1. Using Grief, Homelessness, Illness, End-of-Life and an Interdisciplinary Approach to Teach Spiritual Sensitivity
Curriculum development funded by a grant from the Templeton Foundation
STFM Predoctoral Conference
January 30, 2010

2. Contact Information
David Holmes, MD
Clinical Associate Professor
Director of Clerkship and
Electives
Kimberly Oddo, MS-4
University at Buffalo
School of Medicine and Biomedical Sciences
Department of Family Medicine
Karen Devlin
Course Coordinator

3. Faith
Spirituality
Religion
According to a Gallup poll (2004):
90% of American adults believe in God
84% say that religion is very important or fairly important in their own life.

4. Biomedical Model is Inadequate
While the biomedical model is excellent for describing certain disease mechanisms (e.g. viral illnesses), it has difficulty accounting for psychological, sociological and spiritual factors that influence most, if not all, illnesses.
- Engel GL. The Clinical Application of the Biopsychosocial Model Am J Psychiatry. 1980;137:

5. Whole Person Health Care The Bio-psycho-social Model
This model is also inadequate because it is incomplete

6. Whole Person Health Care The Bio-psycho-social-spiritual Model
Who provides this kind of care?

7. Why Address Spirituality in Health Care?
1. Spiritual beliefs are common among patients and serve a distinct purpose
2. Spiritual beliefs influence medical decision-making
3. There is a relationship between faith and health according to numerous studies
4. Many patients would like their doctors to address
issues of faith and health
5. There is a historical precedent for doing so
The first hospital in the western world was established in 307 AD in Turkey by the Eastern Orthodox Church in response to the Biblical command to “care for the sick”
- Koenig, Spirituality and Patient Care; 2002
Also, addressing spiritual beliefs with patients often improves the doctor - patient relationship
Eastern Orthodox Church established the first known hospital in Asia Minor in 370 AD

8. Why? – JACHO Standard
“Spiritual assessment should, at a minimum, determine the patient's denomination, beliefs, and what spiritual practices are important to the patient. This information would assist in determining the impact of spirituality, if any, on the care/services being provided and will identify if any further assessment is needed.”
- Joint Commission on Accreditation of Healthcare Organizations (JACHO) Jan 1, 2004

9. Why? – AAMC Standard
“Effective communication is the lynchpin in the relationship between physician and patient, as well as critical in exchanging information with families, colleagues and related professionals administering care. In order to communicate effectively with patients, physicians will also need to understand how a person’s spirituality and culture affect how they perceive health and illness, and particularly their desires regarding end-of-life care.”
- American Association of Medical College’s (AAMC) Medical School Objectives Project 1999

10. American Psychiatric Association
recommends that physicians ask about the spiritual orientation of patients “so that they may properly attend to them in the course of treatment.”
- Committee on Religion and Psychiatry. “Guidelines Regarding Possible Conflict Between Psychiatrists’ Religious Commitments and Psychiatric Practice.” Am J Psychiatry. 1990;147:542

11. Health-related quality of life (even during terminal illness)
Most studies have shown that religious involvement are associated with better health outcomes, including . . .
Greater longevity
21,000 adults in US – those who attended church more than once a week lived 7 years longer (on average) than those who never attended church. Among African Americans, the difference was 14 years. - Hummer, Demography 1999
Coping skills
Health-related quality of life (even during terminal illness)
Less anxiety, depression and suicide
- Mueller P, Plevak D, Rummans T, “Religious Involvement, Spirituality and Medicine: Implications for Clinical Practice.” Mayo Clinic Proceedings, 76(12): , Dec 2001

12. Spirituality in Medicine Curricula in U.S. Medical Schools
U.S. Medical schools that have any type of course work
related to the role of spirituality in health and illness
1992: 3 = 2%
1994: 17 = 14%
1998: 38 = 30%
2004: 84 = 64%
2006: 92 = 70%
John Templeton Foundation; Puchalski and Larson, 1998; Levin, 1997; Matthews, 1998
“There are about 102 of the 144 (71%) medical and osteopathic schools that have topics related to spirituality integrated into their curricula.” - John Templeton Foundation Capabilities Report 2008; accessed at:

13. Spirituality in Medicine at UB’s Medical School
1st Yr - Spiritual history taking
2nd Yr – Delivering bad news
3rd Yr - Rounds with a hospital chaplain (Int Med)
- End-of-life care at Hospice (Fam Med)
- Coping with grief (Peds)
- Homelessness and domestic violence
(Ob/Gyn)
4th Yr - “Faith, Medicine and End-of-Life Care”
(Fam Med elective)

