How can I incorporate spirituality into the curriculum at my medical school?
A Model Course Curriculum
Here I present a model course outline for integrating spirituality into patient care that can be used in medical schools, medical or psychiatry residencies, psychology or counseling programs, nursing schools, schools of social work, and in training programs for physical and occupational therapists, physician assistants, nurse practitioners, and other health care professionals. Although there is not a common curriculum currently used in any health professional (HP) training program, other models for medical curricula exist and the reader should be familiar with them.1 Below, I describe the ways that a spirituality course can be structured within the existing curriculum, the form that the course can take, and then describe the content of what needs to be taught, using a spirituality curriculum designed for medical schools as the initial example and then showing how the basic content can be modified for other HP curricula.
Structure and Timing
First, a decision has to be made on how the course will be structured within the existing curriculum. This will depend on how much overall time will be allowed for such a course, and when that time will be allowed. If little or no time is allowed, then a 60-minute lecture with 15 to 30 minutes for discussion will need to suffice. If enough time for a mini-course is allowed, then three or four 60- to 90-minute sessions may be possible. A full course would ideally involve at least ten 60- to 90-minute sessions.
A related issue is whether the course will be elective or required. If elective, only a handful of students are likely to attend, although these will be the students who really want to be there and more time will be available to treat the topic in greater depth. If the course is required, then all students will get some exposure to the topic, although the amount of material taught may be less. Currently, about 70 percent of spirituality courses in medical schools are required, which I think they ought to be.
Next, a decision must be made on when in the medical curriculum the course will be taught, and whether it should be taught only in a single block, separated into more than one block, or distributed throughout the curriculum. The structure of the medical curriculum to some extent determines the ideal time for presenting the spirituality curriculum to medical students. The first two years are often spent learning the basic/clinical sciences and being introduced to the human aspects of medicine. In the third year, medical students begin their clinical clerkships on the wards, learning the clinical material by actually doing it, and become responsible for patient care under the supervision of interns and residents. In the fourth year, more advanced clinical rotations will be taken and there will be time for a few electives. Some medical schools also require that a research project be completed in the third or fourth year.
The spirituality course could be taught in the first or second year of medical school, exposing medical students to these issues when they are just starting out. Another option is to teach the course in the fourth year along with a clinical rotation or a preceptorship with a physician working in the community. A third option is distributing the course throughout the four years of medical school. The spirituality course does not always need to be taught as a separate course; instead, it can be included as part of another course, such as the Medicine and Society course often taught in the first or second year. This course typically involves related topics on behavioral medicine, ethical issues, advanced
care planning, doctor-patient communication, and complementary and alternative medicine. This does not mean simply doing what is already being done in these courses, but rather including specific content that explicitly addresses religious or spiritual issues.
If there is only time for a couple of lectures, then probably the worst time is during the first year of medical school, when students are being bombarded with the basic sciences and have no clinical experience with which to ground the material they learn on spirituality. Without clinical experience, it is difficult for students to grasp the meaning and relevancy of this topic that may be seen as the antithesis of "real science." However, if students are exposed to the material early on and it is reinforced by linking with actual cases during the clinical years, this will help the ideas to stick in their minds. Thus, if time and faculty are available and the dean is supportive, integrating it throughout the four-year curriculum is ideal, with the initial course taught in the first or second year and the concepts explicitly reinforced and modeled during the remaining two years when students are caring for patients.
The form that a spirituality curriculum takes can greatly vary, and it is probably wise to include as many different ways of presenting the material as possible. The available forms in order of low to high impact are: (1) reading an article/s from the medical literature; (2) attending a lecture (no discussion); (3) attending a lecture with a discussion; (4) listening to a case presentation followed by a discussion; (5) exposure to a live patient with questions from the class and later discussion; (6) faculty modeling within clinical settings; and (7) role-playing.
Articles. As with most medical training, students are often given seminal articles to read from the medical literature on topics they are studying. This is one of the least effective ways of learning but better than nothing and uses up virtually no time from the medical curriculum. Student may then be asked to give an oral report on the article to their peers, which will add value to the learning experience.
Lecture. Lectures are important because they can convey large amounts of information in a relatively short time. They are better than reading an article, because there is a live person speaking and hopefully engaging the audience through sight, sound, and personal interaction. Of course, for this modality to be successful, the speaker must be engaging.
Lecture with Discussion. Adding time for discussion after the lecture engages the students further and forces them to think and become involved with the topic. The speaker, however, must be very knowledgeable about the topic in order to handle all sorts of questions, and be able to moderate the discussion and group dynamics that ensue.
