Teaching spirituality and health care to third‐year medical students

Abstract

Between 31 and 78 per cent of UK medical schools provide any teaching on spirituality.1 Brighton and Sussex Medical School (BSMS) opened to students in the autumn of 2003. The third-year curriculum (2005) involved student-selected components (SSCs), and the author was invited to offer an 8-week, half-day per week, module. The SSC 'Spirituality and health care' was run twice during both the 2005/6 and 2006/7 academic years. The relationship between spirituality and health can have far-reaching consequences.1 Research consistently shows that assessing spiritual needs, supporting the patient's beliefs and validating religious distress, and making appropriate referrals, have benefits in a wide range of physical and mental illnesses.2 These may include enhancing the patient's ability to cope, improving the doctor–patient relationship, thereby boosting compliance with treatment, and increasing community-based support.3 Positive results – faster and more complete recovery from illness, and improved satisfaction with medical care – do not depend on which religious or spiritual tradition a patient follows. However, 5–10 per cent of studies show that religion or spirituality may also be harmful to health and mental health. Students should be advised of both aspects. The conception of health has changed in recent years from a disease model to a health model, involving a spiritual element.4 Spirituality, which may be considered the 'active ingredient' of different religions, 'Where the deeply personal meets the universal', involves a dimension of human experience affecting everybody. Spiritual values and skills are increasingly recognised as necessary aspects of clinical care, catering for patients' needs5 and wishes.6 Ancient ties between medicine, healing and spirituality should therefore be revived and updated. Ways of teaching spiritual skills and knowledge, with regard to the impact of spirituality on health, were developed, along with ways of fostering spiritual values7 and assessing patients' spiritual needs.8 Learning objectives included the following. To explore the question 'What is spirituality?' while clarifying the overlap and distinctions between spirituality and religion. To consider that spiritual awareness and practices may be advantageous to patients, and also to health care practitioners. To consider harmful and hazardous aspects of spiritual and religious factors and practices. To substantiate these points with reference to epidemiological research. To offer explanations for the effects encountered according to Levin's 'seven principles'.9 To identify spiritual values and promote spiritual skills relevant to health care. To learn how to assess the religious and spiritual aspects of patients' lives. To encourage and facilitate personal reflection on spirituality and health care in the light of the SSC experience. A total of 27 students (8 male and 19 female) participated in four cohorts. (Cohort sizes, in sequence: 6, 10, 4 and 7.) The group size for each course depended mainly on student choice. Attendance was high, with no student attending fewer than five sessions. The religious and spiritual backgrounds of the students were varied: there were 10 that identified themselves as Christian (from different denominations and varying degrees of involvement), three Hindus, two Muslims, two Buddhists, one Sikh, one 'sceptic' and one atheist. Of those with no formal affiliation, four thought of themselves as 'spiritual' or 'seeking', and three said they were not spiritual or religious in any way. The contents of the sessions are summarised in Box 1. Students were provided with two books: Koenig3 and either Levin9 (2005/6 cohort) or Culliford11 (2006/07 cohort), with expectations to read the first 123 pages, and to consult the second when relevant (weeks 2 and 3, Levin; week 5, Culliford). Weeks 1–3 involved some didactic teaching, made flexible according to the students' curiosity and expressed needs, question and answer sessions, group discussions, and teaching exercises. Tea breaks allowed important further informal discussion. In week 4, students made simple assessments in clinical settings on patients of their own choice, using two main types of question: firstly, 'Do you think of yourself as religious or spiritual in any way? Please explain', and secondly, 'What helps you most when things go badly wrong (such as when you are ill)? Where do you turn for strength, hope and support?' Week 5 involved student feedback after interviewing patients. Students were also introduced to the process of emotional healing and personal (including spiritual) growth in response to losses and threats.11 In week 6, students met an experienced educator and health care worker, who described experiencing, surviving and benefiting from an episode of psychosis requiring hospital care, describing it as 'a spiritual breakthrough'.12 The feedback from students (week 8) was based on, and consistent with, their reports, written in week 7 (See `Student reports' below). Students completed (anonymously) a nine-item, five-point scale feedback form, with space for additional notes (Box 3). For example, eight forms were returned by the 10 students from cohort 2 (80%), with scores indicating high levels of satisfaction (280/360: 78%). Each student wrote a report of about 1500 words. Copies of 25 of these from all four cohorts (93%) were reviewed, and form the main basis of this evaluation. Guidelines for the reports were broad. An element of personal reflection was encouraged. Most students wrote statements of the 'before' and 'after' type. Negative or critical comments were very few. None have been omitted. Frequently occurring themes included the following. Before: spirituality was