14. Anandarajah and Hight, American Family Physician; 2001:63(1)
HOPE QUESTIONS
Hope – sources of hope, meaning, faith, comfort, strength, peace, love, and connection:
Where do you turn for support when you need help? What are your sources of comfort and hope? What keeps you going during difficult times?
Organized religion:
Are you part of a religious or spiritual community? How important is this to you? How helpful to you?
Personal spirituality or practice:
Do you have personal spiritual beliefs? What are they? Do you have spiritual practices that you follow for yourself?
Effects on medical care and end-of-life issues:
Are there any specific practices or restrictions I should know about in providing your medical care (e.g., dietary restrictions, use of blood products?) Should I coordinate your medical care with your chaplain? How do your beliefs affect the kind of medical care you would like?
Anandarajah and Hight, American Family Physician; 2001:63(1)

15. Student Perspective
Student evaluations immediately following each activity including ratings and comments
Personal experiences and the reflections of classmates
I’m going to talk about evaluations of students as well as my own observations and experiences of students that I have spoken with
Year 1 – we learned the HOPE questions and it was about as uncomfortable and mechanical as every other set of questions that we learned at that point in our training
Year two – going from standardized patients to real patients was a great experience.
Stands out to many as one of the best experiences of medical school
More realistic and emotional given their history
The cancer survivors were involved in various support groups that they discussed with us; individual differences in sources of hope

16. Spirituality – Didactic Years
Introduction to HOPE questions
Year 2
Delivering bad news to cancer survivors
Incorporation of HOPE questions
Panel of cancer survivors
Experiences with medical profession throughout their illnesses
Sources of spiritual strength
I will briefly say the Year 1 introduced us to HOPE – at that time it was as foreign as any other of the many mnemonic used for interviewing; then will tell story of My experience with melanoma patient

17. Year 2: Delivering “Bad News”
Describe what you are most apprehensive about in delivering “Bad News”
“… how to handle the situation professionally with empathy”
“… unsure of how to approach issues of spirituality”
“The spirituality section: personal lack of spirituality causes concern about being empathic”
“I have a difficult time separating my own faith practices from the sciences and evidence-based medicine. I don’t want to seem “faithful/hopeful” to the patient, especially if it is a grave situation.”
“remembering the SPIKES and HOPE protocols.”
Concerns with how to deliver, setting, etc.
- How to be “professional” and empathetic; both ends of the spiritual spectrum – how do we reconcile where we are in our personal faith with where the patients are

18. Year 2: Delivering Bad News Evaluation Questions
How confident do you feel in the following spiritual assessment skills?
Q1: Using a protocol for inquiring into a patient’s spiritual views
Q2: Inquiring of a patient what he or she finds or relies upon for sources of hope, comfort, and strength during difficult times
Q3: Inquiring of a patient if he or she participates in organized religion
Q4: Inquiring about a patient’s personal spiritual practices

19. Effectiveness of Improving Student Confidence in “Bad News” Session

20. Year 3: Pediatric Clerkship Spirituality and Coping with Crisis
Families welcomed us into their homes and shared their personal stories of loss of a child
Discussion of how families coped, resources available,
role of faith
Small group discussion
of experiences
* Will discuss my experience with aunt of a child who died

21. Pediatric Clerkship – Spirituality and Coping with Crisis
82% of students either “agreed” or “strongly agreed” that they had increased understanding of the importance of addressing spirituality
Strengths:
“one of the best experiences of the clerkship
“I will be more sensitive to what [families] are going through…”
Weaknesses:
I didn’t support the injection of “spirituality” in medicine or the idea that “all people are spiritual”
* Perhaps at some point comment on the negative comments – that it got students thinking, debating about the role of religion, even when people did not like the experience.. It made some people uncomfortable… but that in itself is also important – at least it started a discussion
N = 74

22. Ob/Gyn Clerkship: Cornerstone Manor
a shelter for women
and children who are homeless and/or victims or domestic violence
Faith based healing
Students were given lecture, tour, and opportunity to interview clients

23. Cornerstone Manor Evaluation
72% of students rated the experience “very good” or “outstanding”
Strengths:
“It was helpful to see what opportunities are available in the community.”
Weaknesses:
“time could have been much better spent elsewhere…”
The comments are mostly activity focused, not sure if should incorporate?
N = 45

