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Spirituality Training For Palliative Care Fellows


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  • 1. JOURNAL OF PALLIATIVE MEDICINE Volume 10, Number 1, 2007 © Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2006.0076.R1 Spirituality Training for Palliative Care Fellows LISA MARR, M.D.,1 J. ANDREW BILLINGS, M.D.,2 and DAVID E. WEISSMAN, M.D.3 ABSTRACT Introduction: Spirituality is a major domain of palliative medicine training. No data exist on how it is taught, nor is there a consensus about the content or methods of such education. We surveyed palliative medicine fellowship directors in the United States to learn how they teach spirituality, who does the teaching, and what they teach. Methods: A PubMed ( ) search using the terms “spirituality” and “med- ical education” was completed. Thirty-two articles outlined spirituality education content and methods in medical schools and residency programs. From these articles, a survey on spiri- tuality education in palliative medicine fellowship training was prepared, pilot-tested, re- vised, and then distributed by e-mail in June 2004 to the 48 U.S. palliative medicine fellow- ship directors listed on the American Board of Hospice and Palliative Medicine (AAHPM) website, but excluding the three fellowship programs represented by the authors. Follow up requests were sent by email twice during the 6-week collection period. The Institutional Re- view Board at the Medical College of Wisconsin approved the study. Results: Fourteen fellowship directors completed the survey (29% of all programs; 42% of those currently teaching fellows as indicated on the AAHPM website). All programs indi- cated they taught “spirituality”; 12 of 14 had separate programs for teaching spirituality and 2 of 14 reported they taught spirituality to their fellows but not as a distinct, separate pro- gram. All respondents taught the definitions of spirituality and religion, common spiritual issues faced by patients at end of life (which was not defined further), and the role of chap- lains and clergy. Chaplains provided spirituality education in all of the responding programs, but other team members were frequently involved. The most common formats for education in the domains of knowledge and attitudes were small group discussion, lecture, and self- study. Small group discussion, supervision, and shadowing a chaplain or other professional were the most common methods used for skills. Faculty written or oral evaluations of fellows were the most common forms of evaluation, with little evidence of more robust assessment methods, such as structured role-play (none of the programs surveyed). Conclusions: Palliative medicine fellowship programs generally agree on the content of training on spirituality, but have not incorporated robust educational and evaluation meth- ods to ensure that fellows have obtained the desired attitudes, knowledge, and skills to meet the Initial Voluntary Program Standards for Residency Education in Palliative Medicine of the American Board of Hospice and Palliative Medicine. Based on the survey data and results from the literature review, broad recommendations are made to enhance spirituality educa- tion. 1Department of Palliative Medicine, 3Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. 2Department of Palliative Medicine, Massachusetts General Hospital, Boston, Massachusetts. 3Palliative Care Center, Division of Neoplastic Disease and Related Disorders, Medical College of Wisconsin, Milwaukee, Wisconsin. 169
  • 2. 170 MARR ET AL. INTRODUCTION should be taught in palliative medicine pro- grams. The purpose of this survey was to assess: S ERIOUS ILLNESS regularly triggers questions of a spiritual nature—questions of meaning, value, and relationships.1 Common spiritual con- 1. How fellowship programs define the domains of spirituality education; cerns include, “Is God punishing me?”, “What is 2. What content and teaching formats are utilized the meaning of my life?”, or “What happens to to teach spirituality; me after I die?” Thus, palliative medicine clini- 3. Who provides spirituality education; and cians regularly find themselves in situations that 4. How fellows’ skills, knowledge, and behaviors require skill in assessing and addressing the spir- in the domain of spirituality are evaluated. itual needs of their patients and families. Inter- disciplinary care of patients and their families is considered a standard of practice in palliative METHODS care2 and many palliative medicine teams contain chaplains. The authors carried out a literature review of The American Board of Hospice and Palliative published articles discussing topics of