February 2014 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Perechocky, A., DeLisser, H., Ciampa, R., Browning, J., Shea, J. A. and Corcoran, A. M. "Piloting a medical student observational experience with hospital-based trauma chaplains." Journal of Surgical Education 71, no. 1 (January-February 2014): 91-95.
SUMMARY and COMMENT: The article for this month reports an initiative to incorporate the shadowing of on-call chaplains -- those serving in a Level 1 Trauma Center, in this case -- into medical education, and it models a straightforward means of capturing data from such experiences. The project was completed at the Hospital of the University of Pennsylvania and was developed by a medical student (lead author Perechocky) who, after being impressed by observing hospice chaplains, asked to shadow a trauma chaplain. The Pastoral Care Department Director (Ciampa) and the Coordinator of CPE (Browning) subsequently became involved as co-authors. Others from Penn's Perelman School of Medicine on the project included the Associate Dean for Diversity and Inclusion (DeLisser), the Program Director of the Hospice and Palliative Medicine Fellowship (Corcoran), and the Associate Dean of Medical Education Research and Director of the Office of Evaluation and Assessment in the Academic Programs Office (Shea).
While other schools have used shadowing experiences [--see Items of Related Interest, below], this study focuses on the value of shadowing a trauma chaplain, in particular.
Shadowing a trauma chaplain would...appear to provide a unique opportunity for medical students to learn skills for engaging and communicating with dying patients and grieving families. Further, such an experience might be particularly relevant for medical students interested in trauma surgery, emergency medicine, or critical care medicine. ...We propose that medical students would perceive benefits to their communication skills, understanding of the role of the chaplain, and knowledge of emotional and spiritual needs of grieving patients and families after shadowing hospital-based trauma chaplains whose work focuses on emergency department traumas and intensive care units. [p. 92]
Out of 21 medical students who shadowed the chaplains, 14 completed an electronic questionnaire (11 first-year students and 3 second-year students). The survey included 5 items for response on a 5-point Likert scale [--see p. 93]:
Results generally supported the idea that shadowing a trauma chaplain would be "an effective approach to developing medical education competences" [p. 93] around providing end-of-life care to patients and support to families.
- This experience provided me with a greater understanding of how to engage patients and/or families in difficult conversations.
- This experience provided me with a greater understanding of the chaplain's role in patient care.
- This experience provided me with a greater understanding of how to appropriately discuss issues of spirituality with patients and/or families.
- This experience was useful for my medical education and/or career.
- This experience was useful for my personal development.
It is noteworthy that respondents rated both the statements "this experience was useful for my medical education and/or career" and "this experience was useful for my personal development" at 4.86 (SD 0.36), with medians of 5.0. All of the respondents (14/14) recommended that other medical students shadow a trauma chaplain at some point during their medical education. [p. 93]
The survey also included an open-ended question: "What did you learn from this experience?" Several examples of those responses are provided, with the main themes being 1) "learning about communication with patients and families during moments of grief and loss," 2) "learning about the role of the chaplain in patient care," and 3) "learning about appropriately addressing issues of spirituality in a healthcare setting" [p. 93]. The authors also note that the experience seems to speak to "interprofessional collaboration between chaplains and physicians" [p. 94]. Future research could explore shadowing experiences for providers in different medical specializations and an assessment of both short-term and long-term effects.
In chaplains' search for ways to help other disciplines understand our own and to enhance others' skills in caring for patients and families, the idea of offering shadowing experiences in the context of medical education may out hold a powerful and productive opportunity. In addition, as our present article shows, the value of such a multidisciplinary project may be captured through a quite simple electronic questionnaire.
EDITOR'S NOTE: The shadowing experience has continued at the Hospital of the University of Pennsylvania, and a news article in the Perelman School of Medicine's May 2013 Monthly Pulse stresses how this project has encouraged curricular innovation. The shadowing process has also evolved since the original round, with subsequent iterations of the process including a log in which medical students may write personal reflections immediately after the fact. As for Dr. Perechocky himself, he is presently an Emergency Medicine Resident at the Boston Medical Center and has said of his own shadowing: "I know I will face intense and emotional situations, and I hope that my experience will allow me to more comfortably address spirituality and establish stronger connections with my future patients and their families" (Monthly Pulse, ibid.).
