that can inform development in spirituality and medicine curricula.
or religion to determine the need for an appropriate referral to a chaplain. Lack of understanding of the nature of a patient’s distress might result in an inappropriate referral to a psychologist, psychiatrist, or social worker in instances when the patient’s needs are purely religious or spiritual. According to a national survey published in 2010, 90% of American medical schools include curricular instruction regarding spirituality,9 and although there have been descriptive reports of the success of these curricula,10–12 there are few reports of assessment measures that capture the effect of spirituality training on students. Method
Background and study hypotheses In 2010, the George Washington Institute for Spirituality and Health (GWish) convened a consortium of medical educators to establish competencies surrounding spirituality and medicine.13 After the list of competencies was established by the participating medical schools, each school was charged with the task of developing a curricular project at its respective institution driven by any of the established competencies.
Academic Medicine, Vol. 89, No. 1 / January 2014
Research Report
At the Albert Einstein College of Medicine of Yeshiva University, Bronx, New York, two of us (M.M., F.M.) designed the standardized patient (SP) case that was used in the present study as an added element in the third-year curriculum (discussed below). The assessment exercise sought to determine the extent to which third-year medical students were able to demonstrate competence in two specific behavioral skill areas extracted from the GWish list of competencies: (1) respond appropriately to verbal and nonverbal signs of spiritual distress, and (2) make a timely referral to chaplain or spiritual advisor. We hypothesized that without specific skills training to explore a patient’s spirituality, the majority of our students would not be adequately equipped to engage a patient in a direct discussion of spiritual distress or to make a chaplain referral. Also, although we hypothesized that most students would not make a chaplain referral, we assumed that students with the most effective general communication skills would be most likely to do so. Setting Teaching about the role of spirituality is integrated longitudinally in the first- and second-year curriculum at our medical school, the Albert Einstein College of Medicine of Yeshiva University. In the mandatory first-year course, Introduction to Clinical Medicine, students address the topic of spirituality during two sessions in which small groups of students discuss a documentary about a Muslim patient whose religious beliefs influence his health care plan. In another session, students attend a panel in which a chaplain discusses his role and work with patients in palliative care. In the mandatory third-year course, Patients, Doctors and Communities, students discuss steps for breaking bad news, in which addressing spiritual beliefs is posed as a strategy for helping the patient identify avenues for coping with a difficult situation. However, we do not incorporate any targeted skills training on how to elicit a spiritual history, nor on how to directly communicate with a patient about his or her spiritual beliefs within the context of the patient’s illness and medical care. To inform our curricular development, we added a spiritual dimension to one of
Academic Medicine, Vol. 89, No. 1 / January 2014
our SP cases within our required objective structured clinical examination (OSCE) at the end of the third year. These elements of the case, however, were not graded or counted as part of a student’s final score. In the rest of this report, we describe the first implementation of the expanded OSCE and the postencounter exercise that were used to assess students’ abilities to respond to a patient in spiritual distress. SP encounter During March and April 2010, 170 third-year medical students completed the eight-station OSCE. One of the scenarios involved a 65-year-old man who presented with acute chest pain. Information about the case on the door outside the examination room stated that the patient had been evaluated by a cardiology fellow and was awaiting transfer from the emergency department to the coronary care unit (CCU). The patient was portrayed to be in stable medical condition at the time the student entered the room, but this acute medical episode had evoked a spiritual crisis for the patient. The SP was instructed to allow the student to explore all aspects of the chief complaint before telling the student that he was a religious man. If the student responded to this verbal cue, the SP would reveal his desire to speak to a chaplain. Additionally, there were other obvious cues to his religiousness: The SP wore a religious medal of a saint, had rosary beads on his bedside table, and expressed fear about dying and his transfer to the CCU. If the student missed all cues and failed to ask with whom the patient would prefer to talk, the SP did not offer any other information regarding his spiritual distress. We did not include checklist items for the SP to assess whether or not the student addressed the SP’s religiousness or made the offer of a chaplain referral. Rather, we assessed each student’s selfreport of chaplain referral and of recog nition of the SP’s spiritual distress via a postencounter note, described below. Postencounter note questions After the encounter, students wrote responses to four open-ended questions (listed in Table 1). The questions were constructed by three of us (M.M., F.M., W.B.), all experts in postnote question construction, with the intention of exploring students’ biopsychosocial–spiritual assessment of their clinical encounter.
Qualitative analysis All data were entered into a locked, password-protected computer and were deidentified. Initially, three of us (M.M., S.S., Z.S.) and two outside experts on the topic of spirituality reviewed a subset of the students’ postencounter notes for emergent themes and came to consensus regarding common codes. These codes were then applied to all 170 postencounter notes by one of us (Z.S.), to the first half by another (S.S.), and to the second half by another (M.M.) using NVivo 8 (Burlington, Massachusetts). As coding progressed, new codes were added and redundant codes were merged by agreement (M.M., S.S., Z.S.) to yield a final list of 34 codes. Interrater reliability was measured by running Cohen kappa coefficients in SAS version 9.3 (Cary, North Carolina). Discrepant codes with low reliability (< 0.6) were discussed by all coders, clarified, and fully adjudicated by two of us (M.M. and S.S.). Codes with kappa coefficient 0.61 to 0.99 were fully adjudicated by the third reviewer (Z.S.). Frequencies of codes were analyzed for the entire class; then, the frequencies of codes were compared for the group of students who offered chaplain referral and the group of students who did not. Additionally, we compared the two groups’ responses to the four postencounter questions by gender and by clinical skills assessment (CSA) scores. Finally, to validate students’ report of their responses to the second question (see Table 1), we randomly selected a subset of the patient encounter videotapes (35/170), which were independently viewed and coded by an outside coder blinded to the students’ postencounter notes. This allowed us to evaluate the level of congruency between self-reported and actual student behavior. The study was deemed exempt by the Einstein College of Medicine institutional review board. Results
Student demographics According to our medical school’s admission office, the Class of 2011 was 48% women, 10% self-identified from groups traditionally underrepresented in medicine, and 30% not U.S.-born. We do not routinely collect data on students’ self-identified religion; however, 20% of
67
Research Report
Table 1 Postencounter Questions and Goals of a Post-OSCE Student Assessment, Albert Einstein College of Medicine, 2010* Question
Goal of student assessment
What was the nature of the patient’s distress?