Presentation of a Case. Holding a case conference, where one of the students presents an actual case to the group that involves religious or spiritual issues, can be very effective learning, since students view cases as more clinically relevant and "stories" are always remembered better than facts. The case conference should include ample time for questions and discussion, allowing other students to get involved and deeper aspects of the topic to be explored.
Presentation of Live Patient. One of the most effective ways of presenting material is to have a live patient come to a conference room or lecture auditorium and describe his or her current experience of grappling with illness and the role that religious/spiritual beliefs and practices play to help him or her cope, derive meaning, and experience hope. The more dramatic the case and the more expressive the patient, the better. A student or faculty member first presents the case to the group. The patient then appears and tells his or her story. This is then followed by questions from students directly to the patient, with faculty moderating the process to clarify and make it easier on the patient. The patient then leaves the room, and a discussion follows.
Faculty Modeling. Here, faculty model taking a spiritual history or otherwise interacting with patients over spiritual matters in a clinical setting. This may take place on the hospital wards during medical rounds or in the outpatient clinics. A student may spend a month in a preceptorship with a clinician in the community who regularly addresses spiritual issues as part of his or her practice. This is one of the most effective forms of learning, because it involves seeing a seasoned clinician in action, direct experience of results, and repetition, and may even involve student practice (depending on the particular patient and the comfort level of the clinician).
Role-playing. Students may take turns role-playing patient and doctor. This works best for taking a spiritual history, supporting beliefs, and deciding on whether to refer to a chaplain (with a third student playing the chaplain, or having a student chaplain play this role). Role-playing, while a bit awkward when being done with fellow students, will help to significantly ease the discomfort involved in doing this with patients. Since discomfort is one of the main barriers that prevent physicians from addressing spiritual issues, role-playing and practice should be central to any well-rounded spirituality curriculum.
In summary, a course should be given designated time to teach issues specifically related to religion and spirituality. This course will start with an initial series of classes as an introduction, and then concepts will be applied and reinforced throughout the four years of medical school, timed so that they are relevant to what students are learning in other areas. It will include all of the above forms of teaching—articles, lectures, discussions, case presentations, faculty modeling, and role-playing. That is the ideal, and in real life, where most medical curricula are already packed to their limits, one takes whatever one can get.
The content of the spirituality curriculum is critical in determining what students will take away from the often brief exposure to this topic. The order of presenting material is also important. Below, I describe a ten-session model curriculum that will need to be
adapted to the time and setting available. This ten-session course should ideally be taught in the first or second year and individual components of the course reemphasized and elaborated on at appropriate times in sync with material taught during the remaining years; alternatively, the individual sessions could be taught at different times during the four-year medical curriculum. The content presented below follows the main chapters of this book, Spirituality in Patient Care (SPC). Each session will take 60-90 minutes.
Session 1. Introduction to topic. Format: lecture and discussion. Content: A broad overview of spirituality and medicine should be presented, including a historical perspective, discussion of definitions (spirituality, religion, humanism), description of patients' spiritual needs and who is available to address them, brief description of each of the remaining nine sessions, and discussion of what is expected of students to successfully complete the course (including attendance and participation). Remainder of time should be allowed for student questions, clarifications, and discussion. Handout material to be read by next class: SPC introduction and chapter 1, along with a review article.2
Session 2. Why address spirituality in patient care? Format: case presentation followed by lecture and discussion. Content: Briefly present case, and then review the six reasons why spirituality should be addressed by physicians (defer discussion of research on religion and health to next session). End lecture with data on how patients feel, how physicians feel, and what physicians are currently doing with regard to identifying or addressing patients' spiritual needs. Use remainder of time for discussion. Handout material to be read by next class: choose a combination of best original research on mental health,3 physical health,4 and pro/con review articles.5
Session 3. The research. Format: lecture and discussion. Content: Lecture should cover three areas: (1) examine religion/ spirituality and mental health; (2) discuss mind-body relationships (psychoneuroimmunology and stress-related cardiovascular system changes); and (3) describe a model of how religion/spirituality could affect physical health, and present research on religion/spirituality and physical health. This is a lot of material to cover, but time is also needed for discussion (pros and cons regarding quality of existing research). Handout material to be read by next class: article about a religious patient.6
Session 4. The patient's perspective. Format: live case presentation, questions, and discussion. Content: Identify a patient who is seriously ill, articulate, deeply religious, and using his or her beliefs or support from a faith community to help him or her cope. The patient may be an inpatient or an outpatient. Students should be given ample time to question the patient directly, although faculty may need to assist by rephrasing questions to make it easier on the patient. End with a discussion after the patient leaves. This can be the most powerful of all the sessions if the right patient is chosen. Handout material to be read by next class: SPC chapters 2 and 7, spiritual history7 and clinical applications8 articles.
