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April 2011 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Anandarajah, G., Craigie, F. Jr., Hatch, R., Kliewer, S., Marchand, L., King, D., Hobbs, R. 3rd. and Daaleman, T. P. "Toward competency-based curricula in patient-centered spiritual care: recommended competencies for family medicine resident education." Academic Medicine 85, no. 12 (December 2010): 1897-1904.


SUMMARY and COMMENT: Our article this month is a research-minded report of a consensus project to identify spiritual care competencies in medical education. It is specifically aimed at family practice residents, but it may have multiple uses for chaplaincy programs. It is also a good illustration of how the Delphi technique may be applied, creating here a kind of focus-group process among a small number of experts.

The project arose from a concern among the members of the Interest Group on Spirituality in the Society of Teachers of Family Medicine, that in spite of a growing interest in spirituality and medicine there was a "lack of clear guidelines for training" [p. 1898]. A panel of experts* was identified (i.e., five MDs, one DO, one PhD psychologist, and one DMin --see more about the authors at the end of this section) and engaged in a Delphi method to build consensus for elements/goals of a spirituality education curriculum. The Delphi process -- involving rounds of e-mail, consolidation of input, and validation by external feedback -- is well lined out by the authors [pp. 1898-1900], and this may be of interest to chaplains as a methodology, in and of itself. A result was the identification of nineteen core competencies for knowledge, skills, and attitudes [--see Table 1, p. 1899]:

Topic:  KNOWLEDGE   --   Resident physicians will be able to...

Understanding of the terms spirituality and religion
...Verbalize an inclusive definition of spirituality and compare/contrast this with religion
Spirituality in patient care
...Provide a conceptual framework of spirituality in whole person patient care with two clinical applications
Diversity and influence of belief
...Describe two examples of diverse spiritual beliefs and the influence of these beliefs on patient care
Roles of specialty resources
...Identify and discuss the roles of two resources for spiritual care (e.g., chaplains, spiritual directors, pastoral counselors, clergy, faith communities, healers)
Ethical considerations
...Describe potential ethical concerns regarding concordant or discordant beliefs and values of patients and physicians
Empirical literature
...Provide a basic understanding of the empirical literature on spirituality and health, outlining potential clinical applications and limitations

Topic:  SKILLS   --   Resident physicians will be able to...

Recognize indications   [Assessment Skill]
...Give examples of two clinical situations in which a spiritual assessment may be useful
Collect spiritually relevant information   [Assessment Skill]
...Identify spiritually relevant elements in a general history and carry out a spiritual history/assessment in a culturally sensitive, patient-centered way
Listen attentively   [Assessment Skill]
...Use patient narratives/stories to gather information regarding spiritual beliefs, values, and concerns
Synthesize and communicate findings   [Assessment Skill]
...Summarize and communicate relevant spiritual information including patients’ spiritual needs, distress, and potential resources
Have a compassionate presence   [Therapeutic Skill]
...Demonstrate empathy and attentiveness to patients
Support patient self-care   [Therapeutic Skill]
...Identify and enable patients to use self-care strategies
Formulate a whole-person care plan   [Therapeutic Skill]
...Modify treatment plans by incorporating an understanding of the patient’s spiritual issues and concerns
Give spiritually integrated care   [Therapeutic Skill]
...Include pastoral and other spiritual care specialists in patient care
Negotiate differences in belief   [Therapeutic Skill]
...Identify and address salient ethical issues in concordant or discordant beliefs and values of patients and physicians.

Topic:  ATTITUDES   --   Resident physicians will demonstrate...

...A nonjudgmental and respectful attitude toward patients, family, and other members of the health care team
Spiritual self-awareness
...An ability to recognize how one’s spiritual beliefs and perspectives influence patient interactions and the delivery of medical care
Spiritual self-care
...A capacity to identify and nurture what is most meaningful and generative in one’s life
Spiritual centeredness
...An understanding of practices that contribute to maintaining mindfulness and healing intention during patient care

These competencies are explained in the text [pp. 1900-1902] and aligned with six competencies of the Accreditation Council for Graduate Medical Education: patient care, medical knowledge, practice-based learning & improvement, interpersonal communication, professionalism, and system-based practice [--see Table 3, p. 1901].

For chaplains, this work would seem to have several important implications. In terms of research, these competencies essentially set out an agenda for the development of "robust evaluation methods" [p. 1902]. Each competency or group of competencies could be the focus of study to create measures and subsequently to track data. In terms of education, the competencies could be considered along side of core competencies or outcomes for chaplaincy training and certification, and a dialogue between chaplain educators and medical educators -- about measures as well as basic content -- could prove fruitful for everyone involved and build both better understanding across disciplines and a deeper foundation for the spiritual care of patients. In terms of chaplaincy department activity at any one center, the competencies could be a basis for collaboration in a medical education curriculum: How might the resources of a Pastoral Care Department be useful and integrated into a medical school program? Finally, it should be noted that the competencies explicitly and implicitly recognize the role of chaplains [--see esp. pp. 1899, 1900, and 1902] and other "spiritual care professionals" and encourage referrals.

Additionally, the authors offer their consensus on three "global" spiritual care competencies: 1) "understand how spiritual and religious factors influence the milieu of patient–physician interactions and the delivery of health care"; 2) "identify spiritually relevant elements in patient encounters, conceptualize this information, and communicate with resources such as pastoral and spiritual care professionals"; and 3)"promote capacities that identify and nurture what is generative and meaningful in one’s life and work" [p. 1900]. These latter competencies are said to be intended for use around "promotion and advancement" [p. 1902], and they might also be adapted to serve as elements in a chaplaincy job interview or evaluation.

