integrating spiritual care in the medical school curriculum

John Wenham highlights the lack of training in spiritual care in Australian medical schools and looks at ways to address this deficit.

Christian doctors and medical students know it is very important to provide holistic care for our patients, addressing their physical, emotional and spiritual needs. The Bible teaches that we are made in God’s image (Genesis 1:26). In Mark 2:1-12, we see that Jesus identified a variety of physical and spiritual needs in those who came to him for healing. Paul writes in 1 Thessalonians 5:23, ‘May God himself, the God of peace, sanctify you through and through. May your whole spirit, soul and body be kept blameless at the coming of our Lord Jesus Christ.’ But what is taught in our twenty-first-century medical schools?

There is very little literature on the teaching of spirituality in medical education in Australia. Significant work has been done in the USA and South America, and a smaller amount in the UK, to develop and demonstrate the value of this element of holistic care being part of core medical school curricula. We aimed to elicit examples of established international medical curricula on spiritual care and use this to map out the core elements to be included in a program fit to equip the modern doctor for this essential task.

A 2009 consensus conference defined spirituality as ‘the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.’ [1]

Despite the apparent importance of spirituality, not many Australian medical schools include it in their curriculum. A survey of 147 GPs practising in Australia by Trudie Rombola regarding spiritual history-taking skills in holistic consultations identified a number of barriers, including insufficient time, personal discomfort with the subject matter, and concerns from doctors about crossing boundaries into spiritual areas that are not perceived to be appropriate for their profession to address. Most participants recognised a lack of knowledge and skills and thus desired further training, especially in spiritual history taking. There was strong support for this being included in Australian medical education. [2]

Our systematic review [3] of international medical school and residency program curricula that address spirituality and religious aspects of patient care demonstrates a wide variety of approaches. However, some common ingredients have been identified, and they should be considered for inclusion in a curriculum designed for the medical educational setting. For example, chaplain shadowing, communications skills training, self-reflection, examining evidence and relationship building are featured frequently (Table 1).

Student feedback suggests chaplain shadowing has merits in broadening students’ understanding of a patient’s spiritual needs in the context of healthcare. Similarly, spending time in a discussion group led by a multidisciplinary team, including a chaplain, allows the reality of whole-person medicine to be modelled in a practical way.

Programmes that include the opportunity for self-reflection, either through journaling and/or group discussion, facilitate the development of spiritual self-awareness. This is essential if current and future doctors are to be effective in recognising a patient’s need to have this aspect of their care addressed. [4] Spiritual histories will not be taken well, if at all, if the skill is not taught effectively, and therefore, this should be a core component of any medical school curriculum.

The best way to improve skills in spiritual history taking and spiritual care is for a supervisor to model them to the students using simulated or actual patients. Students can then attempt the task themselves and receive feedback from their tutors in real time. Several authors described using such methods and reported that the experience was well received. [5,6,7,8]

Christy Ledford et al successfully employed the teaching OSCE (Objective Structured Clinical Examination) concept to help medical students engage with patients in spiritual and faith-based conversations. 9 Traditionally, OSCEs have been used in summative assessment; in this case, the setting was modified to give teacher and peer feedback in a formative setting twice a year. The new format provided direct observation and feedback to students on their doctor-patient relationship skills and their ability to explore a spiritual history.

A question worthy of consideration is, at what stage in medical training is spiritual history-taking best introduced? Six out of ten programs delivered this in clinical years three and four; this would seem to be the more favourable time, given that the students will then have ample opportunity to explore this recently learnt skill with the patients they see. Future doctors need to consider their own spirituality as this will not only enhance their ability to connect with patients on this level but will also set them up for better self-care and lessen the chance of burnout. [10,11]

An online survey of 260 final-year medical students in Australia sought to understand what, if any, exposure these future doctors had experienced, either seeing a spiritual history being taken or taking one themselves. The answer to both was about ten per cent. However, 56 per cent of these students agreed, or strongly agreed, that spiritual care should be included in the medical curriculum. [12]

In response to these survey findings and incorporating the review of international literature, we have developed a half-day curriculum, which is currently being piloted in New South Wales, Australia. We are using formative OSCEs and reflective questionnaires to assess its impact. Once the study has been completed and published, medical deans will be approached to seek their support for its introduction into their medical schools’ curricula. ›

Table 1.