Suggestions for the Use of the Article for Discussion in CPE:
This is a very brief article that could be assigned with little lead time to a CPE group and could engage students in a discussion of shadowing and, more specifically, being shadowed. It might be especially useful in the weeks prior to any planned shadowing, and while it would be obviously suited to programs in academic medical centers, it could easily be adapted for a discussion of shadowing in general. The authors have focused in their questionnaire on how shadowing may affect the shodower's "understanding of how to engage patients and/or families in difficult conversations," "understanding of how to appropriately discuss issues of spirituality with patients and/or families," and "personal development" [p. 93]; in addition to better understanding what chaplains do. The CPE group may want to think about how they may support these foci as the person being shadowed. Would these emphases be the same if shadowers were new chaplains rather than medical students? Are there other aspects of the shadowing experience that the authors may have overlooked? A potential tangent for the discussion could be how the shadowing process puts the chaplain in a leading role that may have implications for their sense of power dynamics with other health care professionals and for issues around authority. Finally, the article could lead to conversation about how students feel about being observed and how that may affect their pastoral practice.
Related Items of Interest:
I. Our featured article notes three references in the literature about shadowing initiatives:
Bell, D., Harbinson, M., Toman, G., Crawford, V. and Cunningham, H. "Wholeness of healing: an innovative student-selected component introducing United Kingdom medical students to the spiritual dimension in healthcare." Southern Medical Journal 103, no. 12 (December 2010): 1204-1209. [(Abstract:) OBJECTIVE: This Student Selected Component (SSC) was designed to equip United Kingdom (UK) medical students to engage in whole-person care. The aim was to explore students' reactions to experiences provided, and consider potential benefits for future clinical practice. METHODS: The SSC was delivered in the workplace. Active learning was encouraged through facilitated discussion with and observation of clinicians, the palliative team, counseling services, hospital chaplaincy and healing ministries; sharing of medical histories by patients; and training in therapeutic communication. Assessment involved reflective journals, literature appraisal, and role-play simulation of the doctor-patient consultation. Module impact was evaluated by analysis of student coursework and a questionnaire. RESULTS: Students agreed that the content was stimulating, relevant, and enjoyable and that learning outcomes were achieved. They reported greater awareness of the benefit of clinicians engaging in care of the "whole person" rather than "the disease." Contributions of other professions to the healing process were acknowledged, and students felt better equipped for discussion of spiritual issues with patients. Many identified examples of activities which could be incorporated into core teaching to benefit all medical students. CONCLUSION: The SSC provided relevant active learning opportunities for medical students to receive training in a whole-person approach to patient care.]
Fuechtmann, M. and Sheehan, M. N. "Introducing students to the spiritual dimension of illness." Academic Medicine 71, no. 5 (May 1996): 529-530. [This is a brief report of a chaplain-mentor program for first-year medical students at the Stritch School of Medicine at Loyola University of Chicago. It includes the pairing of students with chaplains on regular pastoral care visits. "Despite some prior concerns that spirituality might be an uncomfortable topic for medical students, the students have been overwhelmingly positive in their response to the program. Students found that the perspective brought by the chaplains in speaking with patients gave them new insights into how people react to and deal with illness. The students gained new respect for the expertise that skilled chaplains can bring to patient care. Recognition of the ways in which individuals grapple with questions of meaning, despair, fear, and possible death deepened the students' understanding that spirituality can be an important factor in the patient's experience of illness." (p. 530)]
Graves, D. L., Shue, C. K. and Arnold, L. "The role of spirituality in patient care: incorporating spirituality training into medical school curriculum." Academic Medicine 77, no. 11 (November 2002): 1167. [(Abstract:) OBJECTIVE: To answer the call for the implementation of spirituality into medical school curriculum,(1) UMKC-School of Medicine has incorporated experiential spirituality instruction into the third year of a six-year combined BA-MD degree program. The multifaceted objective of the program is to (1) expand students' conceptualization of the patient as person to include dimensions of spiritual beliefs and needs, (2) develop an understanding of how patients' spiritual belief systems impact their health, (3) recognize how the student's spiritual beliefs impact his or her practice of medicine, and (4) highlight the value of the chaplain as a member of the health care team. With increased understanding of the role spirituality plays in healing as well as the spiritual services available to patients, students will be able to serve the needs of their patients. DESCRIPTION: To accomplish this