Sharon K. Hull

Improving the spiritual dimension of whole person care: Reaching national and international consensus

Two conferences, Creating More Compassionate Systems of Care (November 2012) and On Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love and Forgiveness in Health Care (January 2013), were convened with the goals of reaching consensus on approaches to the integration of spirituality into health care structures at all levels and development of strategies to create more compassionate systems of care. The conferences built on the work of a 2009 consensus conference, Improving the Quality of Spiritual Care as a Dimension of Palliative Care. Conference organizers in 2012 and 2013 aimed to identify consensus-derived care standards and recommendations for implementing them by building and expanding on the 2009 conference model of interprofessional spiritual care and its recommendations for palliative care. The 2013 conference built on the 2012 conference to produce a set of standards and recommended strategies for integrating spiritual care across the entire health care continuum, not just palliative care. Deliberations were based on evidence that spiritual care is a fundamental component of high-quality compassionate health care and it is most effective when it is recognized and reflected in the attitudes and actions of both patients and health care providers.

Effect of Gender, Age, and Relevant Course Work on Attitudes Toward Empathy, Patient Spirituality, and Physician Wellness

Background: The emphasis in medical education on viewing the patient as a whole person addresses current concerns about the negative impact of standard physician training that may lead to impaired patient-physician relationships. Purposes: To assess self-ratings of empathy, spirituality, wellness, and tolerance in a sample of medical students and practitioners to explore differences by gender, age, and training. Methods: A survey was created that assesses empathy, spirituality, wellness, and tolerance in the medical setting. Surveys were completed anonymously by medical students and practitioners from the medical school. Results: The youngest groups scored highest on empathy and wellness and lowest on tolerance. Participation in medical school wellness sessions correlated with higher empathy and wellness scores; participation in both empathy and spirituality sessions correlated with higher empathy scores. Conclusion: Exposure to educational activities in empathy, philosophical values and meaning, and wellness during medical school may increase empathy and wellness in medical practice.

Prevalence of Health-Related Behaviors Among Physicians and Medical Trainees

ObjectiveThe authors studied the prevalence of health-promoting and health-risking behaviors among physicians and physicians-in-training. Given the significant potential for negative outcomes to physicians’ own health as well as the health and safety of their patients, examination of the natural history of this acculturation process about physician self-care and wellness is critical to the improvement of the western health care delivery system.Methods963 matriculating medical students, residents, or attending physicians completed the Empathy, Spirituality, and Wellness in Medicine (ESWIM) survey between the years 2000 and 2004. Items specific to physician wellness were analyzed. These included healthy behaviors as well as risk behaviors.ResultsBoth medical students and attending physicians scored higher in overall wellness than did residents. Residents were the lowest scoring group for getting enough sleep, using seatbelts, and exercising. Medical students were more likely to smoke tobacco and drink alcohol. Medical students reported less depression and anxiety and more social contacts.ConclusionMedical school training may prevent students from maintaining healthy behaviors, so that by the time they are residents they exercise less sleep less and spend less time in organizational activities outside of medical school. If physicians do not engage in these healthy behaviors, they are less likely to encourage such behaviors in their patients and patients are less likely to listen to them even if they do talk about it.

Teaching Population Health: A Competency Map Approach to Education

A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals’ training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community’s health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke’s efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.

Associations between Difficulty Paying Medical Bills and Forgone Medical and Prescription Drug Care

Problems paying medical bills have been reported to be associated with increased stress, bankruptcy, and forgone medical care. Using the Behavioral Model for Vulnerable Populations developed by Gelberg et al as a framework, as well as data from the 2010 Ohio Family Health Survey, this study examined the relationships between difficulty paying medical bills and forgone medical and prescription drug care. Logistic regression was used to examine associations between difficulty paying medical bills and predisposing, enabling, need (health status), and health behaviors (forgoing medical care). Difficulty paying medical bills increased the effect of lack of health insurance in predicting forgone medical care and had a conditional effect on the association between education and forgone prescription drug care. Those who had less than a bachelors degree were more likely to forgo prescription drug care than those with a bachelors degree, but only if they had difficulty paying medical bills. Difficulty paying medical bills also accounted for the relationships between several population characteristics (eg, age, income, home ownership, health status) in predicting forgone medical and prescription drug care. Policies to cap out-of-pocket medical expenses may mitigate health disparities by addressing the impact of difficulty paying medical bills on forgone care.

A student-planned memorial service.

No abstract available.

Behavioral Health in Prevention and Chronic Illness Management: Motivational Interviewing

This article reviews the history, methodology, and evidence related to the effective use of motivational interviewing (MI) in the primary care setting. MI has been shown to have a positive effect in promotion and modification of health habits and to increase treatment engagement. MI is also effective when used in conjunction with other treatment modalities, such as educational programs and cognitive behavioral therapy. Practical application of MI can be accomplished in a variety of primary care settings by a wide range of practitioners, incorporates nicely into new health care delivery models, and may improve the patient-provider relationship.

A prevalence study of faith-based healing in the rural southeastern United States

Background: Although prayer and other spiritual practices are common among residents of the rural south, the use of faith-based healers (FBH), or healers who use prayer as their primary healing modality, has not been explored in this population. Methods: Secondary data analysis from a random digit dialing telephone survey of rural adults in eight southern states. Results: Our overall response rate was 51% and 193 subjects (4.1%) had seen an FBH practitioner within the previous year. FBH use was significantly more common among younger respondents (OR 7.21, 95% CI 2.00, 25.94), women (OR 1.49, 95% CI 1.03, 2.14), those reporting poorer health (OR 1.83, 95% CI 1.19, 2.83), and those who believed in avoiding physicians (OR 1.82, 95% CI 1.24, 2.67). A relationship between FBH use and delayed or foregone medical care, and cost as a barrier to obtaining care was not statistically significant after controlling for other factors. Conclusions: Prevalence of FBH use is low, but is significantly related to younger age, female gender, poorer health status, barriers to medical care and devaluing medical care. Clinicians may consider exploring FBH usage with their younger, female patients, and those in poorer health. Policy makers should consider how FBH usage is related to various indicators of health care services demand, utilization and access.

Licensure challenges in preventive medicine: A public policy issue

Introduction Preventive medicine is a unique medical specialty recognized by the American Board of Medical Specialties that employs a population-based approach to healthcare delivery. Physicians certified in preventive medicine often focus their disease prevention and health promotion efforts at both the individual and population levels. Preventive medicine physicians are uniquely trained in both clinical and population-based medicine and are required to earn a Master of Public Health (MPH) or equivalent degree during residency training. Thus, they enter medical practice with a population-based focus and are viewed as leaders in advancing outcomes-based practice in prevention and wellness. Many preventive medicine physicians are involved in one or more medical policy roles, such as establishing regulations, setting clinical standards, monitoring quality of care, and developing the evidence base for such policies. A seminal article reviewing challenges and opportunities in preventive medicine residency training summarizes the value of such roles for the specialty:

Primary care multidisciplinary teams in practice: a qualitative study

BackgroundCurrent recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals’ perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care.MethodsQualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis.ResultsPractices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients.ConclusionsPrimary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices’ control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices’ struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.