Benjamin Blatt

Spirituality and health: the development of a field.

Spirituality has played a role in health care for centuries, but by the early 20th century, technological advances in diagnosis and treatment overshadowed the more human element of medicine. In response, a core group of medical academics and practitioners launched a movement to reclaim medicine’s spiritual roots, defining spirituality broadly as a search for meaning, purpose, and connectedness. This commentary describes the history of the field of spirituality and health—its origins, its furtherance through the Medical School Objectives Project, and its ultimate incorporation into the curricula of over 75% of U.S. medical schools. The diverse efforts in developing this field within medical education and in national and international organizations created a need for a cohesive framework. The National Competencies in Spirituality and Health—created at a consensus conference of faculty from seven medical schools and reported here for the first time—answered that need. Also reported are some of the first applications of these competencies—competency-linked curricular projects. This issue of Academic Medicine features articles from three of the participating medical schools as well as one from an additional medical school. This commentary also describes another competency application: the George Washington Institute of Spirituality and Health–Templeton Reflection Rounds initiative, known as G-TRR, which has provided clerkship students with the opportunity, through reflection on their patient encounters, to develop their own inner resources to address the suffering of others. This commentary concludes with the authors’ proposals for future directions for the field.

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Standardized patient assessment of medical student empathy: ethnicity and gender effects in a multi-institutional study.

Purpose To examine, primarily, the effects of ethnicity and gender, which could introduce bias into scoring, on standardized patient (SP) assessments of medical students and, secondarily, to examine medical students’ self-reported empathy for ethnicity and gender effects so as to compare self-perception with the perceptions of SPs. Method Participants were 577 students from four medical schools in 2012: 373 (65%) were white, 79 (14%) black/African American, and 125 (22%) Asian/Pacific Islander. These students were assessed by 84 SPs: 62 (74%) were white and 22 (26%) were black/African American. SPs completed the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) and the Global Ratings of Empathy tool. Students completed the Jefferson Scale of Empathy and two Interpersonal Reactivity Index subscales. The investigators used 2,882 student–SP encounters in their analyses. Results Analyses of SPs’ assessments of students’ empathy indicated significant interaction effects of gender and ethnicity. Female students, regardless of ethnicity, obtained significantly higher mean JSPPPE scores than men. Female black/African American, female white, and female Asian/Pacific Islander students scored significantly higher on the JSPPPE than their respective male counterparts. Male black/African American students obtained the lowest SP assessment scores of empathy regardless of SP ethnicity. Black/African American students obtained the highest mean scores on self-reported empathy. Conclusions The significant interaction effects of ethnicity and gender in clinical encounters, plus the inconsistencies observed between SPs’ assessments of students’ empathy and students’ self-reported empathy, raise questions about possible ethnicity and gender biases in the SPs’ assessments of medical students’ clinical skills.

Acting on Reflection: the Effect of Reflection on Students’ Clinical Performance on a Standardized Patient Examination

BackgroundLittle evidence exists to support the value of reflection in the clinical setting.ObjectiveTo determine whether reflecting and revisiting the “patient” during a standardized patient (SP) examination improves junior medical students’ performance and to analyze students’ perceptions of its value.DesignStudents completed a six-encounter clinical skills examination, writing a guided assessment after each encounter to trigger reflection. SPs evaluated the students with Medical Skills and Patient Satisfaction checklists. During the last three encounters, students could opt to revisit the SP and be reevaluated with identical checklists.ParticipantsOne hundred and forty-nine third year medical students.MeasurementsChanges in scores in the Medical Skills and Patient Satisfaction checklists between first visit and revisit were tested separately per case as well as across cases.ResultsOn the medical skills and patient satisfaction checklists, mean revisit scores across cases were significantly higher than mean first visit scores [12.6 vs 12.2 (pooled SD = 2.4), P = .0001; 31.2 vs 31.0 (pooled SD = 3.5), P = .0001)]. Sixty-five percent of the time, students rated “reflect–revisit” positively, 34% neutrally, and 0.4% negatively. Five themes were identified in the positive comments: enhancement of (1) medical decision making, (2) patient education/counseling, (3) student satisfaction/confidence, (4) patient satisfaction/confidence, and (5) clinical realism.ConclusionsOffering third year medical students the option to reflect and revisit an SP during a clinical skills examination produced a small but nontrivial increase in clinical performance. Students perceived the reflect–revisit experience as enhancing patient-centered practices (counseling, education) as well as their own medical decision making and clinical confidence.

Verbal interaction analysis: viewing feedback through a different lens.

Background: Verbal interaction analysis, though seldom applied to the feedback-giving process, can be used to assess feedback dimensions not easily assessed by other means. Description: The purpose of this study was to explore verbal interaction analysis as a method to assess feedback interactions between senior medical students trained as teachers and their sophomore learners. We randomly selected 14 videotaped encounters of senior teachers giving feedback to sophomore learners and classified 417 utterances to address (a) verbal dominance, (b) feedback balance, and (c) cognitive level. Evaluation: Teachers did most of the talking (65.2%). Although some feedback was corrective (20.6%), teacher utterances were mostly positive (33.5%) or neutral (45.9%). Cognitively, the teacher utterances occurred largely at the factual (lowest) level (74.3%). Conclusions: Interaction analysis enabled us to describe 3 dimensions of teacher–learner feedback not easily assessed by other means: verbal dominance, positive-corrective balance, and cognitive level. Assessing these dimensions provides information about two theoretically important indices of feedback-giving effectiveness: learner involvement and feedback balance. Future study of verbal interaction analysis in this and other populations is warranted to further evaluate its usefulness.

A core physical exam for medical students: results of a national survey.