objective, students participate in lectures on spirituality, small-group activities focusing on skills such as taking/crafting spiritual histories, and an on-call experience with a hospital chaplain. During the oncall experience, students shadow a chaplain for approximately six hours. The experience includes discussing philosophies of spirituality and medicine with the chaplain, rounding with the chaplain, visiting and praying with patients when requested, comforting family members, and assisting with advance directive discussions and paperwork. After completing the experience, the students are required to write a reflective essay examining the following components: (1) the interaction between the chaplain and other members of the health care team, (2) the utilization of alternative interview and history taking methods, (3) the connection between spirituality and illness as illustrated through patient encounters, and (4) the insights gained from the experience that can be applied to the practice of medicine. DISCUSSION: The writing of one's spiritual history and the on-call experience were integrated into a new portion of the curriculum. The components were initially met with some reticence. In the beginning, students had difficulty distinguishing spirituality from religion and were concerned that the curriculum would take away from their study of "real medicine." To ease concerns regarding the spiritual history, the course director modeled the objectives by sharing her own spiritual journey. Participation in the on-call experience substantially changed students' negative attitudes toward the curriculum. Essays revealed that the on-call experience had greatly impacted their view of the chaplain as well as their practice of medicine. Specifically, students demonstrated an understanding of the role of spirituality in healing, identified key components of the chaplain role in the hospital setting, shared ways in which they would utilize chaplains in the future, and discovered personal struggles. Crafting one's spiritual history, the on-call experience, and essays will continue to be a required part of the third-year curriculum. Modifications include adding the option of constructing one's own advance directive and striving for increased diversity of spiritual perspectives. The data provided in the essays and course evaluations will be utilized in several ways to determine the success of the curriculum and to answer critical research questions in the areas of spirituality and medical education.]
II. Other sources regarding chaplaincy shadowing as part of medical education:
Anandarajah, G., Long, R. and Smith, M. "Integrating spirituality into the family medicine residency curriculum." Academic Medicine 76, no. 5 (May 2001): 519-520. [This brief report describes a component developed for the family medicine residency at Brown University School of Medicine and Memorial Hospital of Rhode Island, including some half-day rounds with a chaplain. Among the concluding comments: "The residents have especially appreciated the interactive nature of the tutorial and bereavement sessions and the practical exposure on rounds with chaplains" (p. 519).]
Dundjerski, M. "Faith and healing." U Magazine [of the UCLA Health System/David Geffen School of Medicine] 33, no. 4 (Fall 2013): 14-17. [This article about spirituality and medicine at UCLA notes the chaplaincy shadowing component of the Doctoring 1 course at the David Geffen School of Medicine. "One of the important aspects that chaplain rounds emphasize is to put the students in a position to have empathy -- not just to address a patient’s symptoms…" [p.16]. The article is available online, and the full issue is also downloadable as a PDF. (Note: the UCLA shadowing experience is also featured in an online article in UCLA Magazine, posted July 1, 2007: Geffner, D., "The Human Touch," at http://magazine.ucla.edu/features/emphasis-on-empathy/index2.html.) ]
Harris, D. "Chaplain rounds." The Merck Manual Student Stories, A Health Care Education Blog (August 8, 2013): online as of 2/10/14 at http://medstudentstories.merckmanuals.com/chaplain-rounds-2. [This is a brief personal account of a UCLA first year medical student's experience of shadowing. It speaks to the potential of the shadowing experience for non-religious shadowers and how the experience may affect medical providers' assumptions and misconceptions about chaplaincy.]
III. For additional examples of shadowing initiatives at various medical schools, see the relevant web pages for the University of Minnesota, the University of Alberta, and the University of Pittsburgh School of Medicine.
IV. The Hospital of the University of Pennsylvania, the location for our featured article, has offered shadowing experiences to other non-chaplains. Two examples:
Greenberg, D. "Walking the 'sacred landscape' with a hospital chaplain: at the crossroads of spirituality and medicine." The International Journal of Healing and Caring 5, no. 3 (September 2005): online journal with the article at http://www.wholistichealingresearch.com/53greenberg.html, also available as a PDF. [This is an account of a journalist in a Masters program. She later became part of the Pastoral Care Department's CPE Advisory Committee.]
Shrum, G. "Reporter's notebook: on-call with a hospital chaplain." The Daily Pennsylvanian [of the University of Pennsylvania] (April 23, 2012): online as of 2/10/14 at http://www.thedp.com/r/52fb7367. [This is a straight news story, with a University of Pennsylvania reporter following a trauma chaplain overnight.]