Session 5. How to include spirituality. Format: lecture and role-playing. Content: Describe how to take a spiritual history, patient-centered approach, showing respect for and supporting the patient's beliefs, and praying with patient. During this session, the role of the professional chaplain should be discussed, paying particular attention to the training of the board-certified chaplain, the tasks of the chaplain in the health care setting (chapter 7), and when to refer patients to chaplains. Lecture should be followed by questions from students to clarify the "how-to's." If there is time left, students should be broken up into pairs for practice taking a spiritual history on each other. Handout material to be read by next class: SPC chapter 3 and Hastings Center Report article.9
Session 6. When to include spirituality. Format: lecture, discussion, and role-playing. Content: Lecture will focus on the timing of spiritual histories, the conditions for praying with patients, and when a chaplain referral is necessary, with discussion to follow. If there was insufficient time in Session 5 for role-playing, this might be a good time for students to practice these techniques. Handout material to be read by next class: SPC chapter 4 and article on clinical trial involving spiritual history.10
Session 7. Consequences of including spirituality. Format: case presentation, lecture, and discussion. Content: Case and lecture should focus on what might result when physician takes a spiritual history, supports beliefs of patient, engages in religious activities with patients (prayer), or refers patients to chaplains. Both positive and negative consequences should be discussed. This will help students understand the benefits of addressing spirituality and also some of the negative responses that they may run into. Handout material to be read by next class: SPC chapter 5, Annals of Internal Medicine article on boundaries,11 and legal update on church-state separation issues.12
Session 8. Barriers and boundaries. Format: lecture and discussion. Content: Lecture should focus on barriers that physicians say prevent them from taking a spiritual history or communicating with patients about the spiritual aspects of medical care. For this session, it is particularly important to have plenty of time for discussion. May also wish to expose students to church-state separation controversies. Discussing issues related to (a) patient "choice," (b) patient "isolation" from religious support tailored to medical illness, and (c) need for the physician's focus to be on secular goals (i.e., the patient's health, not religion) will help students avoid future problems in this area. Handout material to be read by next class: SPC chapter 6, NEJM article by Sloan13 and brief letter to the editor in response.14
Session 9. Possibility of harm. Form: case presentation, lecture, and discussion. Content: Case and lecture should focus on the potential harm that could result from physicians taking a spiritual history, supporting patients' beliefs, participating in religious activities such as prayer with patients, or referring to chaplains. The purpose of discussing the possibility of "harm" is so that the physician will be fully prepared for any situation that may arise (no matter how unlikely). Again, plenty of time should be reserved for discussion among students. Handout material to be read by next class: SPC chapter 13.
Session 10. Addressing spirituality in a multicultural, multireligious setting. Format: Case presentation, lecture, and discussion. Content: Case should be of a devoutly religious patient from a religious background that is completely different from that of most students. In a pluralistic health care setting, physicians are likely to encounter patients from many different religious traditions. Students should have a general knowledge of how different religious traditions deal with birth and contraception, diet, illness, death, and dying, so that accommodations can be made to show respect for these traditions. This is also a good time to reinforce chaplains as an important resource, given their knowledge about and training on how to address the needs of patients from diverse religious backgrounds.
After completing these ten sessions, medical students and residents should have confidence in their ability to appropriately and sensitively address spiritual issues in patient care. They should understand why communication with patients about spiritual
issues is important, how to go about doing this, when to do so, what boundaries they should not cross, what the consequences might be, and how to handle different situations. They should also understand the roles of professional chaplains, pastoral counselors, and clergy, and how they can assist the physician in this area. The only thing left, then, is for students to actually begin doing it—integrating spirituality into the way they care for patients.
Adapting the Course for Other HPs
Nursing, social work, and physical and occupational therapy programs can easily adapt the above model curriculum to meet the needs of their students. The research reviewed in chapters 8, 9, and 10 makes it clear that the vast majority of HPs in these disciplines are not receiving adequate training to address the spiritual needs of their patients. Even though the above curriculum is directed towards physicians, the content is basic for the training of all HPs so that they can screen for spiritual needs, determine what they can and cannot address, and know when to refer patients to spiritual care specialists. Bear in mind that only about one in ten physicians regularly takes a spiritual history or addresses these issues. This means that if patients' spiritual needs are going to be identified and addressed, in nine out of ten cases, someone other than a physician will have to do it.