physician ed- Medicine (ABHPM) presented Initial Voluntary ucation and spirituality.5–36 Based on this review, a Program Standards for Residency Education in spiritual education self-assessment survey for pal- Palliative Medicine in 2003. One of the learning liative medicine fellowship directors was devel- domains is “spiritual support of patients and oped by the authors. The survey was pilot-tested families,” including “the assessment and man- and reviewed with one current palliative care fel- agement of spiritual suffering faced by patients low, three fellowship directors, and two palliative with life-limiting illnesses and their families.”3 care chaplains. We condensed all the various top- The document does not specify how this topic ics and themes into thirteen discrete domains should be taught, what specifically should be within the commonly used attitudes/knowl- taught, which professional discipline(s) should edge/skills paradigm to categorize education ob- do the teaching, or how competency should be jectives (Table 1). The final survey contained four evaluated. With one exception,4 there are no pub- questions: What specific content domains within lished reports on how palliative medicine fellows the broader title of spirituality are included?, What are acquiring spirituality education and no guide- teaching methods are used?, Who is providing the lines exist as to how spiritual assessment and care teaching?, and How are fellows evaluated?. TABLE 1. WHAT ARE THE DOMAINS THAT ARE COMMONLY INCLUDED IN SPIRITUALITY EDUCATIONa Yes No Unsure Knowledge/attitudes Definitions of spirituality and religion 14 0 0 Common spiritual issues faced by patients at end of life 14 0 0 How different cultures view and address death and dying issues 12 1 1 How different religions view and address death and dying issues 12 1 1 Role of chaplains and clergy 14 0 0 Recognizing spiritual distress (such as “Why me?,” “God is 13 0 1 punishing me,” guilt, etc.) Rituals for death and dying 12 1 1 “Unusual” (paranormal) patient experiences near time of death 10 2 2 Review of data examining link between spirituality and physical 9 1 4 and mental health Skills Completing a spiritual assessment 13 1 0 Responding to spiritual distress (counseling, referral, etc.) 13 1 0 Physician’s ability to self-reflect on personal spiritual issues and 10 0 4 how these affect patient care Physician self-care 11 0 2 aFrom Palliative Care Fellowship Self-Assessment Questionnaire.
  • 3. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 171 The survey was distributed by e-mail to all 48 training sites.” We used the number of active pro- palliative medicine fellowship directors listed on grams (or potentially active programs) to calcu- the American Academy of Hospice and Palliative late the response rate. Medicine website in June 2004,34 excluding the three fellowships represented by the authors. Two e-mail reminders were sent during the 6- RESULTS week data collection period. On the website, 33 of 48 programs (69%) indicated that their pro- Fourteen fellowship directors completed the grams were training fellows, while 13 (26%) re- survey, representing 29% of all programs listed ported they had not yet started to accept fellows. on the website and 42% of those training fellows. The start date of two fellowship training pro- Twelve directors who responded were currently grams was unclear based on their website post- teaching fellows; 2 had programs that had not yet ing, and they were considered to be “potential accepted fellows but had curricula prepared, thus TABLE 2. WHAT TEACHING METHODS ARE USED?a Shadow Small chaplain or group Role- other Other Lecture discussion Supervision play Self-study professional None methods Knowledge Definitions of spirituality 10 9 2 0 8 7 0 and religion Common spiritual issues 9 12 7 0 7 6 0 that occur at the end of life How different cultures 7 10 3 0 7 5 0 view and address death and dying How different religions 8 10 3 0 7 4 0 view and address death and dying Role of chaplains and 8 9 4 0 4 7 0 clergy Recognizing spiritual 5 10 6 1 6 7 1 1 (conference) distress (such as “Why me?,” “God is punishing me,” guilt, etc.) Rituals for death and 4 8 4 0 5 6 2 dying “Unusual” (paranormal) 3 6 5 0 4 3 4 patient experiences near time of death Review of data examining 5 5 3 0 7 2 2 link between spirituality and physical and mental health Skills Completing a spiritual 3 6 7 3 7 7 1 assessment Responding to spiritual 3 7 5 3 4 8 1 distress (counseling, referral, etc.) Physician’s ability to self- 3 9 6 1 5 3 1 reflect on personal spiritual issues and how these affect patient care Physician self-care 4 7 5 1 4 3 0 aFrom Palliative Care Fellowship Self-Assessment Questionnaire.