To recognize the standardized patient’s verbal and nonverbal cues of spiritual/religious distress To demonstrate skills in responding to the standardized patient’s spiritual/religious distress
How did you respond to the patient’s distress? If you had more time and could go back, what else would you have liked to address with this patient?
To reflect on their response to the standardized patient’s distress and perceived challenges of the encounter
What was challenging about this patient encounter?
To reflect on their response to the standardized patient’s distress and perceived challenges of the encounter
*Third-year medical students were given 10 minutes to respond to these questions after they completed a 15-minute objective structured clinical examination (OSCE) case of a patient with spiritual distress. This study was part of a mandatory eight-station OSCE given at the end of the third year of medical school.
the class completed their undergraduate education at Yeshiva University, of which the student population is 97% Jewish. Interrater reliability and congruency Interrater reliability of the coding of postencounter notes revealed kappa coefficients ranging from 0.39 to 1.0, with 70% of these being greater than 0.7. There was a 92% congruency rate between students’ self-reported behavior, as documented in the postencounter notes, and their actual behavior, as demonstrated in the 35 patient encounter videotapes that were reviewed. Postencounter reported responses Coding frequencies of the postencounter notes for emergent themes revealed that 108 students (64%) reported making an offer of chaplain referral. In response to the first question, 78 students (46%) reported that the patient is “religious”; only 3 students (2%) referred to the patient as “spiritual”; 40 students (24%) described the patient as emotionally distressed; no one specifically used the term “spiritual distress”; and 113 (67%) noted that he was fearful of dying. Students who made a chaplain referral were significantly more likely than students who did not make a chaplain referral to report that the patient was religious (P = .0001) and fearful of dying (P = .0019). In response to the second question, 102 students (60%) reported having offered reassurance about the patient’s physical condition; 84 (49%) reported having addressed the patient’s emotional state. Suggestions for a referral to a psychiatrist,
68
psychologist, or social worker were reported by 18 students (11%). Only 4 (2%) students reported that they engaged the patient in a direct discussion of his spiritual/religious beliefs. Responses to Question 2 did not differ by gender or between students who offered chaplain referral and those who did not. In response to the third question, 70 students (41%) reported that “if I had more time and could go back,” they would have liked to explore the patient’s fears or distress. Fifty-eight students (34%) reported that they would have collected more biomedical information, 25 (15%) would have provided more comfort or reassurance, and 13 (8%) would have had a discussion of code status. Desire to have conducted further investigation of spiritual concerns was cited by 34 students (20%); only 2 students thought of offering chaplain referral in retrospect. In response to the fourth question, 45 students (26%) cited the challenge of balancing attention to biomedical and spiritual needs; 25 students (15%) identified time constraints hindering collection of more biomedical information. Students who made a chaplain referral were significantly more likely than students who did not to report the challenge of “balancing biomedical and spiritual issues” (P = .021) and that time was a hindrance to collecting more biomedical information (P = .027). CSA scores Comparison of CSA scores on history taking, communication skills, physical
examination, and total score for this case, as well as the combined score for all eight CSA cases, revealed no significant differences between the scores of students who offered chaplain referral and the scores of those who did not. Discussion and Conclusions
Our study assessed third-year medical students’ ability to respond to the verbal and nonverbal cues of an SP in spiritual distress and to make the offer of chaplain referral. The majority (64%) of students reported offering the chaplain referral in the postencounter written exercise, whereas only four students actually engaged the SP directly in a discussion regarding his spiritual beliefs or the nature of the distress. Our findings supported the primary hypothesis that few students would actively engage an SP in a discussion of his spiritual distress, but did not support the hypothesis that few students would make a chaplain referral. In addition, we did not find an expected association between communication skills scores and chaplain referrals. One explanation for this set of findings is that the spirituality component of our current curriculum, though limited, raises students’ awareness of the role of religion and spirituality for a patient during a medical crisis. Such sensitization may have equipped the majority of students to respond to the SP’s desire to talk to a chaplain, although we cannot be sure this is the case. However, this interpretation is supported by the fact that students who, in their postencounter notes, acknowledged the SP’s religiousness were more likely to make a chaplain referral than were students who did not acknowledge the SP’s religiousness. Alternatively, it is possible that in trying to create a realistic scenario, we may have included cues of the SP’s religiousness that were too obvious. Students who made the chaplain referral were more likely than those who did not to acknowledge the patient’s religiousness and fear of dying in their postencounter note. It is possible that the offer of the chaplain referral was done by some students to relieve themselves of the responsibility to address religious or spiritual distress and allow them to move on to the biomedical issues of the
Academic Medicine, Vol. 89, No. 1 / January 2014
Research Report
