Reflection Rounds:An Interdisciplinary Curricular Innovation for

Medical Students to Encourage Self-Reflection and Strengthen Spiritual Inquiry

MEG Spring SymposiumMarch 2015

David S. Kountz, MD, MBAVice President, Academic AffairsAssociate Dean, Rutgers RWJMS

Goals

• To review the importance of spirituality training for physicians and current gaps in medical education

• To review the literature on spiritual inquiry in medical education and patient care

• To provide a rationale for the importance of self-reflection for medical students

• To describe a grant obtained by Rutgers RWJMS/JSUMC from the George Washington Institute for Spirituality and Health (hereafter referred to as “GWish”) to organize and study Reflection Rounds

Case Presentation

Jennifer is a third year medical student assigned to the hematology oncology service. She is part of a team caring for Sara, a middle-aged woman mother of two with Stage 4 breast cancer. Sara has exhausted conventional treatments and is contemplating palliative care and no further treatment. Jennifer notices an open bible on Sara’s nightstand and that she clutches and rubs her cross during her visits.

Jennifer feels as though she should say something, but doesn’t know how to initiate a conversation.

Background

• Spiritual inquiry in health care controversial• Patient spirituality and religiosity correlate with

– Reduced morbidity and mortality– Better physical and mental health– Improved coping skills

• Patients desire spiritual discussions with physicians, and believe that it is as important as physical health

• Spiritual discussions rarely take place

Background

• Physician issues with spiritual inquiry– Departing from established areas of expertise– Lack of spirituality training– Time constraints– Perception of invasion of privacy– Ethics of physicians acting as pastoral counselors

Spiritual History

• Taken at initial visit as part of the social history, at each annual exam, and at follow-up visits as appropriate

• Recognition of cases to refer to chaplains• Opens the door to conversation about values and beliefs• Uncovers coping mechanisms and support systems• Reveals positive and negative spiritual coping • Opportunity for compassionate care

“FICA”

F What is your belief or faith?I Is it important in your life? What influence

does it have on how you take care of yourself?C Are you part of a spiritual or faith community?A How would you like your healthcare

provider to address these issues?

Research in Spirituality and HealthCoping: Pain Questionnaire by American Pain Society

to Hospitalized Patients

• Personal Prayer most commonly used non-drug method for pain management

- Pain Pills 82%- Prayer 76%- Pain IV med 66%- Pain injections 62%- Relaxation 33%- Touch 19%- Massage 9%

Christina Puchals

ki MD

Research in Spirituality and Health

• Mortality: People who have regular spiritual practices tend to live longer

• Coping: Patients who are spiritual utilize their beliefs in coping with illness, pain and life stresses

• Recovery: Spiritual commitment tends to enhance recovery from illness and surgery

Research in Spirituality and Health Immune System Functioning: Study of 1,700 older adults

• Those attending church were half as likely to have elevated levels of Interleukin (IL-6)

• Increased levels of IL-6 associated with increased incidence of disease

• Hypothesis: religious commitment may improve stress control by:- better coping mechanisms- richer social support- strength of personal values and world-view- may be mechanism for increased mortality observed in other

studies

Compassionate CarePatients as Teachers of Compassion

Students learn to be compassionate by:

• Learning to listen

• Learning to love

• Learning to be present to patients in the midst of their suffering

• Learning themes of forgiveness, loneliness, suffering

• Learning to be servers, not fixers

US Schools Teaching Courses on Spirituality and Health

1992 2000

Schools with Courses

Schools without Courses

3

122

Schools with Courses

Schools without Courses

72

47

Reflection in Medical Education

“…active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions

to which it stands…” (Dewey, 1933)

• Both individual and small-group sessions valuable• Aim of reflective activities to move learners from lower

to higher levels of reflection• Activities that foster reflection

– Learning portfolios, reflective essays, reflective log sheets

– Group sessions with trained facilitators

Reflection in Medical EducationQuestions that Trigger Reflection

Types of Questions Questions that Trigger Reflection

Noticing What were you thinking when…?What surprised us in that case?How does it make you feel?

Processing What does this mean?What are the consequences of you feeling like this?Are we doing this the right way?

Future Action What can facilitate…?What are the barriers to…?What will we do differently next time?

• Reflection is not an abstract concept• Professional competence “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefits of the invidiauls and communities being served (Epstein, 2002)

April 19, 2014

Dear Dr. Kountz,

Congratulations! On behalf of GWish and the John Templeton Foundation, I am pleased to inform you that Rutgers Robert Wood Johnson has been selected to participate in the GWish-Templeton Reflection Rounds(G-TRR 2) project. Attached please find a formal award letter with more details regarding the program.We are looking forward to working with you.

Christina

Christina M. Puchalski, MD, FACPDirector, George Washington Institute for Spirituality and HealthProfessor, Dept of Medicine and Health SciencesGeorge Washington University School of MedicineProfessor, Health Leadership and ManagementGeorge Washington University School of Public Health2030 M Street NW Suite 4014Washington DC, 20036202 9946220

cpuchals@gwu.eduwww.gwish.org

Reflection Rounds Activities

• Train-the-trainer session held at

GW June 2014• Volunteer participation by students

on psychiatry rotation at JSUMC• Weekly reflection rounds with member of hospital pastoral

care staff; co-facilitated by member of Dept of Psychiatry• IRB-approved research project through GWish soliciting

student feedback from all sites• Monthly call facilitated by GW with participating schools

9 Month Perspective…

• Medical students enjoy reflection rounds sessions– Safe environment– Engaged facilitators

• Subjectively not only learning about soliciting spiritual history but mechanism to decompress, share stories

• Inter-professional sessions with Pastoral Care unique and welcomed

• Update for Rutgers RWJMS academic leadership and hospital Pastoral Care leaders held December 2015

The physician will do better to be close by to tune in carefully on what may be

transpiring spiritually both in order to comfort the dying and to broaden his or

her own understanding of life at its ending.

Sally Leighton. Spiritual Life: 1996

Selected References

McCord G, et al. Ann Fam Med 2004;2(4): 356-61

Levin JS et al. JAMA 1997;278:792-793

Post SG et al. Ann Intern Med 2000;132:578-583

Sloane RP et al. N Engl J Med 2000;342:1913-1916

Pulchalski C et al. J Palliative Med 2000;3:129-137

Koenig HG. Am Fam Phys 2001;63:30-33Ibid. Int’l J Psy Med 1997;27(3) 233-250McNeil JA et al. J of Pain and Symptom Management 1998:16(1) 29-40Menard L et al. Can Fam Physician 2013;59(1):105-107Sandars J. Med Teach 2009;3(8):685-695