Original Articles Spirituality in Medicine: A Comparison of Medical Students Attitudes and Clinical Performance

David W. Musick, Ph.D. Todd R. Cheever, M.D. Sue Quinlivan, M.A. Lois Margaret Nora, M.D., J.D.
Objective: The authors sought to examine attitudes about spirituality in medicine among medical students in psychiatric clerkships and determine whether instruction on concepts of spirituality in medicine had an effect on students clinical performance in related tasks. Methods: A total of 192 students entering psychiatric clerkships were randomly assigned to one of two groups; both groups received identical didactic instruction on spirituality in medicine. One group worked on a problem-based learning case that featured spirituality as a prominent theme, whereas the other group worked on problem- based learning cases that made no mention of it. Students completed pre- and posttest questionnaires, and their examination at the end of rotation included a standardized patient encounter requiring them to elicit a spiritual history. Results: Among the 131 students who completed and returned both questionnaires, a signicant difference (p 0.001) was noted between groups on students self-reported knowledge of taking a spiritual history. However, students in the two groups received identical scores on the component of the examination requiring them to write a spiritual history. Conclusions: Although students who were exposed to material on spirituality in medicine reported greater understanding of the issue, no difference in clinical performance was observed. (Academic Psychiatry 2003; 27:6773)

n increasing number of medical educators are suggesting that physicians should be willing to discuss the spiritual needs of their patients as part of a comprehensive approach to clinical care (1). More than 70 U.S. medical schools now offer some type of formal instruction on spirituality in medicine, and residency training programs are addressing the subject as well (1,2). Religion is propounded as an important variable that affects health outcomes that should be subjected to more scientic study (3). This emphasis on spirituality in medicine has implications for training physicians. The Association of American Medical Colleges has recommended that students be trained to understand the meaning of patients stories in the context of the patients beliefs and family and cultural values (4). One organization

has developed a spirituality curriculum for psychiatric residency programs and is working on developing curricula for residency programs in primary care disciplines (5). At the University of Kentucky College of Medicine, we received funding in 1997 to incorporate principles of spirituality in medicine into the undergradDr. Musick is with the Department of Rehabilitation Medicine, University of Pennsylvania School of Medicine. Dr. Cheever and Ms. Quinlivan are with the Division of Academic Affairs, University of Kentucky College of Medicine, Lexington, Kentucky. Dr. Nora is President and Dean of the Northeastern Ohio Universities College of Medicine in Rootstown, Ohio. Address correspondence to Dr. Musick, Department of Rehabilitation Medicine, University of Pennsylvania School of Medicine, 5 West Gates, 3400 Spruce Street, Philadelphia, PA 19104. E-mail: david.musick@uphs.upenn.edu Copyright 2003 Academic Psychiatry.