case. Chaplain referral might, therefore, indicate different underlying skills and clinical goals in different students. This possibility might also explain the lack of association between making chaplain referral and communication scores, as well as the positive association between making a chaplain referral and wanting to collect more biomedical information. Because few students reported engaging the patient in a direct discussion of his spiritual distress, we were unable to evaluate the meaning of this outcome variable. Evaluation of the postencounter openended written exercise revealed that students’ perceptions of and reflections on their management of the SP’s distress were varied and multidimensional. Although almost half (46%) of the students reported that the patient was “religious,” only 3 students (2%) referred to the patient as “spiritual.” This finding may indicate that students are making an important distinction and that the language used in curricular activities matters (in this case, religious versus spiritual, explained at the beginning of this report). The finding that students found it challenging to balance the biomedical needs of the SP while addressing his spiritual distress and felt constrained by time raises the question of how we can enable students to become efficient and comfortable assessing a patient’s spirituality. Tools that are designed to help clinicians channel a discussion of spirituality and improve counseling competence—for instance, the FICA tool14 (faith, importance and influence, community, and address)—might be an effective and efficient strategy for addressing a patient’s spirituality and religion for busy clinicians. Another important finding of our study is the extremely high degree of congruence between viewed videos and self-report of chaplain referral in students’ postencounter notes. The ability to use students’ self-reports as an accurate means of behavioral assessment provides an opportunity to further mine postencounter notes for other aspects of behavior and reflection. Our study has several limitations. Because we conducted this study at only one institution, our findings are
Academic Medicine, Vol. 89, No. 1 / January 2014
probably not generalizable. Also, we did not gather information on students’ self-identified religion or spirituality, a factor that can affect interviewing praxis, as Curlin15 notes, particularly in the case of diagnosing and managing spiritual distress. Last, because the SP’s spiritual distress was exhibited within the context of a medical crisis in a graded exercise, students may have perceived this distress as a distraction. They might have performed differently if they had been explicitly assessed on their skills of addressing spiritual distress in a nongraded exercise or real-time clinical observation. In summary, our findings suggest that in the context of a third-year OSCE case, the majority of medical students without robust skills training in addressing patients’ spiritual needs are able to complete an action-oriented behavior of chaplain referral. However, a significant minority (one-third) did not make the offer of a chaplain despite the obvious cues and the SP’s willingness to reveal his desire for the referral when prompted. The disparity between report of chaplain referral and engaging the SP in a discussion of his spiritual needs raises questions regarding whether chaplain referral should be used as an isolated assessment measure of competence in this area. A next step would be to develop a more sensitive assessment tool to determine whether the skills needed for spiritual assessment and counseling differ from those involved in having empathic responses. However, the creation of our OSCE case and postencounter note provides a starting point for assessing students’ skill level in this area. The emergent themes that we gleaned from students’ postnotes—for instance, “recognition of patient’s religiousness” and “recognition of the patient’s fear of dying”—might be used as a basis to develop specific checklist items to assess the validity of other performance-based assessments with a focus on spiritual assessment or spiritual history taking. We conclude that until more accurately targeted assessment tools are developed, we are unable to clearly determine the relevant curricular interventions to equip students with the content and communication skills needed to adequately address patients’ distress
within the spiritual realm. Such studies could help determine whether we need more content-specific training in spiritual beliefs affecting patient care or, instead, need deeper communication skills training for attentive listening alone. Our view is that the former type of training would be more promising, based in part on the fact that our medical school has a robust communication skills training program but currently no targeted sessions on addressing spiritual beliefs. Thus, if attentive listening had been the only necessary ingredient in our study, we would have expected more students to engage the patient in a discussion of his religious/spiritual beliefs than was the case. Acknowledgments: The authors wish to thank Christina Puchalski, MD, and Mikhail Kogan, MD, at the George Washington Institute for Spirituality and Health for their help and assistance with this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The study was deemed exempt by the Einstein College of Medicine institutional review board.
References 1 Hebert RS, Jenckes MW, Ford DE, O’Connor DR, Cooper LA. Patient perspectives on spirituality and the patient–physician relationship. J Gen Intern Med. 2001; 16:685–692. 2 Sulmasy DP. Spirituality, religion, and clinical care. Chest. 2009;135:1634–1642. 3 Curlin FA, Chin MH, Sellergren SA, Roach CJ, Lantos JD. The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Med Care. 2006;44:446–453. 4 Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: Family physicians’ attitudes and practices. J Fam Pract. 1999;48:105–109. 5 McCauley J, Jenckes MW, Tarpley MJ, Koenig HG, Yanek LR, Becker DM. Spiritual beliefs and barriers among managed care practitioners. J Relig Health. 2005;44: 137–146. 6 Pargament K. The psychology of religion and spirituality? Yes and no. Int J Psychol Relig. 1999;9:3–16. 7 King DE. Faith, Spirituality and Medicine— Toward the Making of the Healing Practitioner. Binghamton, NY, Haworth Pastoral Press; 2000. 8 Herman TH. NANDA International Nursing Diagnoses. Definitions and Classifications, 2012–2014. 9th ed. Oxford, UK: WileyBlackwell; 2012. 9 Koenig HG, Hooten EG, Lindsay-Calkins E, Meador KG. Spirituality in medical school
69
Research Report curricula: Findings from a national survey. Int J Psychiatry Med. 2010;40:391–398. 10 King DE, Blue A, Mallin R, Thiedke C. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teach Learn Med. 2004;16:64–68. 11 Barnett KG, Fortin AH 6th. Spirituality and medicine. A workshop for medical students and residents. J Gen Intern Med. 2006;21:481–485.