Nurses. As mentioned earlier, if the physician does not do it, then the task of taking a spiritual history naturally falls to nurses, especially if spiritual needs are to be identified early enough during hospitalization so that they can be addressed by chaplains before discharge. However, the nursing curriculum is just as packed as the medical curriculum, especially as nurses training becomes shorter and shorter in attempts to make up for the growing nursing shortage we are facing as the population ages. However, because of the JCAHO requirement and the fact that chaplains are not able to see all patients to do spiritual assessments, it is imperative that nursing education include something about spirituality in the required curriculum. The content of that training should focus on why, how, and when to conduct a spiritual history, where to document this, when to refer to chaplains, and the health-related traditions of different religious groups. This will at least meet the minimum requirement. I recommend sessions 2, 5, 6 and 10 above; assigned reading of SPC chapters 1-3, 5, 7, 8 and 13; and supplemented with readings from one of the major "spirituality in nursing" texts.15
Social Workers. As emphasized previously, if nurses do not screen patients for spiritual needs, then this task falls to the social worker. The social work curriculum has no more free time to devote to learning these tasks than does the nursing curriculum. And social workers have an additional role that nurses do not have. Ensuring that spiritual needs are adequately addressed at the time of discharge and developing a discharge spiritual care plan (with the chaplain) are other social work tasks. Social workers need to ensure that any incompletely addressed spiritual needs of patients are conveyed to the community where the patient will be living (home, nursing home, or rehabilitation setting) so that pastoral care follow-up can be arranged. Thus, social workers not only need to know how to take and document a spiritual history (if not already done), but also must work with chaplains to develop a discharge plan that addresses the spiritual needs uncovered. This will require a short course in the social work curriculum addressing the why, how, and when of addressing spiritual needs, the role of chaplains and pastoral counselors, the health-related practices of different religions, developing a spiritual care discharge plan, and working with faith communities. I recommend sessions 2, 5, 6, and 10 above; assigned reading of SPC chapters 1-3, 5, 7, 9 and 13; and articles from the social work literature.16
Physical and Occupational Therapy. As noted in chapter 10, physical and occupational therapists are involved in enabling patients to regain physical functioning and independent living. Spiritual and religious beliefs play an important role in motivating religious patients to regain their function so that they can once more engage in religious and altruistic activities that give live meaning, purpose, and joy. Training on how and when to take a spiritual history, pray with patients if requested, and work with chaplains to address patients' spiritual needs should be a part of any holistic training program in the rehabilitation specialties. I recommend sessions 2, 5, 6, and 10; assigned reading of SPC chapters 1-3, 5, 7, 10 and 13; and articles from the rehabilitation literature.17
Summary and Conclusions
In this chapter, the structure, timing, and form of a spirituality curriculum were discussed, and the content of a ten-session model curriculum was described. Although the initial curriculum was developed with reference to medical students and residents, I demonstrated ways that the curriculum could be adapted for the training of nurses, social workers, and rehabilitation therapists. The goal is to have a single, consistent curriculum implemented across the health care specialties that takes advantage of the unique training, strengths, and position of each health care profession to ensure that patients' spiritual needs are met in whatever setting patients find themselves.18
- Spirituality and Medicine Interest Group at the Medical University of South Carolina, see Web site http://www.musc.edu/dfm/Spirituality/Spirituality.htm; and, The George Washington Institute for Spirituality and Health (GWISH), see Web site, http://www.gwish.org/.
- H. G. Koenig, "Religion and Medicine I: Historical Background and Reasons for Separation," International Journal of Psychiatry in Medicine 30 (2000): 385-98.
- H. G. Koenig, L. K. George, and B. L. Peterson, "Religiosity and Remission of Depression in Medically Ill Older Patients," American Journal of Psychiatry 155, no. 4 (1998): 536-42; H. G. Koenig, "Religion and Depression in Older Medical Inpatients," American Journal of Geriatric Psychiatry 15 (2007)): (April), in press ; H. G. Koenig, "Religion and Remission of Depression in Medical Inpatients with Heart Failure/Pulmonary Disease," Journal of Nervous and Mental Disease 195 (2007): (May/June), in press.
- W. J. Strawbridge, R. D. Cohen, S. J. Shema, and G. A. Kaplan, "Frequent Attendance at Religious Services and Mortality over 28 Years," American Journal of Public Health 87 (1997): 957-61; S. K. Lutgendorf, D. Russell, P. Ullrich, T. B. Harris, and R. Wallace, "Religious Participation, Interleukin-6, and Mortality in Older Adults," Health Psychology 23, no. 5 (2004): 465-75.