  • 4. 172 MARR ET AL. 12 of 31 reports (39%) represented teaching in ac- ation was most commonly used for both knowl- tual training programs. Of the 14 responding pro- edge/attitudes and skills, with little emphasis on grams, all indicated they taught “spirituality”; 12 more robust methods of evaluation, such as struc- of 14 had distinct programs for teaching spiritu- tured role-play (Table 4). ality and two reported they taught spirituality to their fellows, but integrated spirituality educa- tion with other content areas, not as a separate DISCUSSION program. Spirituality education in medical school, What are the domains that are commonly residency, and palliative care fellowships included in spirituality education? The goal of the project was to understand bet- All of the respondents are teaching the defini- ter how fellowship directors view the various ed- tions of spirituality and religion, common spiritual ucational domains that comprise “spirituality” issues faced by patients at end of life, and the role and, by extension, how they provide that educa- of chaplains and clergy (Table 1). Most respondents tional content and evaluate trainees. The data indicated they were teaching the majority of the from this survey can be considered a snapshot of other domains listed in the survey instrument. how fellowship programs are attempting to meet the ABHPM training guidelines, as well as their What teaching methods are used? own goals for training fellows. Small group discussion, lecture, and self-study The development of spirituality education in were the most commonly employed teaching palliative care fellowships parallels has followed formats for spirituality knowledge and attitude a growing interest in spirituality education in domains (Table 2). Small group discussion, medical school and residency training that began supervision, shadowing a chaplain or other pro- around 1990. In this section, we look for educa- fessional, and self-study were the most commonly tional guidance from spirituality teaching pro- reported methods to enhance spirituality skills. grams in medical schools and residency pro- Role-play was a rarely used educational technique. grams, and discuss the similarities and differences between this teaching and the current Which health professionals provide state of teaching in palliative care fellowships, spirituality education? Domains of education Chaplains and physicians were most com- monly identified as providing spirituality educa- Many domains, topics, and broad themes have tion, followed by social workers, nurses and psy- been described as part of “spirituality” in med- chologists (Table 3). ical schools and residency programs. A summary of key components in medical school curricula is How are fellows evaluated? provided by Larson and Puchalski26 and is listed in Table 5. Some topics commonly included in Although programs described a variety of eval- spirituality curricula are related to spiritual as- uation techniques, written or oral faculty evalu- sessment and care, while others, such as break- ing bad news,7 hospice/palliative care,7,27,30,31 TABLE 3. WHICH HEALTH PROFESSIONALS PROVIDE and self-care14,28 cannot be specifically related to SPIRITUALITY EDUCATION?a,b spirituality. For the palliative medicine fellow- ship survey, Respondents to our survey indicated Chaplain 100% general agreement that the topics we included Physician 86% Social worker 64% within the concept of spirituality were appropri- Nurse 50% ate, and had no suggestions for other topics that Psychologist 50% were not listed. Other 0% aFrom Palliative Care Fellowship Self-Assessment Teaching methods for spirituality education Questionnaire. bPercent of programs reporting spirituality educator by Spirituality is offered in a variety of medical discipline. school courses or concentration areas: medical
  • 5. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 173 TABLE 4. HOW ARE FELLOWS EVALUATED?a Patient Staff Self- Faculty Faculty and/or survey/ assessment evaluation eval. Role family 360° Chart Test (written) (written) (oral) play survey eval. audit None Knowledge/attitudes Definitions of spirituality 1 1 7 6 0 0 2 1 5 and religion Common spiritual issues 1 1 6 7 0 0 2 1 4 that occur at the end of life How different cultures 1 1 6 5 0 0 2 1 6 view and address death and dying How different religions 1 1 7 6 0 0 2 1 5 view and address death and dying Role of chaplains and 1 2 6 6 0 0 2 1 4 clergy Recognizing spiritual 1 2 6 5 0 0 2 1 4 distress (such as “Why me?,” “God is punishing me,” guilt, etc.) Rituals for death and dying 1 1 5 4 0 0 2 1 6 “Unusual” (paranormal) 1 1 4 4 0 0 2 1 9 patient experiences near time of death Review of data examining 1 1 5 5 0 0 2 1 6 link between spirituality and physical and mental health Skills Completing a spiritual 1 1 6 7 0 1 4 4 3 assessment Responding to spiritual 1 1 7 7 0 1 4 2 2 distress (counseling, referral, etc.) Physician’s ability to self- 1 2 7 7 0 0 2 1 3 reflect on personal spiritual issues and how these affect patient care Physician self-care 1 3 6 7 0 0 2 1 3 aFrom Palliative Care Fellowship Self-Assessment Questionnaire. humanities and/or bioethics8,9,25; end-of-life