An 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 scientific 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 undergraduate 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.
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 1998—1999 and 1999—2000 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).
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 first and the eighth week of the clerkship. We hypothesized that because PBL is an active learning process, a higher level of 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 modified 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 patient's illnesses and the importance of spirituality in the patient's 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 Office 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 6-week 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 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 t1.
We administered the questionnaire to all students in the psychiatry clerkship during the study period, distributing forms and collecting them on the first day of the rotation (pretest) and again on the final day of the rotation (posttest). Students were told that all survey results were confidential and had no impact on course grading. The students' post office box numbers were used to match up completed pre- and posttest instruments. Participation was voluntary, and the study received approval by the medical center's 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 (1998—1999 versus 1999—2000); 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 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 college's Student Progress and Promotions Committee, and a comment about their performance on the clinical performance examination is included in students' dean's 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 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 task—those who worked on the PBL featuring spirituality and those who worked on PBLs that did not mention spirituality. We hypothesized that students in the first 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.
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 student's post office 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 1—"no opinion"—were extracted from the data; these responses accounted for nearly 8% of all responses. The alpha reliability coefficient 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 findings on the six personal spirituality items of the questionnaire are related to students' clinical performance, we find them interesting and indicative of student support for our teaching efforts on this subject.
We first examined within-group differences on item means across all students on the pre- and posttest forms. For the six physician practice items, students in the group that worked on the PBL featuring spirituality gave only one item a significantly 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 significant 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 significant differences were noted (as expected, given random assignment to the groups). On the posttest surveys, significantly 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 significant 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 significant difference on the item pertaining to taking a spiritual history from a patient (3.52 for the 1998—1999 academic year and 3.95 for the 1999—2000 academic year; p=0.001). No significant differences were found on any item means on the posttest surveys.
Clinical Performance Examination
There was no significant difference in the performance of the two groups on the psychiatry station tasks featuring a diagnosis of panic disorder and the preparation of a patient's 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%, respectively, 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 1999—2000 academic year performed significantly better on the spiritual history task than students who completed the rotation in the 1998—1999 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 men's and women's clinical performance examination results on the spiritual history task across both academic years. We found that the women's scores were higher than the men's scores in the spiritual history task (52% compared with 50%), but the difference was not statistically significant (p=0.36). There was no significant difference between men and women in overall performance across the two academic years.
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 findings of a study by Chibnall and Duckro that indicated that greater exposure to certain types of educational material on spirituality may influence 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 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 Duckro's 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 Duckro's call for longitudinal studies (9). that can shed more light on this important issue.
During the first 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 reflected 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 first three years of the curriculum, it is possible that students were already confident 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' confidence about specific clinical skills related to spirituality—in 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 finding as a confirmation of the willingness of students to add this particular skill to their clinical arsenals.
The finding 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 1999—2000 being the third year of implementation. Hence we were encouraged to find that students who were exposed to the curriculum during that year were apparently more confident in their ability to perform this clinical task. As we continue to refine this curriculum in coming years, we do so with greater confidence 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 first 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 first academic year of the study. However, the overall confidence 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' confidence 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 subject 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 years—particularly in realms such as bioethics, professionalism, and the like—is affected by a hidden curriculum whereby clinician role modeling has a greater influence 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.