12 Anandarajah G, Mitchell M. A spirituality and medicine elective for senior medical students: 4 years’ experience, evaluation, and expansion to the family medicine residency. Fam Med. 2007;39:313–315. 13 National Competencies. GW School of Medicine and Health Sciences. http://www. gwumc.edu/gwish/education/medicalschool-programs/national-competencies/ index.cfm. Accessed September 16, 2013.
14 Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA Tool for Spiritual Assessment. J Pain Symptom Manage. 2010;40:163–173. 15 Curlin FA, Lawrence RE, Odell S, et al. Religion, spirituality, and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. Am J Psychiatry. 2007;164: 1825–1831.
Teaching and Learning Moments The Mentor
The last time I saw him he looked old. Although I recognized his eyes and his smile, his countenance disturbed me. His stooped frame was supported by a cane, and he shuffled a bit as he ambled down the path toward me. I knew then that he was in his last season. I thought back to a time when we were both younger, more active, sharing interests and endeavors, even though a generation separated us. We were both teachers, but he was extraordinary in his ability to anticipate students’ thoughts and needs. I remember asking him long ago for the secret to becoming a good teacher and mentor. He put his arm around me and said, “Transform.” “What do you mean by that?” I asked. He explained: “The main struggle in life and work is how to evolve. You cannot gain knowledge without a profound modification in your being.” He thought all teachers and mentors needed spirituality because it “links knowledge, the activity of knowing and the conditions and the effects of this activity, to a transformation of your being.” I remembered being dumbfounded by such commentaries that seemed to
70
appear out of the intellectual ether that surrounded him. His piercing eyes stared at me through those round glasses as he waited for an acknowledgment that I understood. At times, those piercing eyes gave away his disappointment when the lost look on my face corroborated my ignorance of what he thought was obvious. However, he never shamed or belittled me. That day, I met him at the end of the path and shook his hand. It had a frailty that frightened me, not of him, but of what time will do to us all. I could tell that he sensed my pause. “How have you been?” I asked. He dropped my hand, gave me a big hug, and said, “I have been transforming.” I felt acutely embarrassed that after years of teaching and mentoring, my perceptive abilities and intellectual acuity lagged so far behind his. His short retort made me realize that I needed to reassess my evolution as a teacher and mentor. He made me aware of this deficiency with only a hug and grin. After all, that is what a good mentor and teacher does—he or she causes you to recognize an inadequacy in yourself, in effect allowing
you to right yourself, without shame or harsh words, much like a parent would. Now, time and infirmity have placed him in the past; he no longer mentors or teaches students. But I remain in the present, still a student of his yet also with students of my own, trying to understand my place and responsibility in the succession of students who become teachers. Socrates once told his student Alcibiades: “Pay some attention. Reflect a bit on what you are. Look at the education you have received. You will do well to know yourself a little better.” We all should follow Socrates’ instructions, which would have pleased my mentor. As the years pass, we should reflect from time to time on the interactions, events, and people that make a difference in our careers and personal lives. I pay homage to an intellectual benefactor, who shall remain anonymous, but who is easily recognizable if you just take a moment to pause and remember. Thomas J. Papadimos, MD, MPH Dr. Papadimos is vice chair for academic affairs and professor, Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio; e-mail: [email protected].
Academic Medicine, Vol. 89, No. 1 / January 2014
Assessing Third-Year Medical Students’ Ability to Address a Patient’s Spiritual Distress Using an OSCE Case Mimi McEvoy, MA, NP, Sheira Schlair, MD, MS, Zsuzsanna Sidlo, PhD, William Burton, PhD, and Felise Milan, MD
Abstract Purpose To inform curricular development by assessing the ability of third-year medical students to address a patient’s spiritual distress during an acute medical crisis in the context of an objective structured clinical examination (OSCE) case. Method During March and April 2010, 170 third-year medical students completed an eight-station videotaped OSCE at Albert Einstein College of Medicine of Yeshiva University. One of the standardized patients (SPs) was a 65-year-old man with acute chest pain who mentioned his religious affiliation and fear of dying.