ed- “verbatim” reports, role playing with standard- ucation24; self-care curriculum26,28; cultural com- ized patients or fellow learners, and the use of petency29; humanism and professionalism22; poetry and literature to convey spiritual and ex- psychiatry clerkship11,19; internal medicine clerk- istential themes26,30 (Table 6). Unfortunately, ship22; family medicine clerkship19; medical in- many of the published reports lack details about terviewing18,23; community practice experience31; the curricula. For instance, although “read- and complementary and alternative medi- ings,”6–10,16,19,25,26,28,32 “lectures,”6,7,10–12,14,17,19,21, 25–27,29,30,32,36 and “experiential exercises”14 on cine.33,34 Residencies in family medicine,14,15,20,36 internal medicine,7 and psychiatry10,12 also in- “spirituality and medicine” are reported, more clude spirituality in their curricula. The teaching information about these exercises is not provided. formats used in the various spirituality curricula The McGill Working Group on Healing and include didactic sessions, small group discussion, Healthcare38 has proposed training for medical reflective writing, storytelling, case presentation students consisting of regular small group dis- and discussion, panel discussions with patients, cussions with a mentor, and keeping a jour-
  • 6. 174 MARR ET AL. TABLE 5. DOMAINS OF SPIRITUALITY EDUCATION and spirituality training in a palliative medicine fellowship. As part of their curriculum, they of- Communication of bad news7,26 Concepts of suffering and spiritual distress30 fer an optional 6-month, 1-day-per-week training Data of the link between spirituality and/or religion in clinical pastoral education, working with non- and health outcomes10,14,26,27,32,35 chaplain and chaplain trainees. One article out- Difference between spirituality and religion21,35 lines a spiritual care training program for pro- The doctor–patient relationship, and how spiritual and cultural factors influence it29,32 fessionals working in palliative care.44 Among Exploration of views of the world’s religions, such as the palliative medicine programs in our survey, Judeo-Christian, Hindu, Buddhist, etc.7,10,26 the most commonly reported method for teach- Historical relationship between medicine and ing knowledge and attitude domains was small religion10,27 Meditation and/or the relaxation response10,14,34 group discussion, followed by lecture and self- Palliative care, end-of-life care (pain management, study. Small group discussion was also named palliation, advanced directives, ethical issues) and commonly when teaching spirituality skills, fol- coping with cancer7,24,27,30,31 lowed by supervision, and shadowing a chaplain Psychic functions of spiritual/religious beliefs, as well as transference, countertransference and boundary or other professional. Based on recommendations issues relating to spiritual inquiry 10 from medical school and residency programs, ex- Role of the chaplain, and how the chaplain functions as periential training should be mandatory in pal- part of the health care team10,14,21,26,30,35 liative medicine fellowships. Other strong rec- Self-care14,28,35 Taking a spiritual history and addressing spiritual ommendations from the literature include needs, including the skills of compassion, presence training that incorporates time for personal re- and listening7,10,11,14,18,21,24,26,27,29,30,32,34 flection and feedback and discussion of transfer- Spiritual considerations in bereavement care14 ential dynamics that arise in the care of the dy- Understand how your (the trainee’s) spiritual beliefs affect patient care9,14,21,26,29–32 ing, similar to that found in the training of Understand the spiritual beliefs of patients, including chaplains.40 those from different spiritual/religious or cultural backgrounds (including how they affect their health, medical decisions, affect the doctor-patient relationship, help cope, etc.)7,11,14,18,21,26,29,30,32 TABLE 6. SPIRITUALITY EDUCATION METHODS—LITERATURE REVIEW Case presentation and discussion10,11,12,26,27,29–31 nal/portfolio documenting emotional reactions, Combining students in CPE with medical students27 Essay, reflective writing or discussion, or story- insights and questions relating to their evolving telling9,17,21,23,24,26,30,31,35 clinical experience, similar to that proposed by Experiential exercises on self care and well-being14,31 Rita Charon.39 Lecture6,7,10,11,12,14,17,19,21,25,26,27,29,30,32,34,35 There are no data to suggest what formats are Panel of invited discussants for question/answer sessions10,19,29,30 most effective. Several prefellowship spirituality- Rounds with a mentor who “emphasizes the spiritual training programs ask for written and verbal aspects of patient care and faith based resources in feedback about effectiveness of their curricula. the hospital and community” (modeling by Some course directors have reported that an ex- physician)7,19,21,36 Self-study (readings)6–10,16,18,19,22 (gives a list),23 (spirit periential approach to spirituality (such as shad- catches you),25,26,28,32 owing a chaplain), writing ones own spiritual his- Shadowing a