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uate medical education program. We incorporated a variety of learning experiences into 12 required courses, placing particular emphasis on teaching medical students to elicit a spiritual history from patients as part of the medical interviewing process. We felt that this ability is an especially important addition to the skill set of clinicians. In the clinical clerkship curriculum, the psychiatry rotation seemed a good place to begin to incorporate selected learning experiences pertaining to spirituality in medicine, not only because of the emphasis on this subject in many psychiatric training programs but also because of the interest of one of the authors (T.C.) in this subject. Our twofold objective in this study was to examine medical students self-reported attitudes and clinical performance regarding the general topic of spirituality in medicine. METHOD The psychiatry clerkship is part of an 8-week program that combines 4 weeks of psychiatry and 4 weeks of neurology. Approximately 16 students rotate through the psychiatry clerkship every 8 weeks, for a total of about 96 students per academic year. All students complete assigned readings and participate in lectures, problem-based learning (PBL) sessions, and patient care activities in both inpatient and outpatient settings. All students who had their psychiatry clerkship during the 19981999 and 19992000 academic years received approximately 1 hour of didactic instruction on the importance of issues related to spirituality in medicine and received a set of written instructions on how to elicit a spiritual history from a patient. The psychiatry clerkship has been described in greater detail elsewhere (6). Problem-Based Learning As part of the PBL portion of the clerkship, students generally work through three paper cases on topics in substance abuse, dementia, and seizures. Each case is covered for 2 weeks, during the course of which students conduct research on learning issues generated during small group discussions. PBL cases were not conducted during the rst and the eighth week of the clerkship. We hypothesized that because PBL is an active learning process, a higher level of
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exposure to concepts related to spirituality in medicine in the PBL component of the clerkship would lead to more positive attitudes toward those concepts as well as to higher levels of clinical skill in eliciting a spiritual history from patients. To test this hypothesis, we modied the PBL process during the clerkship. We wrote a new PBL case concerning a patient with depression and multiple sclerosis. Students who worked through this case were required to interview a standardized patient portraying this patient and to elicit a spiritual history. The students then met in small groups to discuss relevant learning issues concerning both the treatment of the patients illnesses and the importance of spirituality in the patients overall life. Unlike in previous years, where PBL consisted of three separate cases, each lasting 2 weeks, this new case ran for 6 weeks. Thus, students assigned to this case worked on only a single PBL case during the entire clerkship. Faculty who taught in this PBL case were given a lesson plan to help them in teaching the students how to take a spiritual history and what to do with the information received. To ensure some degree of uniformity for the study, the majority of the PBL sessions during the study period were taught by the same faculty member (T.C.). Students were randomly assigned to one of two groups. For all clerkships, our Ofce of Academic Affairs uses a balanced-structure approach to assign students to rotation groups with demographic and other variables distributed proportionately. In our clerkship, students in even-numbered rotations throughout the year were assigned to work on the 6week PBL case that featured spirituality as a prominent theme. Students in odd-numbered rotations were assigned to work on three 2-week PBL cases that made no mention of spirituality. Random assignment of students resulted in about half of the students working on the single case featuring spirituality issues and the other half working on three cases with no mention of spirituality. We developed a 12-item pretest-posttest questionnaire after a review of the literature pertaining to spirituality in medicine. The 12-item instrument, designed as a self-report measure of students knowledge, contained six items that focused on physician practice issues related to spirituality and six items that focused on personal spirituality issues. Items were rated on a 5-point scale in which 2 through 5
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indicated strongly disagree through strongly agree and 1 indicated no opinion (items coded 1 were not included in computations of means). The questionnaire items are listed in Table 1. We administered the questionnaire to all students in the psychiatry clerkship during the study period, distributing forms and collecting them on the rst day of the rotation (pretest) and again on the nal day of the rotation (posttest). Students were told that all survey results were condential and had no impact on course grading. The students post ofce box numbers were used to match up completed pre- and posttest instruments. Participation was voluntary, and the study received approval by the medical centers institutional review board. Comparisons of mean item ratings were made on the basis of demographic variables as well as of the following variables: pretest means versus posttest means; academic year (19981999 versus 19992000); and assignment to the PBL case emphasizing spirituality versus the cases with no mention of spirituality. Independent measures t tests (two-tailed) were used to compare item means. We also compiled descriptive statistics and performed reliability analysis of the data collection instrument. Clinical Performance Examination for Medical Students At the end of the clinical clerkship year, all students are required to undergo a clinical performance
TABLE 1.

examination before beginning their fourth year of medical school (7). This examination is designed to provide feedback to students pertaining to basic clinical skills. The examination consists of approximately 16 stations that require students to interact with standardized patients who portray a variety of conditions. Each station consists of two parts: in part 1, which lasts 15 minutes, the student interviews and examines the standardized patient and formulates a diagnosis. In part 2, which lasts 5 minutes, the student completes a secondary task related to the case for example, writing a differential diagnosis or describing cost-effective treatment approaches. The students performance on part 1 is rated by means of a checklist completed by the standardized patients and on part 2 by the assignment of points by trained graders. A norm-referenced total score for the examination is determined for each student by comparison with all other members of the class. The results are reviewed by the colleges Student Progress and Promotions Committee, and a comment about their performance on the clinical performance examination is included in students deans letters. During both years of this study, a psychiatry clinical performance examination station featured standardized patients who were trained to portray a patient who presented in an outpatient clinic with symptoms of shortness of breath and anxiety and a diagnosis of panic disorder. The standardized patient was instructed to verbalize issues regarding the importance of her religious faith as a cue that spirituality

Spirituality and health care questionnaire administered to students at the start and at the end of their psychiatric clerkship