equated exclusively with religion. After: there were clear distinctions between the two – a person's spirituality was no longer considered to be dependent on religious affiliation, conviction or practice. Before: neither religion nor spirituality was thought to have a place in modern (scientific, evidence-based) medicine. After: spirituality is seen to be important, and patients' spirituality should be assessed routinely. Before: students were hesitant to discuss spirituality with their teachers or colleagues. After: they preferred being more open, feeling equipped to discuss the subject. Before: students were unsure about taking a spiritual history. After: they uniformly expressed confidence in being able to do this. Before: students were uncertain about the value of taking a spiritual history. After: students considered that all health care staff in training should learn to do this, so that appropriate steps can be initiated to meet patients' spiritual needs, where possible. Before: students had minimal knowledge of the epidemiology of spiritual and religious factors affecting health or illness. After: students demonstrated a satisfactory general overview of the epidemiology. Although the 'holistic' or 'bio-psycho-social' approach to health care dominated the rhetoric of teaching, students expressed concern that religion and spirituality had not previously been mentioned. The idea that people continue to grow spiritually through life, especially through adversity, resonated positively with several students. Students reported that taking spiritual histories alone seemed to benefit patients. (One student, for example, declared, 'That is the first time in 3 years that I felt I actually helped somebody'.) Several students also mentioned the inspiring effect of meeting and holding a discussion with the external tutor. Some students reported previously neglecting their own spiritual development, and having doubts about its relevance, particularly in medicine. Several expressed their gratitude and relief, saying the SSC had rekindled optimism in their spiritual search, and that they had found new importance for a spiritual perspective in their chosen career. Students were assessed on their reports by the course leader, who was required by the BSMS to complete a six-point form for each student to confirm 'That this report is satisfactory and the student has passed the SSC' (see Box 4). The pass rate was 100 per cent. In addition, five students (18.5%) created posters on spirituality and health care for presentation, which counted towards their examination results. One student also later completed a related research project and dissertation ('Stages of faith and blood pressure in South Asians'), supervised by the author. The students' reports confirm that the SSC was successful in meeting the major aims and learning objectives, and in other unforeseen ways, such as, for some, assisting their coming to terms with personal illness (personal communications). Only one student, writing, 'Spirituality wasn't really my thing', reacted less than enthusiastically. Many students reported that they expected the SSC to have a lasting impact on them. For example, one wrote 'I have started to see my study of medicine as a life-long spiritual journey of growth and discovery'. The wide range of students' religious and spiritual backgrounds served to emphasize the universality of spirituality, as they explored a complex subject together entirely harmoniously, with respect for and genuine interest in each other's religious, spiritual and philosophical backgrounds. Most students selected the SSC, introducing the likelihood of bias in its favour. However, greater improvements could result should students with lower initial interest or weaker religious or spiritual involvement be exposed to the course contents. The costs involved would be modest. A teaching module on spirituality and health care, in the form of a third-year SSC, was introduced into the curriculum of a new medical school for two academic years. The comments written by students showed it to have been well-received, and also to have met and surpassed their learning objectives. On teaching about spirituality, Neely and Minford state, 'There is little uniformity between medical schools with regard to form and content… There is significant room for improvement'.1 This was a rewarding SSC to teach, and it is hoped that this paper provides both useful suggestions and encouragement to those wishing to correct the identified deficit in medical education, where it exists. Arguably, all health care professionals might benefit, and the advantages transfer directly to patient wellbeing. Barker P. & Buchanan-Barker P. (eds) Spirituality and mental health: Breakthrough. London: Whurr 2004. Broom B. Meaning-full Disease: How personal experience and meanings cause and maintain physical illness. London: Karnac 2007. Culliford L. Love, Healing and Happiness: spiritual wisdom for secular times. Winchester: O Books, 2007. De Hennezel M. Intimate Death: How The Dying Teach Us How To Live. (Trans. Janeway C.) New York, Vintage, 1998. Dein S. Working with patients with religious beliefs. Advances in Psychiatric Treatment 2004; 10: 287-294. Fowler J. Stages of Faith: The Psychology of Human Development and the Quest for Meaning. San Francisco: HarperCollins 1995. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delta 1990. Koenig H. McCullough M. & Larson D. Handbook of Religion and Health. Oxford: OUP, 2001. Plante T. & Thoresen C. (eds) Spirit, Science and Health: How the spiritual mind fuels physical wellness. Westport, Conn, & London: Praeger 2007. Swinton J. Spirituality and Mental Health Care: Rediscovering a Forgotten Dimension. London: Jessica Kingsley 2001.

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