S
tudies suggest that many patients welcome inquiry from their physicians about their spiritual or religious beliefs,1,2 yet in another study,3 45% of physicians said it is inappropriate to initiate discussions of patients’ religion or spirituality during clinical encounters. Ms. McEvoy is associate professor of family and social medicine and assistant professor of pediatrics, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Schlair is assistant professor, Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Sidlo is a fourth-year medical student, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Burton is associate professor, Family and Social Medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Dr. Milan is professor of clinical medicine, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Correspondence should be addressed to Ms. McEvoy, Albert Einstein College of Medicine, 1300 Morris Park Ave., Van Etten Building, RLG Clinical Skills Center, 2A30, Bronx, NY 10461; telephone: (718) 862-1778; fax: (718) 862-1797; e-mail: mimi. [email protected]. Acad Med. 2014;89:66–70. First published online November 25, 2013 doi: 10.1097/ACM.0000000000000061
66
If prompted, he revealed his desire to speak with a chaplain. The SP assessed students’ history taking, physical examination, and communication skills. In a postencounter written exercise, students reported their responses to the patient’s distress via four open-ended questions. Analysis of the postencounter notes was conducted by three coders for emergent themes. Clinical skills performance was compared between students who reported making chaplain referral and those who did not. Results A total of 108 students (64%) reported making a chaplain referral; 4 (2%) directly
Two primary reasons for this omission are thought to be physicians’ discomfort addressing the topic and a lack of targeted training.4,5 Broadly defined, spirituality can be understood as a “search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives.”6 Religion is a formal belief system that provides meaning to life through a common or shared set of beliefs, tenets, rituals, and practices.7 In this report, we use the term spiritual distress—defined as a disturbance of one’s belief system8—to convey the crisis that can occur when one’s meaning and purpose of life is threatened. Although discussions of spirituality or religion are not uniformly thought to be within the realm of a physician’s role, there is general agreement that meaningful doctor–patient relationships thrive on the doctor’s ability to understand and respond sensitively to the patient’s distress, whether it is of a medical, emotional, or spiritual nature. And although chaplains are available in many health care settings, physicians may sometimes need to engage patients in an initial discussion of spirituality
addressed the patient’s religious/spiritual beliefs. Students’ clinical performance scores showed no significant association with whether they made a chaplain referral. Conclusions Findings suggest that the majority of medical students without robust training in addressing patients’ spiritual needs can make a chaplain referral when faced with a patient in spiritual crisis. Yet, few students explicitly engaged the patient in a discussion of his beliefs. Thus, future studies are needed to develop more precise assessment measures that can inform development in spirituality and medicine curricula.
or religion to determine the need for an appropriate referral to a chaplain. Lack of understanding of the nature of a patient’s distress might result in an inappropriate referral to a psychologist, psychiatrist, or social worker in instances when the patient’s needs are purely religious or spiritual. According to a national survey published in 2010, 90% of American medical schools include curricular instruction regarding spirituality,9 and although there have been descriptive reports of the success of these curricula,10–12 there are few reports of assessment measures that capture the effect of spirituality training on students. Method
Background and study hypotheses In 2010, the George Washington Institute for Spirituality and Health (GWish) convened a consortium of medical educators to establish competencies surrounding spirituality and medicine.13 After the list of competencies was established by the participating medical schools, each school was charged with the task of developing a curricular project at its respective institution driven by any of the established competencies.
Academic Medicine, Vol. 89, No. 1 / January 2014
Research Report
At the Albert Einstein College of Medicine of Yeshiva University, Bronx, New York, two of us (M.M., F.M.) designed the standardized patient (SP) case that was used in the present study as an added element in the third-year curriculum (discussed below). The assessment exercise sought to determine the extent to which third-year medical students were able to demonstrate competence in two specific behavioral skill areas extracted from the GWish list of competencies: (1) respond appropriately to verbal and nonverbal signs of spiritual distress, and (2) make a timely referral to chaplain or spiritual advisor. We hypothesized that without specific skills training to explore a patient’s spirituality, the majority of our students would not be adequately equipped to engage a patient in a direct discussion of spiritual distress or to make a chaplain referral. Also, although we hypothesized that most students would not make a chaplain referral, we assumed that students with the most effective general communication skills would be most likely to do so. Setting Teaching about the role of spirituality is integrated longitudinally in the first- and second-year curriculum at our medical school, the Albert Einstein College of Medicine of Yeshiva University. In the mandatory first-year course, Introduction to Clinical Medicine, students address the topic of spirituality during two sessions in which small groups of students discuss a documentary about a Muslim patient whose religious beliefs influence his health care plan. In another session, students attend a panel in which a chaplain discusses his role and work with patients in palliative care. In the mandatory third-year course, Patients, Doctors and Communities, students discuss steps for breaking bad news, in which addressing spiritual beliefs is posed as a strategy for helping the patient identify avenues for coping with a difficult situation. However, we do not incorporate any targeted skills training on how to elicit a spiritual history, nor on how to directly communicate with a patient about his or her spiritual beliefs within the context of the patient’s illness and medical care. To inform our curricular development, we added a spiritual dimension to one of
Academic Medicine, Vol. 89, No. 1 / January 2014
our SP cases within our required objective structured clinical examination (OSCE) at the end of the third year. These elements of the case, however, were not graded or counted as part of a student’s final score. In the rest of this report, we describe the first implementation of the expanded OSCE and the postencounter exercise that were used to assess students’ abilities to respond to a patient in spiritual distress. SP encounter During March and April 2010, 170 third-year medical students completed the eight-station OSCE. One of the scenarios involved a 65-year-old man who presented with acute chest pain. Information about the case on the door outside the examination room stated that the patient had been evaluated by a cardiology fellow and was awaiting transfer from the emergency department to the coronary care unit (CCU). The patient was portrayed to be in stable medical condition at the time the student entered the room, but this acute medical episode had evoked a spiritual crisis for the patient. The SP was instructed to allow the student to explore all aspects of the chief complaint before telling the student that he was a religious man. If the student responded to this verbal cue, the SP would reveal his desire to speak to a chaplain. Additionally, there were other obvious cues to his religiousness: The SP wore a religious medal of a saint, had rosary beads on his bedside table, and expressed fear about dying and his transfer to the CCU. If the student missed all cues and failed to ask with whom the patient would prefer to talk, the SP did not offer any other information regarding his spiritual distress. We did not include checklist items for the SP to assess whether or not the student addressed the SP’s religiousness or made the offer of a chaplain referral. Rather, we assessed each student’s selfreport of chaplain referral and of recog nition of the SP’s spiritual distress via a postencounter note, described below. Postencounter note questions After the encounter, students wrote responses to four open-ended questions (listed in Table 1). The questions were constructed by three of us (M.M., F.M., W.B.), all experts in postnote question construction, with the intention of exploring students’ biopsychosocial–spiritual assessment of their clinical encounter.