Item Physician practice 1. 2. 3. 4. 5. 6. Personal spirituality 7. 8. 9. 10. 11. 12. I believe in God I attend religious services on a regular basis I try hard to live by my spiritual/religious beliefs I belong to a spiritual or religious group or faith community My spirituality or religious faith is the most important inuence in my life I feel that there are many more important things in life than spiritual beliefs/religion strongly agree, 4 agree, 3 disagree, 2 strongly disagree, 1 no opinion. Religious faith or spirituality is an important aspect of the lives of patients Spirituality plays an important role in the physician-patient relationship Most patients would like to discuss the spiritual or religious implications of their health care I understand what it means to take a spiritual history from a patient A physician should reect on his/her personal spirituality and how it impacts medical practice When asked to do so, a physician should consider praying with a patient

Note: Items were rated on the following scale: 5

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was an important feature of the case. The task in part 2 for this station was for students to write a spiritual history about the patient they had interviewed in part 1. We compared the performance of the two groups of students on this taskthose who worked on the PBL featuring spirituality and those who worked on PBLs that did not mention spirituality. We hypothesized that students in the rst group would perform at a higher level than those in the second. Independent t-tests (two-tailed) and analysis of variance were used to make comparisons of performance in terms of demographic variables, academic year, and group. RESULTS

Pre- and Posttest Questionnaires A total of 192 pretest and posttest questionnaires were distributed during each of the two academic years, for a total of 384 forms. A returned form was considered suitable for analysis if all items had been completed and if the students post ofce box number had been listed; all others were excluded. The total number of forms analyzed for the study period was 262 (131 each for pre- and posttest forms), or 68%. Item means were computed after all individual responses of 1no opinionwere extracted from the data; these responses accounted for nearly 8% of all responses. The alpha reliability coefcient for the survey instrument was 0.67 for this sample, a moderately high indicator of internal consistency. A majority of the students in our study were interested in spiritual or religious aspects of health care and either strongly agreed or agreed that the issue is important both in regard to patient care and, to some extent, at a personal level. For example, a majority of students (74%) strongly agreed or agreed that a physician should be willing to pray with a patient if asked to do so. Similarly, a majority of students (89%) strongly agreed or agreed with the item that asked whether they personally believe in God. Although we make no inferences about how our ndings on the six personal spirituality items of the questionnaire are related to students clinical performance, we nd them interesting and indicative of student support for our teaching efforts on this subject. We rst examined within-group differences on item means across all students on the pre- and post70

test forms. For the six physician practice items, students in the group that worked on the PBL featuring spirituality gave only one item a signicantly higher rating on the posttest: the item containing the statement I understand what it means to take a spiritual history from a patient (3.48 on the pretest and 4.09 on the posttest; p 0.001). No signicant differences were found on any posttest item means for the comparison group. We next considered whether differences in item means occurred between the two groups. On the pretest surveys, no signicant differences were noted (as expected, given random assignment to the groups). On the posttest surveys, signicantly different means were observed on one item: again, the item regarding the taking of a spiritual history (4.43 for the spirituality PBL group and 3.84 for the comparison group; p 0.001). We also considered whether mean item differences occurred between male and female students. In the pretest survey, women agreed more strongly than men with the statement Religious faith or spirituality is an important aspect of the lives of patients (4.57 for women and 4.38 for men; p 0.03). There were no signicant differences between male and female student responses on any of the posttest items. We then examined differences between the two academic years. On the pretest survey, we again found a signicant difference on the item pertaining to taking a spiritual history from a patient (3.52 for the 19981999 academic year and 3.95 for the 1999 2000 academic year; p 0.001). No signicant differences were found on any item means on the posttest surveys. Clinical Performance Examination There was no signicant difference in the performance of the two groups on the psychiatry station tasks featuring a diagnosis of panic disorder and the preparation of a patients spiritual history. For both groups, the mean score on the task of taking a spiritual history was 51% (for the spirituality PBL group, SD 17.5%, range 0%90%; for the comparison group, SD 13%, range 10%80%; p 0.77). To provide context for interpreting this result, it should be noted that the mean scores across all clinical performance examination stations (including both part 1 and part 2 scores) were 68% and 66%, respecAcademic Psychiatry, 27:2, Summer 2003