24. Internal Medicine Clerkship: Day With Chaplain
Discussed the role of hospital chaplain, when to refer, and how chaplains approach patients with different faiths
Shadowed the chaplain for a half day during patient visits

25. Chaplain Session Evaluation
What were the most important things you learned from this experience?
“I learned how and when to call the chaplain service.”
“I really enjoyed the opportunity to communicate with patients about their spiritual beliefs and offer support in a different, and perhaps more meaningful way.”
“I think it makes an important point to think of the patient as a whole and consider what might help them get through illness outside of medical intervention”
Negative feedback:
“Eliminate all aspects of any particular religion. In fact, even calling it Spirituality biases things very heavily towards Catholicism… It is wrong to assume “everyone has spiritual needs” and it is very thinly veiled Christianity that has no use in the hospital.”
The negative feedback highlights that when dealing with matters of religion in medicine, there is always a small percentage of patients who are strongly opposed to religious involvement in medicine, and likewise physicians who are strongly opposed

26. Chaplain Session: Student Responses
Maybe just include these charts, but don’t discuss them
N = 109

27. Chaplain Session: Student Responses
In a survey, 55% of physicians stated that it was usually or always appropriate to inquire aobut patient’s R/S beliefs, but only 10% usually or always did so.
N = 109

28. Family Medicine Clerkship: Spirituality and End-of-Life Session
Physicians and staff from Hospice teach about palliative care and end-of-life issues
Leaders of different religions teach the basic tenets of faith and how they relate to health, well-being, and end-of-life decision making

29. Family Medicine Clerkship: Spirituality and End-of-Life Session
What did you learn about the faiths that you didn’t already know?
Various aspects of Hinduism, Buddhism, Atheism, Islam, Christianity, Sikhism
How will you incorporate what you learned into your practice?
More openness and consideration of different belief systems
Be more sensitive and aware of patients’ beliefs
Weaknesses of session
Not enough emphasis on clinical
practice, correlation, and relevance

30. Faith in Medicine Elective
Elective offered to 3rd and 4th year students
Time spent with hospice, immunodeficiency clinic, and physician’s office
This experience immerses us into the spiritual side – the opposite of what we normally do in medicine

31. Faith in Medicine Elective
“I think that the experiences made me more comfortable to talk to patients about their personal lives and spiritual lives, which aids in patient-physician relationship/therapeutic alliance…”
“This rotation served as a wonderful reminder to me that patients were always people, with complicated psychosocial and spiritual needs, before they were medical cases. It made patients human again. It made me human again. And for once, the big picture of each person’s life was not lost in the minutia that is such a necessary but mundane part of modern medicine…”
The sentiment of this student’s evaluation was what resounded to me not so much in the evaluations of the students at the time of the sessions, but in speaking with fourth year students – they recall the spirituality in medicine component as, more than anything, forcing them to take a step back and remember why we all are here… to remember the human component of medicine,

32. ~ Harold G. Koenig, M.D., in Spirituality in Patient Care
“…No, most of us become HPs because we want to help people, because we want to make a difference in people’s lives and the world around us. Sometimes, though, the training of HPs and the rigors of daily care for patients stamp out that idealism. When this happens, HPs begin to experience emptiness and lack of fulfillment in what they are doing, which may lead them to question their choice of profession. HPs who address the spiritual needs of patients sometimes experience an arousal of that buried sense of idealism that drove them to become HPs in the first place.”
~ Harold G. Koenig, M.D., in Spirituality in Patient Care

33. Summary of Student Feedback
Provides the opportunity to take a step back and remind us of the human element of medicine
Teaches how and when to elicit a spiritual history
Improves cultural and religious sensitivity and awareness
I appreciate it even more retrospectively, same with others.
Second point – add my story of the patient I had recently, how I used the HOPE questions

34. Resources Websites/Organizations:
George Washington Institute for Spirituality and Health GWISH.org
Duke University Center for Spirituality, Theology and Health spiritualityandhealth.duke.edu
John Templeton Foundation templeton.org
Books:
Handbook for Mortals: Guidance for People Facing Serious Illness by Joanne Lynn, M.D. and Joan Harrold, M.D.
Spirituality in Patient Care: Why, How, When, and What by Harold G. Koenig, M.D.
Faith, Spirituality, and Medicine by Dana E. King, M.D.
VHS:
“Give Me Strength” Spirituality in the Medical Encounter, Moderated by Ben Carson, M.D.