Qualitative analysis All data were entered into a locked, password-protected computer and were deidentified. Initially, three of us (M.M., S.S., Z.S.) and two outside experts on the topic of spirituality reviewed a subset of the students’ postencounter notes for emergent themes and came to consensus regarding common codes. These codes were then applied to all 170 postencounter notes by one of us (Z.S.), to the first half by another (S.S.), and to the second half by another (M.M.) using NVivo 8 (Burlington, Massachusetts). As coding progressed, new codes were added and redundant codes were merged by agreement (M.M., S.S., Z.S.) to yield a final list of 34 codes. Interrater reliability was measured by running Cohen kappa coefficients in SAS version 9.3 (Cary, North Carolina). Discrepant codes with low reliability (< 0.6) were discussed by all coders, clarified, and fully adjudicated by two of us (M.M. and S.S.). Codes with kappa coefficient 0.61 to 0.99 were fully adjudicated by the third reviewer (Z.S.). Frequencies of codes were analyzed for the entire class; then, the frequencies of codes were compared for the group of students who offered chaplain referral and the group of students who did not. Additionally, we compared the two groups’ responses to the four postencounter questions by gender and by clinical skills assessment (CSA) scores. Finally, to validate students’ report of their responses to the second question (see Table 1), we randomly selected a subset of the patient encounter videotapes (35/170), which were independently viewed and coded by an outside coder blinded to the students’ postencounter notes. This allowed us to evaluate the level of congruency between self-reported and actual student behavior. The study was deemed exempt by the Einstein College of Medicine institutional review board. Results
Student demographics According to our medical school’s admission office, the Class of 2011 was 48% women, 10% self-identified from groups traditionally underrepresented in medicine, and 30% not U.S.-born. We do not routinely collect data on students’ self-identified religion; however, 20% of
67
Research Report
Table 1 Postencounter Questions and Goals of a Post-OSCE Student Assessment, Albert Einstein College of Medicine, 2010* Question
Goal of student assessment
What was the nature of the patient’s distress?
To recognize the standardized patient’s verbal and nonverbal cues of spiritual/religious distress To demonstrate skills in responding to the standardized patient’s spiritual/religious distress
How did you respond to the patient’s distress? If you had more time and could go back, what else would you have liked to address with this patient?
To reflect on their response to the standardized patient’s distress and perceived challenges of the encounter
What was challenging about this patient encounter?
To reflect on their response to the standardized patient’s distress and perceived challenges of the encounter
*Third-year medical students were given 10 minutes to respond to these questions after they completed a 15-minute objective structured clinical examination (OSCE) case of a patient with spiritual distress. This study was part of a mandatory eight-station OSCE given at the end of the third year of medical school.
the class completed their undergraduate education at Yeshiva University, of which the student population is 97% Jewish. Interrater reliability and congruency Interrater reliability of the coding of postencounter notes revealed kappa coefficients ranging from 0.39 to 1.0, with 70% of these being greater than 0.7. There was a 92% congruency rate between students’ self-reported behavior, as documented in the postencounter notes, and their actual behavior, as demonstrated in the 35 patient encounter videotapes that were reviewed. Postencounter reported responses Coding frequencies of the postencounter notes for emergent themes revealed that 108 students (64%) reported making an offer of chaplain referral. In response to the first question, 78 students (46%) reported that the patient is “religious”; only 3 students (2%) referred to the patient as “spiritual”; 40 students (24%) described the patient as emotionally distressed; no one specifically used the term “spiritual distress”; and 113 (67%) noted that he was fearful of dying. Students who made a chaplain referral were significantly more likely than students who did not make a chaplain referral to report that the patient was religious (P = .0001) and fearful of dying (P = .0019). In response to the second question, 102 students (60%) reported having offered reassurance about the patient’s physical condition; 84 (49%) reported having addressed the patient’s emotional state. Suggestions for a referral to a psychiatrist,
68
psychologist, or social worker were reported by 18 students (11%). Only 4 (2%) students reported that they engaged the patient in a direct discussion of his spiritual/religious beliefs. Responses to Question 2 did not differ by gender or between students who offered chaplain referral and those who did not. In response to the third question, 70 students (41%) reported that “if I had more time and could go back,” they would have liked to explore the patient’s fears or distress. Fifty-eight students (34%) reported that they would have collected more biomedical information, 25 (15%) would have provided more comfort or reassurance, and 13 (8%) would have had a discussion of code status. Desire to have conducted further investigation of spiritual concerns was cited by 34 students (20%); only 2 students thought of offering chaplain referral in retrospect. In response to the fourth question, 45 students (26%) cited the challenge of balancing attention to biomedical and spiritual needs; 25 students (15%) identified time constraints hindering collection of more biomedical information. Students who made a chaplain referral were significantly more likely than students who did not to report the challenge of “balancing biomedical and spiritual issues” (P = .021) and that time was a hindrance to collecting more biomedical information (P = .027). CSA scores Comparison of CSA scores on history taking, communication skills, physical
examination, and total score for this case, as well as the combined score for all eight CSA cases, revealed no significant differences between the scores of students who offered chaplain referral and the scores of those who did not. Discussion and Conclusions