chaplain7,14,21,35,36 tory, and/or interactive tutorials are powerful Small group discussion/seminar6,9,10,11,14,17,19,22–24,26,28, 30,32,34,35,36 teaching methods7,14,21,35; lectures are not as well Retreat14 received.32 Others have reported positive feed- Senior physician sharing own spiritual journey, and/or back from small group discussions and senior interactions with patients on spiritual issues21,32 physicians’ sharing personal experiences with Taking a spiritual history on a fellow student, family spiritual issues in patient care, and patient’s per- member, standardized patient (role play) or actual patient7,10,11,14,17–23,24,26,29,30,31,35 sonal stories.32 Taking a spiritual history on oneself21 In the palliative medicine literature, the only Verbatim27 report of spirituality education for fellows is from Watch a video on patient and physician experiences the program at Massachusetts General Hospital,4 with spiritual coping during illness32 Working with a hospice team7,17,31 which described their approach to psychosocial
  • 7. SPIRITUALLY TRAINING FOR PALLIATIVE CARE FELLOWS 175 Spirituality education faculty Evaluation of competency Various learner evaluation tools have been re- Educators from many different professional ported in medical school and residency programs backgrounds are involved with medical school including: reflective essay,9,17,21,24,26,30,31 question- and residency spirituality education.10,14,27,29,32,34 naire regarding satisfaction and self-reported Such programs have noted that inclusion of fac- changes in attitude or knowledge,18,19,22,28,32 craft- ulty from diverse backgrounds (race, gender, ing a spiritual history on a patient,11 a faith, and/or health care profession) is a useful pretest/posttest questionnaire,11 writing one’s educational strategy, as is recognizing the diverse own spiritual history,21 videotaping of an end-of- spiritual and religious background of the curriculum standardized patient interview on trainees. Three groups report training-the-train- end-of-life care and spirituality,18 oral presenta- ers in “spirituality” before a program in spiritu- tion,31 and a written exam question.18 In our sur- ality education.11,23,32 There is no data on the rel- vey, a written evaluation by the faculty was the ative effectiveness of individuals from different most common method of competency evaluation, backgrounds in the teaching of spirituality con- while some programs reported no specific evalu- cepts, or on the effectiveness of faculty develop- ation for spirituality knowledge or skills. Given ment programs for this domain. the importance of spirituality education in pallia- In our survey, respondents noted that chap- tive care, a standardized and rigorous approach lains were utilized in all programs to provide to trainee evaluation should be adopted. Because spirituality education; other team members were spirituality education includes key attitudes, a also involved, indicating the potential for inter- core of knowledge, and testable skills and behav- disciplinary spiritual care education. We do not ior, the optimal evaluation will need to be multi- know what kinds of attitudes, knowledge, and dimensional, moving beyond the standard writ- skills any of these trainers bring to spirituality ed- ten faculty evaluation to include measures such ucation, or whether they themselves have under- as recommended by the Accreditation Council for gone specific training on the topic of spirituality. Graduate Medical Education (ACGME), for ex- It should be noted that chaplains with formal ample, 360-degree evaluation, portfolios, and Clinical Pastoral Education (CPE) receive a spe- standardized patient evaluations.40 cialized form of instruction that may make them This study has methodological limitations. uniquely qualified to be involved in spirituality Most importantly, only 29% of program directors education.40 CPE students are specifically trained responded. Therefore, this data may not be re- to understand how their attitudes, values as- flective of all current fellowship programs. Sec- sumptions, strengths and weaknesses affect their ond, a self-assessment report from fellowship di- pastoral care. They participate in reflective exer- rectors may not reflect actual practice, with cises of patient interactions with a chaplain su- program directors possibly over- or under-re- pervisor in an effort to understand the theologi- porting actual educational activities. A concur- cal, psychological and social issues arising in rent survey of fellows might have helped assess these interactions. CPE includes regularly sched- the reliability of the information. Finally, al- uled one-on-one meetings with a supervisor to though the survey was adopted from the current discuss issues that arise in patient care, and the literature on physician spirituality education, we emotions that work triggers. A common educa- may have missed topics of importance that are tional tool in CPE training is a narrative verba- unique to palliative medicine fellowship training. tim, where pastoral students record from mem- ory their conversations with patients that focus on spiritual issues, and then analyze the text from a medical, psychological, theological, and ethical CONCLUSION framework with the assistance of a supervisor. AND RECOMMENDATIONS Most physician, nurses, and social workers pro- viding training to palliative care fellows have not Training in spirituality involves developing had this type of educational experience or train- fundamental knowledge, skills, and attitudes ing, although one program has adapted CPE for about this realm of human existence and clinical nonchaplains.45 practice, and touches on issues of professional