- R. P. Sloan, E. Bagiella, and T. Powell, "Religion, Spirituality, and Medicine," The Lancet 353 (1999): 664-67; H. G. Koenig, E. Idler, S. Kasl, J. Hays, L. K. George, M. Musick, D. B. Larson, T. Collins, and H. Benson, "Religion, Spirituality, and Medicine: A Rebuttal to Skeptics," International Journal of Psychiatry in Medicine 29 (1999): 123-31; P. S. Mueller, D. J. Plevak, and T. A. Rummans, "Religious Involvement, Spirituality, and Medicine: Implications for Clinical Practice," Mayo Clinic Proceedings 76, no. 12 (2001): 1225-35.
- H. G. Koenig, "An 83-Year-Old Woman with Chronic Illness and Strong Religious Beliefs," Journal of the American Medical Association 288, no. 4 (2002): 487-93.
- H. G. Koenig, "Taking a Spiritual History," Journal of the American Medical Association 291 (2004): 2881.
- H. G. Koenig, "Religion, Spirituality and Medicine: Research Findings and Implications for Clinical Practice," Southern Medical Journal 97 (2004): 1194-1200.
- C. B. Cohen, S. E. Wheeler, and D. A. Scott, "Walking a Fine Line: Physician Inquiries into Patients' Religious and Spiritual Beliefs," Hastings Center Report (September/October 2001): 29-39.
- J. L. Kristeller, M. Rhodes, L. D. Cripe, and V. Sheets, "Oncologist Assisted Spiritual Intervention Study (OASIS): Patient Acceptability and Initial Evidence of Effects," International Journal of Psychiatry in Medicine 35 (2005): 329-47.
- S. G. Post, C. Puchalski, and D. Larson, "Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics," Annals of Internal Medicine 132 (2000): 578-83.
- I.C. Lupu and R. W. Tuttle, "Freedom from Religion Foundation, Inc. (and others) vs. R. James Nicholson, Secretary of the Department of Veterans Affairs (and others)," The Roundtable on Religion and Social Welfare Policy, May 30, 2006 (http://www.religionandsocialpolicy.org/legal/legal_update_display.cfm?id=48), with January 16, 2007 update, "Federal Court Strikes Down Challenge to VA Chaplaincy Program" (http://www.religionandsocialpolicy.org/news/article.cfm?id=5890)
- R. P. Sloan, E. Bagiella, L. VandeCreek, M. Hover, C. Casalone, T. J. Hirsch, Y. Hasan, and R. Kreger, "Should Physicians Prescribe Religious Activities?" New England Journal of Medicine 342 (2000): 1913-16.
- H. G. Koenig, "Religion and Medicine: Letter in Response to 'Should Physicians Prescribe Religious Activities?'" New England Journal of Medicine 343 (2000): 1339.
- V. B. Carson and H. G. Koenig, Spiritual Caregiving for the Health Professional, 2nd ed. (St. Louis, MO: Elsevier, 2007); M. E. O'Brien, Spirituality in Nursing: Standing on Holy Ground (Boston: Jones & Bartlett, 1999); B. S. Barnum, Spirituality in Nursing: From Traditional to New Age, 2nd ed. (New York: Springer, 2003).
- A. Fontana and R. Rosenheck, "Trauma, Change in Strength of Religious Faith, and Mental Health Service Use among Veterans Treated for PTSD," Journal of Nervous & Mental Disease 192 (2004): 579-584.
- S. S. Doe, "Spirituality-Based Social Work Values for Empowering Human Service Organizations," Journal of Religion & Spirituality in Social Work 23, no. 3 (2004): 45-65; L. J. Praglin, "Spirituality, Religion, and Social Work: An Effort towards Interdisciplinary Conversation," Journal of Religion & Spirituality in Social Work 23, no. 4 (2004): 67-84; D. R. Hodge, "Developing a Spiritual Assessment Toolbox: A Discussion of the Strengths and Limitations of Five Different Assessment Methods," Health and Social Work 30, no. 4 (2005): 314-23.
- M. A. McColl, "Spirit, Occupation and Disability," Canadian Journal of Occupational Therapy 67, no. 4 (2000): 217-28; C. Coyne, "Addressing Spirituality Issues in Patient Interventions: A Patient's Belief Structure Can Play a Role in the Patient's Health and the Effectiveness of Interventions," PT-Magazine of Physical Therapy 13, no. 7 (2005): 38-44; D. Johnston and C. Mayers, "Spirituality: A Review of How Occupational Therapists Acknowledge, Assess and Meet Spiritual Needs," British Journal of Occupational Therapy 68, no. 9 (2005): 386-92.
From Harold G. Koenig, M.D., Spirituality in Patient Care: Why, How, When, and What, 2nd ed. (Philadelphia: Templeton Foundation Press, 2007), 175-87.