Our study assessed third-year medical students’ ability to respond to the verbal and nonverbal cues of an SP in spiritual distress and to make the offer of chaplain referral. The majority (64%) of students reported offering the chaplain referral in the postencounter written exercise, whereas only four students actually engaged the SP directly in a discussion regarding his spiritual beliefs or the nature of the distress. Our findings supported the primary hypothesis that few students would actively engage an SP in a discussion of his spiritual distress, but did not support the hypothesis that few students would make a chaplain referral. In addition, we did not find an expected association between communication skills scores and chaplain referrals. One explanation for this set of findings is that the spirituality component of our current curriculum, though limited, raises students’ awareness of the role of religion and spirituality for a patient during a medical crisis. Such sensitization may have equipped the majority of students to respond to the SP’s desire to talk to a chaplain, although we cannot be sure this is the case. However, this interpretation is supported by the fact that students who, in their postencounter notes, acknowledged the SP’s religiousness were more likely to make a chaplain referral than were students who did not acknowledge the SP’s religiousness. Alternatively, it is possible that in trying to create a realistic scenario, we may have included cues of the SP’s religiousness that were too obvious. Students who made the chaplain referral were more likely than those who did not to acknowledge the patient’s religiousness and fear of dying in their postencounter note. It is possible that the offer of the chaplain referral was done by some students to relieve themselves of the responsibility to address religious or spiritual distress and allow them to move on to the biomedical issues of the
Academic Medicine, Vol. 89, No. 1 / January 2014
Research Report
case. Chaplain referral might, therefore, indicate different underlying skills and clinical goals in different students. This possibility might also explain the lack of association between making chaplain referral and communication scores, as well as the positive association between making a chaplain referral and wanting to collect more biomedical information. Because few students reported engaging the patient in a direct discussion of his spiritual distress, we were unable to evaluate the meaning of this outcome variable. Evaluation of the postencounter openended written exercise revealed that students’ perceptions of and reflections on their management of the SP’s distress were varied and multidimensional. Although almost half (46%) of the students reported that the patient was “religious,” only 3 students (2%) referred to the patient as “spiritual.” This finding may indicate that students are making an important distinction and that the language used in curricular activities matters (in this case, religious versus spiritual, explained at the beginning of this report). The finding that students found it challenging to balance the biomedical needs of the SP while addressing his spiritual distress and felt constrained by time raises the question of how we can enable students to become efficient and comfortable assessing a patient’s spirituality. Tools that are designed to help clinicians channel a discussion of spirituality and improve counseling competence—for instance, the FICA tool14 (faith, importance and influence, community, and address)—might be an effective and efficient strategy for addressing a patient’s spirituality and religion for busy clinicians. Another important finding of our study is the extremely high degree of congruence between viewed videos and self-report of chaplain referral in students’ postencounter notes. The ability to use students’ self-reports as an accurate means of behavioral assessment provides an opportunity to further mine postencounter notes for other aspects of behavior and reflection. Our study has several limitations. Because we conducted this study at only one institution, our findings are
Academic Medicine, Vol. 89, No. 1 / January 2014
probably not generalizable. Also, we did not gather information on students’ self-identified religion or spirituality, a factor that can affect interviewing praxis, as Curlin15 notes, particularly in the case of diagnosing and managing spiritual distress. Last, because the SP’s spiritual distress was exhibited within the context of a medical crisis in a graded exercise, students may have perceived this distress as a distraction. They might have performed differently if they had been explicitly assessed on their skills of addressing spiritual distress in a nongraded exercise or real-time clinical observation. In summary, our findings suggest that in the context of a third-year OSCE case, the majority of medical students without robust skills training in addressing patients’ spiritual needs are able to complete an action-oriented behavior of chaplain referral. However, a significant minority (one-third) did not make the offer of a chaplain despite the obvious cues and the SP’s willingness to reveal his desire for the referral when prompted. The disparity between report of chaplain referral and engaging the SP in a discussion of his spiritual needs raises questions regarding whether chaplain referral should be used as an isolated assessment measure of competence in this area. A next step would be to develop a more sensitive assessment tool to determine whether the skills needed for spiritual assessment and counseling differ from those involved in having empathic responses. However, the creation of our OSCE case and postencounter note provides a starting point for assessing students’ skill level in this area. The emergent themes that we gleaned from students’ postnotes—for instance, “recognition of patient’s religiousness” and “recognition of the patient’s fear of dying”—might be used as a basis to develop specific checklist items to assess the validity of other performance-based assessments with a focus on spiritual assessment or spiritual history taking. We conclude that until more accurately targeted assessment tools are developed, we are unable to clearly determine the relevant curricular interventions to equip students with the content and communication skills needed to adequately address patients’ distress
within the spiritual realm. Such studies could help determine whether we need more content-specific training in spiritual beliefs affecting patient care or, instead, need deeper communication skills training for attentive listening alone. Our view is that the former type of training would be more promising, based in part on the fact that our medical school has a robust communication skills training program but currently no targeted sessions on addressing spiritual beliefs. Thus, if attentive listening had been the only necessary ingredient in our study, we would have expected more students to engage the patient in a discussion of his religious/spiritual beliefs than was the case. Acknowledgments: The authors wish to thank Christina Puchalski, MD, and Mikhail Kogan, MD, at the George Washington Institute for Spirituality and Health for their help and assistance with this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The study was deemed exempt by the Einstein College of Medicine institutional review board.