Purpose Medical students are traditionally taught the physical exam as a comprehensive battery of maneuvers, yet they express uncertainty about which maneuvers are “core” and should be performed routinely on patients and which ones should be performed only when clinically indicated. The authors sought to determine whether educator consensus existed on the concept and the specifics of a core physical exam for students. Method The authors developed a 45-maneuver core physical exam to be performed by a medicine clerkship student on every newly admitted patient, with the expectation that it would be supplemented by clinically indicated additional maneuvers. From 2011 to 2012 they sent surveys to physical diagnosis course directors (PDCDs) and internal medicine clerkship directors (IMCDs) from all 132 U.S. allopathic medical schools to determine the extent of their agreement with the proposed 45 maneuvers and their opinions about the concept of a core exam. Results Seventy-one percent (94/132) of PDCDs and 63% (83/132) of IMCDs responded to the survey. In total, 84% (111/132) of all schools surveyed were represented by either their PDCD or IMCD. Of the 45 proposed maneuvers, 37 were deemed “core” by a majority of respondents. The majority of IMCDs preferred a slightly leaner 37-maneuver core exam than the majority of PDCDs, who voted for 41 maneuvers. Conclusions Among PDCDs and IMCDs, there was openness to teaching medical students a streamlined core physical exam to which other maneuvers are added as clinically indicated. These educators closely agreed on the maneuvers this core exam should include.

Preparing students to be academicians: A national student-led summer program in teaching, leadership, scholarship, and academic medical career-building

Medical schools have the responsibility of producing future leaders in academic medicine, yet few students choose academic medicine as a career. In 2009, the American Medical Student Association (AMSA) and the George Washington University School of Medicine and Health Sciences joined forces to provide students with a comprehensive introduction to careers in academic medicine through the redesign of an existing annual summer program for medical students. Since 2004, AMSA had hosted the Medical Education Leadership Institute, a weeklong program that attracted medical students from across the country who were interested in gaining teaching skills. In the redesigned sixth annual program, the authors expanded the curriculum to include principles of leadership, of medical education scholarship (or project development), and of academic medicine career-building. The purpose of this article is to describe the features of this comprehensive program and to share the lessons learned from its development and implementation. The authors also describe the multifaceted approach they used to evaluate the program, which featured a rubric they derived from social cognitive career theory.

Perspective: successfully negotiating the clerkship years of medical school: a guide for medical students, implications for residents and faculty.

Medical students face significant learning and cultural challenges during the transition from the classroom to the clinical setting. The authors recommend that students be proactive in preparing themselves for this difficult journey by understanding and applying principles of adult learning. To guide students in this preparation, the authors propose a model that incorporates adult learning principles into a cycle emphasizing reflective practice. This model, based on the Kolb learning cycle, consists of five sequential steps: (1) preparing for the clinical setting, (2) experiencing the clinical setting, (3) reflecting on experience, (4) conceptualizing new approaches, and (5) testing new approaches on return to the clinical setting. This fifth stage in the cycle completes the first iteration. The cycle never ends, however; experimentation leads to new reflection, which in turn leads to new approaches and new experience.

Educating pediatric residents about breastfeeding: evaluation of 3 time-efficient teaching strategies.

Background: Previously reported breastfeeding curricula for residents have combined different teaching methods, have focused on knowledge and attitudes, and have been time-intensive. Objective: This study aimed to evaluate 3 time-efficient breastfeeding curricula for effectiveness in regard to pediatric residents’ knowledge, confidence, and skills in managing a simulated breastfeeding scenario. Methods: First-year pediatric residents during their 4-week community hospital newborn nursery rotation were consecutively assigned to 1 of 3 groups. Group 1 shadowed an International Board Certified Lactation Consultant (IBCLC) for 1 hour; group 2 watched a 25-minute case-based breastfeeding DVD; and group 3 observed a 3-hour prenatal parent breastfeeding class (CLS). Residents were assessed by (1) a pretest and posttest evaluating their breastfeeding knowledge and confidence, and (2) a clinical skills scenario managing a breastfeeding standardized patient (SP). Results: Thirty-nine pediatric residents participated in the study (11 in IBCLC, 16 DVD, 12 CLS) over a 1-year period. All groups significantly improved their knowledge scores and confidence in managing breastfeeding problems, with the IBCLC group showing more improvement in knowledge than the other groups (P = .02) and a higher rating of their teaching method (P = .01). All groups performed well on the SP clinical skills scenario, with no significant difference between groups. Conclusion: All 3 teaching methods were time-efficient and produced important gains in knowledge and confidence, with residents in the IBCLC group demonstrating greatest improvement in knowledge and a higher rating of their teaching method. Our study provides support for 3 methods of teaching residents breastfeeding management and demonstrates that IBCLCs are well-received as interprofessional educators.

Introducing medical students to careers in medical education: The student track at an annual medical education conference

Few avenues exist to familiarize medical students with careers as clinician–educators, and the clinician–educator career pathway has not been well defined. In this article, the authors describe how they integrated a career-oriented student track into the 2011 Northeast Group on Educational Affairs (NEGEA) annual retreat to introduce students to careers in medical education. Annual education conferences are principal sources of educational scholarship, networking, collaboration, and information sharing; as such, they represent attractive venues for early exposure to the culture of medical education. The authors’ goal in creating the NEGEA conference student track was to excite students about careers in medical education by providing them with an array of opportunities for active involvement in both student-specific and general conference activities. The authors draw from their experience to provide a guide for recruiting student participants to career-building student tracks. They also offer a guide for developing future student tracks, based on their experience and grounded in social cognitive career theory. Although their focus is on medical education, they believe these guides will be useful for educators planning a conference-based student track in any field.