Reflection Rounds:
An Interdisciplinary Curricular Innovation for
Medical Students to Encourage
Self-Reflection and Strengthen Spiritual Inquiry
MEG Spring Symposium
March 2015
David S. Kountz, MD, MBA
Vice President, Academic Affairs
Associate 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
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–
–
–
–
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
I
C
A
What is your belief or faith?
Is it important in your life? What influence
does it have on how you take care of yourself?
Are you part of a spiritual or faith community?
How would you like your healthcare
provider to address these issues?
Research in Spirituality and Health
Coping: 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%
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
Chri
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 Care
Patients 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
2000
1992
3
122
Schools with Courses
Schools without Courses
47
72
Schools with Courses
Schools without Courses
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 Education
Questions 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, FACP
Director, George Washington Institute for Spirituality and Health
Professor, Dept of Medicine and Health Sciences
George Washington University School of Medicine
Professor, Health Leadership and Management
George Washington University School of Public Health
2030 M Street NW Suite 4014
Washington DC, 20036
202 9946220
cpuchals@gwu.edu
www.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;63:30-33
Ibid. Int’l J Psy Med 1997;27(3) 233-250
McNeil JA et al. J of Pain and Symptom Management 1998:16(1) 29-40
Menard L et al. Can Fam Physician 2013;59(1):105-107
Sandars J. Med Teach 2009;3(8):685-695