The article constitutes a research-minded case not only for the inclusion of spirituality in medical education but for the importance of spiritual care to patients. There is a quite extensive bibliography of 65 references.

*The members of the expert panel -- also the authors of the article -- are:

  • Gowri Anandarajah, MD, is professor (clinical) and residency director, Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI. [Dr. Anandarajah's work has also been featured in our Fall 2008 Newsletter (§5), and she is the co-creator of the HOPE Spiritual Assessment.]
  • Frederic Craigie, Jr., PhD, is associate professor, Department of Community and Family Medicine, Dartmouth Medical School, and director of behavioral science, Maine–Dartmouth Family Medicine Residency Program, Augusta, ME.
  • Robert Hatch, MD, MPH, is professor and director of medical student education, Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL.
  • Stephen Kliewer, DMin, is assistant professor, Department of Family Medicine, Oregon Health and Science University, Portland, OR. [Dr. Kliewer's work has also been featured in our Spring 2006 Newsletter (§1).]
  • Lucille Marchand, MD, is professor, Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
  • Dana King, MD, MS, is professor and vice chair, Department of Family Medicine, Medical University of South Carolina, Charleston, SC.
  • Richard Hobbs, III, MD, is assistant professor, Department of Community and Family Medicine, Dartmouth Medical School/Maine–Dartmouth Family Medicine Residency Program, Augusta, ME.
  • Timothy P. Daaleman, DO, MPH, is associate professor and vice chair, Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC. [Dr. Daaleman's work has also been featured for our December 2004 Article of the Month.]


Suggestions for the Use of the Article for Discussion in CPE: 

The most straightforward approach to discussion of this month's article would be to have students focus on the table of competencies [p. 1899] and consider: 1) How many of the goals involved in the list suggest competencies that chaplains should have, and how many of those might be a challenge for themselves personally at this stage of their chaplaincy training? 2) How might students imagine working with physicians who held such competency in spiritual care? How might physician competence in these areas affect the chaplain-physician relationship? Would care planning, referral, and treatment be different than that which they experience currently in their clinical work? 3) Are there any competencies that seem to be omitted or insufficiently emphasized in the listing, or that might go beyond what would be appropriate for the physician role? In addition, students could discuss how spiritual care competencies might best be taught to physicians and how a CPE educational model could be either an essential or optional means for achieving competency. Finally, how could physicians be evaluated on these competencies, and what are various ways that chaplains could be so evaluated?


Related Items of Interest:

I. Our authors refer at the outset of the article to "the recommendation by the Joint Commission on Accreditation of Healthcare Organizations that there be a spiritual assessment for patients admitted to acute hospitals" [p. 1897]. The link referenced in the bibliography is no longer operable, but another source from the Joint Commission that speaks to an interest in promoting spiritual assessment would be their 2010 monograph, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (--see esp. p. 15). For a summary of the Joint Commission's acute care hospital standards mentioning spirituality, religion, beliefs, and cultural diversity, see: (by J. Ehman).


II. Our authors also refer at the outset to the World Health Organization's "spiritual and religious inventory for gauging quality of life" [p. 1897], and they give a reference to an article: WHOQOL SRPB Group, "A cross-cultural study of spirituality, religion and personal beliefs as components of quality of life," Social Science and Medicine 622, no. 6 (March 2006): 1486-1497. Note that a critical commentary on this article was subsequently published in the journal by Alexander Moreira-Almeida and Harold G. Koenig: "Retaining the meaning of the words religiousness and spirituality: a commentary on the WHOQOL SRPB group's 'a cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life'" [vol. 63, no. 4 (August 2006): 843-845; with errata appearing in vol. 63, no. 10 (November 2006): 2753]. The actual 32-item instrument may be found on the WHO website at (--see pp. 20-23), printed with a larger Quality-of-Life field-test instrument.

An aside: one WHO-linked reference to spirituality in health care that is sometimes mentioned in the literature is the so-called WHO "Pastoral Intervention Coding". Actually, these codes were developed in an expansion of the WHO's "International Statistical Classification of Diseases and Related Health Problems" by the National Centre for Classification in Health (NCCH) in Australia after a request from the Australian College of Chaplains. Bibliographic citations for these codes are often confusing and misleading, but the most proper form should probably be:

National Centre for Classification in Health. Tabular List of Procedures ICD-10-AM: Australian Classification of Health Interventions (ACHI). Vol. 3 of The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM). Third edition. Sydney: University of Sydney, 2002.
See in volume 3 of the 2002 third edition: p. 268 (Pastoral Assessment), p. 278 (Pastoral Counseling or Education), p. 281 (Pastoral Ritual/Worship), and p. 296 (Pastoral Ministry), along with a further code on p. 297 for Allied Health Intervention, Pastoral Care. The codes have been continued in later editions.


III. For more on the Delphi method/technique, there are many resources available on the Internet, though most require some adaptation to the context of spirituality & health. One brief but helpful "tip sheet" is available from the University of Wisconsin at A detailed book, The Delphi Method: Techniques and Applications (2002), ed. by Linstone, H. A. and Turoff, M., is available online from the New Jersey Institute of Technology at



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