  • 8. 176 MARR ET AL. role boundaries, personal competency and self- care can be invited to participate in spiritual- confidence in intense interpersonal encounters, ity education. Individual programs will need and cross-cultural care, all in the context of a po- to decide how specific content areas are pro- tentially highly charged emotional atmosphere vided to fellows in a manner that respects the surrounding end-of-life care. Fellows should; discipline-specific strengths of each team have the skills to complete a spiritual assessment; member. know their limitations in providing spiritual care • Trainee evaluation in spirituality must provide and how to work with others more skilled in the sufficient depth to gauge the learner’s atti- work; have the ability to self reflect and under- tudes, knowledge, skills and clinical practice stand their own spiritual history and how this af- behavior. We support the learner evaluation fects their care of patients; be prepared to criti- methods endorsed by the ACGME that go be- cally evaluate the literature; and be familiar with yond the standard written faculty evaluation the skills of chaplain, psychologists and others tool.41,43 who can assist patients in their spiritual journey. At the same time, palliative care physicians will not obtain the full skill set of a CPE-trained chap- lain. REFERENCES Our survey suggests that fellowship training in 1. Sulmasy D: Is medicine a spiritual practice? Acad the domain of spirituality education could be Med 1999;74:1002–1005. greatly improved. Experiential educational meth- 2. National Consensus Project for Quality Palliative ods and trainee evaluation tools that are de- Care: Clinical Practice Guidelines for Quality Pallia- scribed in the medical education literature are un- tive Care, Executive Summary. J Palliat Med 2004; der-utilized in palliative medicine training. With 7:611–627. the background provided in this survey and the 3. Billings J Andrew, Block SD, Finn JW, LeGrand SB, growing experience with medical school and res- Lupu D, Munger B, Schonwetter RS, von Gunten CF: Initial voluntary program standards for fellowship idency education on spirituality, we can make training in palliative medicine. J Palliat Med 2002; some broad suggestions for spirituality curricu- 5:23–33. lum development: 4. Billings JA, Dahlin C, Dungan S Greenberg D, Krakauer EL, Lawless N, Montgomery P, Reid C: Psy- • Based on the general agreement from respon- chosocial training in a palliative care fellowship. J Pal- dents to our survey, we believe that program liat Med 2003;6:355–363. directors can consider the thirteen domains 5. Allen EA: Integrating spirituality in the training of medical students. West Indian Med J 2003;52:151–154. outlined in Table 1 as the core learning objec- 6. Chibnall JT, Duckro PN: Does exposure to issues of tives for a spirituality curriculum. spirituality predict medical students’ attitudes to- • A needs assessment should be completed to as- ward spirituality in medicine? Acad Med 2000; sess (1) faculty and fellow baseline learning 75:661. needs in spirituality education, (2) faculty and 7. Pettus MC: Implementing a medicine-spirituality cur- fellow self assessment of competency in spiri- riculum in a community-based internal medicine res- tuality skills, and (3) local educational training idency program. Acad Med 2002;77:745. opportunities that can be incorporated into fel- 8. Magwood B, Cassiro O, Hennen B: The medical humanities program at the University of Manitoba, low training (e.g., affiliated CPE program). Winnipeg, Manitoba, Canada. Acad Med 2003;78: • The educational methods chosen must be ap- 1015–1019. propriate for the desired learning objective.42 9. Andre J, Brody AJ, Fleck L, Thomason CL, Tomlinson Because of the predominance and importance T: Ethics, professionalism, and humanities at Michi- of listening and communication skills in spiri- gan State University College of Human Medicine. tual care, the curriculum must include oppor- Acad Med 2003;78:968–972. tunities for skill practice with real or simulated 10. McCarthy MK, Peteet JR: Teaching residents about re- ligion and spirituality. Harvard Rev Psychiatry patients, direct observation and feedback by 2003;11:225–228. training faculty, and opportunities for self-re- 11. Musick DW, Cheever TR, Quinlivan S, Nora LM: Spir- flection and guided discussion. ituality in medicine: A comparison of medical stu- • As an interdisciplinary specialty, all team dents’ attitudes and clinical performance. Acad Psy- members with expertise in the area of spiritual chiatry 2003;27:67–73.
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