References 1 Hebert RS, Jenckes MW, Ford DE, O’Connor DR, Cooper LA. Patient perspectives on spirituality and the patient–physician relationship. J Gen Intern Med. 2001; 16:685–692. 2 Sulmasy DP. Spirituality, religion, and clinical care. Chest. 2009;135:1634–1642. 3 Curlin FA, Chin MH, Sellergren SA, Roach CJ, Lantos JD. The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Med Care. 2006;44:446–453. 4 Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: Family physicians’ attitudes and practices. J Fam Pract. 1999;48:105–109. 5 McCauley J, Jenckes MW, Tarpley MJ, Koenig HG, Yanek LR, Becker DM. Spiritual beliefs and barriers among managed care practitioners. J Relig Health. 2005;44: 137–146. 6 Pargament K. The psychology of religion and spirituality? Yes and no. Int J Psychol Relig. 1999;9:3–16. 7 King DE. Faith, Spirituality and Medicine— Toward the Making of the Healing Practitioner. Binghamton, NY, Haworth Pastoral Press; 2000. 8 Herman TH. NANDA International Nursing Diagnoses. Definitions and Classifications, 2012–2014. 9th ed. Oxford, UK: WileyBlackwell; 2012. 9 Koenig HG, Hooten EG, Lindsay-Calkins E, Meador KG. Spirituality in medical school
69
Research Report curricula: Findings from a national survey. Int J Psychiatry Med. 2010;40:391–398. 10 King DE, Blue A, Mallin R, Thiedke C. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teach Learn Med. 2004;16:64–68. 11 Barnett KG, Fortin AH 6th. Spirituality and medicine. A workshop for medical students and residents. J Gen Intern Med. 2006;21:481–485.
12 Anandarajah G, Mitchell M. A spirituality and medicine elective for senior medical students: 4 years’ experience, evaluation, and expansion to the family medicine residency. Fam Med. 2007;39:313–315. 13 National Competencies. GW School of Medicine and Health Sciences. http://www. gwumc.edu/gwish/education/medicalschool-programs/national-competencies/ index.cfm. Accessed September 16, 2013.
14 Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA Tool for Spiritual Assessment. J Pain Symptom Manage. 2010;40:163–173. 15 Curlin FA, Lawrence RE, Odell S, et al. Religion, spirituality, and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. Am J Psychiatry. 2007;164: 1825–1831.
Teaching and Learning Moments The Mentor
The last time I saw him he looked old. Although I recognized his eyes and his smile, his countenance disturbed me. His stooped frame was supported by a cane, and he shuffled a bit as he ambled down the path toward me. I knew then that he was in his last season. I thought back to a time when we were both younger, more active, sharing interests and endeavors, even though a generation separated us. We were both teachers, but he was extraordinary in his ability to anticipate students’ thoughts and needs. I remember asking him long ago for the secret to becoming a good teacher and mentor. He put his arm around me and said, “Transform.” “What do you mean by that?” I asked. He explained: “The main struggle in life and work is how to evolve. You cannot gain knowledge without a profound modification in your being.” He thought all teachers and mentors needed spirituality because it “links knowledge, the activity of knowing and the conditions and the effects of this activity, to a transformation of your being.” I remembered being dumbfounded by such commentaries that seemed to
70
appear out of the intellectual ether that surrounded him. His piercing eyes stared at me through those round glasses as he waited for an acknowledgment that I understood. At times, those piercing eyes gave away his disappointment when the lost look on my face corroborated my ignorance of what he thought was obvious. However, he never shamed or belittled me. That day, I met him at the end of the path and shook his hand. It had a frailty that frightened me, not of him, but of what time will do to us all. I could tell that he sensed my pause. “How have you been?” I asked. He dropped my hand, gave me a big hug, and said, “I have been transforming.” I felt acutely embarrassed that after years of teaching and mentoring, my perceptive abilities and intellectual acuity lagged so far behind his. His short retort made me realize that I needed to reassess my evolution as a teacher and mentor. He made me aware of this deficiency with only a hug and grin. After all, that is what a good mentor and teacher does—he or she causes you to recognize an inadequacy in yourself, in effect allowing
you to right yourself, without shame or harsh words, much like a parent would. Now, time and infirmity have placed him in the past; he no longer mentors or teaches students. But I remain in the present, still a student of his yet also with students of my own, trying to understand my place and responsibility in the succession of students who become teachers. Socrates once told his student Alcibiades: “Pay some attention. Reflect a bit on what you are. Look at the education you have received. You will do well to know yourself a little better.” We all should follow Socrates’ instructions, which would have pleased my mentor. As the years pass, we should reflect from time to time on the interactions, events, and people that make a difference in our careers and personal lives. I pay homage to an intellectual benefactor, who shall remain anonymous, but who is easily recognizable if you just take a moment to pause and remember. Thomas J. Papadimos, MD, MPH Dr. Papadimos is vice chair for academic affairs and professor, Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio; e-mail: [email protected].
Academic Medicine, Vol. 89, No. 1 / January 2014
