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Bringing Spirituality to a
PENN Medicine Residency Program

By Dina Greenberg, Pennpulse Editor
Pennpulse 99 (November 2003): pp. 5-6
Published by The University of Pennsylvania Health System
Reprinted with permission
[This article in Pennpulse is available as a PDF by clicking HERE. See pp. 5-6.]

"One of the challenges in delivering high quality graduate medical education is to convey the importance of humanistic issues like spirituality without compromising the hard clinical training," says Kevin Fosnocht, M.D., assistant professor in the Department of Medicine. As an internist with the Penn Center for Primary Care at UPMS-Presbyterian and the program director of Penn's Primary Care Internal Medicine Residency Program, Fosnocht places a great deal of emphasis on establishing this delicate balance. Fosnocht believes that, particularly as a general internist, he must have "an openness to his patients' experience of illness and health that includes an assessment of physical, emotional, and spiritual well being." He believes that to be a truly exceptional doctor, one must "develop that additional desire to understand the whole person." This, says Fosnocht, takes time, experience, and maturity.

Directing 150 residents with 24 specialty tracks through the three-year residency program, he is especially aware of the "enormous anxiety" residents experience at this crucial point in physician training, a time when mastering technical skills is paramount. Resident training is delivered in month-long blocks, a short time-frame that does not allow residents to build long-term relationships with their patients. "Much of what patients may reveal about their spirituality depends upon a strong doctor-patient relationship and this is harder to appreciate as a resident," says Fosnocht.

Fosnocht refers to a small study done by a Florida researcher that maps interest in understanding spirituality as an aspect of patient care from the point of medical student status, to residency, and on through one's tenure as a practicing physician. Initially, explains Fosnocht, interest is high. He points, however, to a dramatic drop during the residency years, followed by a rebound once physicians become established in their fields.

Fosnocht contends that the study represents a general national trend and, from a personal perspective, is in line with his own experience throughout his medical career. "What attracts many people to medical school," he says, "is the idea of healing the whole person, of dealing not just with medicine and illness, but also with what it is that makes us human. So, in those early stages, when you're unfamiliar with the biology, you're drawn to the humanistic piece of doctoring."

At the residency stage, however, Fosnocht describes a period when "a premium is put on clinical practice skills." This is the time when physicians-in-training must effectively synthesize the countless technical skills required in their specialty area. "It's imperative to know all of the small details that can dramatically affect patient care," says Fosnocht. "Now is the time to know when to order a thyroid test and to know how to interpret the results, for example."

Therefore, says Fosnocht, making the humanistic aspect of patient care a lower priority during residency "is not entirely inappropriate." Putting himself in the role of a patient who is given the choice of either a "well-versed clinician" or a "kind and caring person," Fosnocht says that he would "have to go with the skilled clinician." He emphasizes, though, "The goal is to combine the two."

In Fosnocht's view, once the clinical skills have been mastered, it is not unusual for practicing physicians to explore a more holistic view of patient care, "to ask what more there is to learn" and to delve into what he describes as "the real art of medicine." Fosnocht believes that the way to teach this intangible skill is through modeling.

According to Fosnocht, the Primary Care Internal Residency Program provides a practical means of accomplishing this skill. In 2000-2001, with a grant from the John Templeton Foundation, Fosnocht put into practice some of the heartfelt principles he relies upon as a physician and as a teacher. He developed a year-long, multi-disciplinary course for residents, focusing on spirituality in medicine. Culling input from specialists across the University, the program included a series of lectures, role-playing scenarios, homework, and videotaping sessions. Residents were exposed to several diverse examples of religious beliefs that "call upon physicians' cultural competency in regard to delivering appropriate and respectful health care."

The basis for the course, according to Fosnocht, was to illustrate that expressing interest in patients' spiritual needs often leads to a stronger doctor-patient relationship with the increased potential for better health outcomes. "The physician's ability to communicate and to show empathy is an essential element in caring for his patient," says Fosnocht. "Even though I'm not a psychiatrist, I need to be open to the emotional life of my patient. I must be able to respond in a humane and therapeutic sense."

Building upon the prototype course, a similar class offered this year emphasizes training residents to take a spiritual history from patients. Fosnocht likens the spiritual history to a sexual history of a patient; the information gathered helps the physician to have a more complete understanding of the patient and to know better what he or she may be at risk for. "It's so important not to presume, not to make general assumptions," says Fosnocht, "so that as a physician, I know how to deal with you as an individual." To Fosnocht, there is a far-reaching context in which to gather information regarding patients' spiritual beliefs, what he refers to as "shared humanity an aspect of being human that doctors need to know in order to provide quality health care."

Learning this information early in the doctor-patient relationship is advantageous, according to Fosnocht. "Better now than in crisis," he advises residents. "What is gained from taking a spiritual history, apart from the cultural competency issue and the specifics of religious or spiritual beliefs as they pertain to making health-care decisions, is that the provider is sending the message that he or she is interested in the whole person; conveying that message is fundamental to establishing a therapeutic relationship."

Fosnocht points out, however, that as a primary-care physician, he faces particular challenges in determining how to make inquiries regarding patients' religious or spiritual beliefs.

Unlike in critical care settings where health crises often prompt patients and family members to seek spiritual guidance it is not always clear when or how the physician should "insert religion or spirituality into the picture" during a routine medical examination. "What we're really doing here is just putting the question of spiritual matters out there on the table. We're asking the question in an open-ended, respectful way: 'Do you have any spiritual or religious beliefs that you would like me to know about?' And, mind you, a spiritual history need not be a lengthy theological or philosophical discussion. The answer may simply be 'No.'" At the other end of the spectrum, Fosnocht points out, "many of our residents spend time in the intensive care unit at HUP, where they have to face hysterical family members who need to make life and death decisions about their loved ones' care." At both extremes, Fosnocht believes that acknowledging that spiritual beliefs may play a role in a patient's health and illness sends a clear message that "you are concerned and open to this information. This, alone, is quite meaningful to the patient and reinforces the doctor-patient relationship."

For this year's primary care residents, the spirituality in medicine course will reinforce this humanistic aspect of medicine. In addition to didactic sessions, medical residents will take call along with pastoral care residents. In one session, patients will talk to residents about how spirituality has affected their choices regarding health and illness and about the relationships they have built with their physicians. "We keep raising the bar higher on our expectations of physicians' ability to put this additional factor on their radar screen," says Fosnocht. Still, he is not, in any way, suggesting that physicians should be trained as chaplains, as well. From his vantage point, integrating spirituality into the residency program fits neatly within the context of professionalism and humanism modules. "Ultimately, it's an issue of meaning [of one's life], of the inexplicable nature of illness, not something that is explicitly religious. I think you would be hard-pressed to find any physician who would dismiss the importance of this issue."