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tively, for the two academic years of the study. Part 2 scores ranged from 35% to 100% across both years. These scores are consistent with the experiences of others using this testing format (8). We compared students performance between the two academic years and found that students who completed the rotation in the 19992000 academic year performed signicantly better on the spiritual history task than students who completed the rotation in the 19981999 academic year (53% compared with 47%; p 0.03). On average, students in the 1999 2000 academic year indicated on the pretest survey that they were more knowledgeable about how to take a spiritual history from a patient. We also compared mens and womens clinical performance examination results on the spiritual history task across both academic years. We found that the womens scores were higher than the mens scores in the spiritual history task (52% compared with 50%), but the difference was not statistically signicant (p 0.36). There was no signicant difference between men and women in overall performance across the two academic years. DISCUSSION The purpose of this study was twofold: to examine the attitudes of medical students toward issues pertaining to spirituality in medicine and to determine whether exposure to material on the subject would improve clinical performance in taking a spiritual history from a patient. The results of our study support the ndings of a study by Chibnall and Duckro that indicated that greater exposure to certain types of educational material on spirituality may inuence the attitudes of medical students (9). In their study, greater exposure to spiritual and religious issues in health was found to be predictive of a more positive attitude on the part of students. In our sample of students undergoing a psychiatry clerkship, self-reported ratings of knowledge of how to take a spiritual history from a patient were higher on posttest questionnaires among those who received PBL material featuring spirituality as a prominent theme than among those in the comparison group. This result was obtained using a newly developed instrument of adequate reliability. A larger issue that remains unaddressed, in our study or in the Chibnall and Duckro study, is whether
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there is a formal link between students attitudes about spirituality in medicine and their performance in taking a spiritual history in a clinical setting. Although there is evidence that clinicians support the notion that attention to spiritual concerns would be helpful to their patients (10), neither this study nor Chibnall and Duckros can specify the precise relationships between teaching methods, students attitudes, and actual performance. In our study, we were able to some extent to address Chibnall and Duckros call for longitudinal studies (9). that can shed more light on this important issue. During the rst three years of the educational grant we received to develop curriculum pertaining to spirituality in medicine, our school incorporated a wide variety of teaching materials into the medical curriculum, including lectures, problem-based learning cases, interactive seminars, and training sessions on taking a spiritual history from patients. Learning objectives for these activities reected a general focus on raising students awareness of the issue, providing information about formats used to take a spiritual history in the clinical setting, and giving students the opportunity to practice taking a spiritual history in small group exercises with standardized patients. Because of these multiple exposures to material pertaining to spirituality during the rst three years of the curriculum, it is possible that students were already condent of their knowledge about these issues before the study. It is also possible that the different teaching methods between the two PBL groups, with one group working on a 6-week case and the other on three 2-week cases, confounded our intervention. Nevertheless, we interpret our results (albeit cautiously) as an indication that it is possible to have a positive impact on students condence about specic clinical skills related to spiritualityin this case, the ability to take a spiritual history. Since the taking of a spiritual history is advocated for all clinicians, regardless of their personal level of interest in the issue (11), we interpret this nding as a conrmation of the willingness of students to add this particular skill to their clinical arsenals. The nding that students in the second year of the study were more likely to report that they knew what it means to take a spiritual history is important to our college. We implemented the spirituality in medicine curriculum gradually over four academic years, with the academic year 19992000 being the
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third year of implementation. Hence we were encouraged to nd that students who were exposed to the curriculum during that year were apparently more condent in their ability to perform this clinical task. As we continue to rene this curriculum in coming years, we do so with greater condence that our students are responding positively to our efforts. The results of the clinical performance examination task of taking a spiritual history were disappointing, however. The fact that students performed poorly (51%) on this task, regardless of whether they had undergone the PBL that emphasized spirituality during their psychiatry clerkship, was somewhat surprising. Given the amount of exposure they had to issues related to spirituality in medicine, not only in the psychiatry clerkship but during the rst three years of the curriculum, we anticipated higher performance scores. We were encouraged that students in the second academic year did perform at a higher level than those in the rst academic year of the study. However, the overall condence expressed by all students from the two academic years about their knowledge of how to take a spiritual history was not supported by clinical performance, at least as measured by the examination used in our clerkship. We know of no other study that has looked at this issue and thus cannot compare our results to others. This gap between students condence about the taking of a spiritual history and their actual performance is consistent with other research showing that clinical performance is affected by many factors (12). Primary among them is testing conditions. It is possible that our students did not perform well on the spiritual history portion of the clinical performance examination because of the structure of the examination itself. For example, several students indicated afterward that they were asked to write a spiritual history during part 2 of the examination without realizing that this was important to the standardized patient whom they interviewed during part 1 of the examination. We were unable to determine precisely how this structural aspect of the examination affected students scores on the task. It is also possible that students who received instruction during the preclinical years on the importance of spirituality in medicine did not see this sub-

