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Auguste H. Fortin VI, MD, MPH; Katherine Gergen Barnett
Yale University School of Medicine, New Haven, Conn

JAMA. 2004;291:2883.

A growing number of medical schools are offering courses in spirituality in medicine. In 1994, only 17 of the 126 accredited US medical schools offered courses on spirituality in medicine.¹ By 1998, this number had increased to 39,¹ and by 2004, to 84 schools.² To characterize the curricula, we conducted a search of PubMed, PsychINFO, the Educational Resources Information Clearinghouse (ERIC), and the Social Science Citation Index (details are available from the authors). We then determined whether the articles reported on curriculum development, curricular goals and objectives, topical content, educational strategies, evaluation methods, or evaluation of outcomes.³

Ten reports met these inclusion criteria.^4-13 Three programs had been developed for first-year students, 2 for first- and second-year students, 2 for second-year students, and 2 for third-year students. Four of these 10 curricula specifically focused on spirituality and medicine, while 2 other courses included additional components on cultural competency and end-of-life care. Three curricula taught students in the context of a medical humanities course that included spirituality as a component topic.

Although authors generally described the content of their courses, most did not report the key steps of the curriculum development process. Only one described a needs assessment, though only for the local community and not for the medical students.¹² Four included objectives, the most common of which were to understand how patients' spiritual beliefs impact health; to understand how medical students' own belief systems can affect the care they provide; and to develop skills to take a spiritual history.

Most curricula used several educational methods, such as lectures, small group discussion, standardized patient interviews, and readings. One included a 6-hour on-call experience with a hospital chaplain.⁵ The majority of reports in the reviewed literature failed to specify what particular aspects of spirituality and medicine the courses covered. For example, several articles stated that students attended lectures on "spirituality and medicine" without providing additional details. Other articles mentioned the assignment of "selected readings" but did not list any of the assigned references.

Most schools evaluated their programs' effectiveness with student surveys of satisfaction or self-reported changes in attitude or knowledge. However, to evaluate the effectiveness of psychiatry clerkship problem-based case studies concerning spiritual issues at one school, Musick et al¹¹ randomized students to either a case that involved spiritual issues or cases that made no mention of spirituality. At the end of the course they interviewed a standardized patient with spiritual issues and were assigned to write the patient's spiritual history. Only the students who worked with the spiritual case study had a statistically significant increase in self-reported knowledge about taking a spiritual history. Students in the intervention and control groups obtained statistically equivalent scores on the standardized patient interview.

Unfortunately,most curricula were not presented in enough detail to replicate and few assessed outcomes on effectiveness. The lack of detail in these published reports is not unique; recent reviews of resident research¹⁴ and evidence-based medicine curricula¹⁵ note similar deficiencies.

Our review has several limitations. First, we included only published reports; and though unpublished curricula could be just as useful to educators they are difficult to access. Second, our search strategy, though thorough according to accepted standards of literature review, may still have missed some of the published curricula. Indeed, spirituality may be taught in several venues, including courses on holistic medicine¹⁶ and complementary and alternative medicine (CAM). Brokaw et al¹⁷ surveyed CAM course directors at 53 medical schools and found that 64% included teaching about spirituality, faith, and/or prayer.

Acknowledgement: We thank Jan Glover, MLS, for assistance with literature searching.

REFERENCES
1. Puchalski CM, Larson DB. Developing curricula in spirituality and medicine. Acad Med. 1998;73:970-974. WEB OF SCIENCE | PUBMED 2. John Templeton Foundation Spirituality and Health Programs. Available at: http://www.templeton.org/spirituality_and_health/programs.asp. Accessed May 19, 2004. 3. Green ML. Identifying, appraising, and implementing medical education curricula: a guide for medical educators. Ann Intern Med. 2001;135:889-896. FREE FULL TEXT 4. Deloney LA, Graham CJ, Erwin DO. Presenting cultural diversity and spirituality to first-year medical students. Acad Med. 2000;75:513-514. FULL TEXT | PUBMED 5. Graves DL, Shue CK, Arnold L. The role of spirituality in patient care. Acad Med. 2002;77:1167. FULL TEXT | PUBMED 6. Hull SK, DiLalla LF, Dorsey JK. Student attitudes toward wellness, empathy, and spirituality in the curriculum. Acad Med. 2001;76:520. FULL TEXT | WEB OF SCIENCE | PUBMED 7. King DE, Blue A, Mallin R, Thiedke C. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teach Learn Med. 2004;16:64-68. FULL TEXT | WEB OF SCIENCE | PUBMED 8. Lie D, Rucker L, Cohn F. Using literature as the framework for a new course. Acad Med. 2002;77:1170. FULL TEXT | PUBMED 9. Lypson ML, Hauser JM. Talking medicine. Acad Med. 2002;77:1169-1170. PUBMED 10. Montgomery K, Chambers T, Reifler DR. Humanities education at Northwestern University's Feinberg School of Medicine. Acad Med. 2003;78:958-962. FULL TEXT | WEB OF SCIENCE | PUBMED 11. Musick DW, Cheever TR, Quinlivan S, Nora LM. Spirituality in medicine. Acad Psychiatry. 2003;27:67-73. FREE FULL TEXT 12. Quill TE, Dannefer E, Markakis K, et al. An integrated biopsychosocial approach to palliative care training of medical students. J Palliat Med. 2003;6:365-380. FULL TEXT | PUBMED 13. Tang TS, White CB, Gruppen LD. Does spirituality matter in patient care? establishing relevance and generating skills. Acad Med. 2002;77:470-471. PUBMED 14. Hebert RS, Levine RB, Smith CG, Wright SM. A systematic review of resident research curricula. Acad Med. 2003;78:61-68. WEB OF SCIENCE | PUBMED 15. Green ML. Graduate medical education training in clinical epidemiology, critical appraisal, and evidence-based medicine: a critical review of curricula. Acad Med. 1999;74:686-694. WEB OF SCIENCE | PUBMED 16. Graham-Pole J. "Physician, heal thyself. Acad Med. 2001;76:662-664. WEB OF SCIENCE | PUBMED 17. Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The teaching of complementary and alternative medicine in US medical schools: a survey of course directors. Acad Med. 2002;77:876-881. WEB OF SCIENCE | PUBMED

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