ject emphasized during their clinical clerkships. If so, the lack of attention to the subject in the clerkships could have negated the importance of the material as students began to interact with real patients. There are indications in the medical education literature that much of what is learned during the clinical yearsparticularly in realms such as bioethics, professionalism, and the likeis affected by a hidden curriculum whereby clinician role modeling has a greater inuence than more formal teaching (13). It would be interesting to determine whether medical students at our school receive any role modeling of taking a spiritual history by attending and resident physicians during the clinical clerkship years. In the absence of such role modeling, students may choose not to elicit a spiritual history from a patient even when an opportunity arises, for fear of alienating other members of the health care team. We conclude that the teaching of concepts related to spirituality in medicine to medical students is important, not only because of the literature that shows that patients want their physicians to be open to this subject (14) but also because our students agree that the subject is important. Nevertheless, medical educators must recognize that acceptable clinical performance on tasks related to spirituality in medicine will not necessarily occur as a result of exposure to didactic or other forms of instruction on this topic. Care must be taken to observe and test actual clinical performance in a variety of formats so that we can be certain that performance matches students expressions of having learned the material. Such testing should ideally involve a variety of reliable formats, including ratings based on the personal observation of attending physicians and standardized patients (15), in order to obtain a more comprehensive view of the clinical performance of individual students.

This work was made possible in part by an educational grant from the National Institute for Healthcare Research and the John Templeton Foundation. The authors gratefully acknowledge the planning assistance and other support received from Ms. Tagalie Heister, of the Department of Psychiatry, and Dr. John Slevin, of the Department of Neurology, at the University of Kentucky College of Medicine.

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References
1. Puchalski CM, Larson DB: Developing curricula in spirituality and medicine. Acad Med 1998; 73:970974 2. Barnard D, Dayringer R, Cassel CK: Toward a person-centered medicine: religious studies in the medical curriculum. Acad Med 1995; 70:806813 3. McCullough ME, Hoyt WT, Larson DB, et al: Religious involvement and mortality: a meta-analytic review. Health Psychol 2000; 19:211222 4. Association of American Medical Colleges: Report 1: Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Medical School Objectives Project. Washington, DC, Association of American Medical Colleges, 1998 5. George Washington Institute for Spirituality and Health. Available at http:/ /www.gwish.org 6. Barlow W, Cheever T, Quinlivan S: Reinvigorating PBL by integrating standardized-patient interviews. Acad Med 1999; 74:587588 7. Elam CL, Musick DW, Nora LM, et al: Buzzwords in medical education: what they are, what they mean, and what we are doing about them at the University of Kentucky College of Medicine. Kentucky Medical Association Journal 2002; 100(4):201207 8. Vu NV, Barrows HS, Marcy ML, et al: Six years of comprehensive, clinical, performance-based assessment using standardized patients at the Southern Illinois University School of Medicine. Acad Med 1992; 67:4250 9. Chibnall JT, Duckro PN: Does exposure to issues of spirituality predict medical students attitudes toward spirituality in medicine? Acad Med 2000; 75:661 10. Larimore WL, Parker M, Crowther M: Should clinicians incorporate positive spirituality into their practices? What does the evidence say? Ann Behav Med 2002; 24:6973 11. Post SG, Puchalski CM, Larson DB: Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 2000; 132:578583 12. Battles JB, Carpenter JL, McIntire DD, et al: Analyzing and adjusting for variables in a large-scale standardized patient examination. Acad Med 1994; 69:370376 13. Hafferty FW, Franks R: The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69:861871 14. Ehman JW, Ott BB, Short TH, et al: Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999; 159:1803 1806 15. Remmen R, Derese A, Scherpbier A, et al: Can medical schools rely on clerkships to train students in basic clinical skills? Med Educ 1999; 33:600605

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