Despite the growing research base on spirituality, religiousness and health [1, 4], few medical schools have been addressing this issue worldwide [10].
In the present study, the first to evaluate S/H courses in a medical school from a Latin American country, we found that 10.4% of Brazilian medical schools have dedicated S/H courses and 40.5% have courses or content on spirituality and health. These results are in line with a recent Brazilian study which found that 84% psychology courses do not address spirituality in their curriculum, which underscores the challenges faced by academic institutions in including such courses in Brazil [16].
These findings are quite different compared to surveys in other countries such as United Kingdom (UK) and United States (US). In 2008, Neely et al. reported that 59% of UK medical schools had some type of course content on spirituality in their medical curriculum. Likewise, a recent survey conducted by Koenig et al. [12] showed that 90% of US medical schools have courses or content on S/H. Additionally, Fenton et al. found that 58% of US nursing schools offered content on spirituality in their curricula [17].
The results from the present study are surprising, given that Brazil is a high religious/spiritual country [18] in which 83% of the population consider religion very important in their lives, 37% attend religious services at least once a week, and 95% report an affiliation with a religious denomination. Despite this, however, there appears to be little of teaching on spirituality and health in medical curricula.
The present findings, in fact, likely represent a “best case scenario,” given that the 50% of schools not responding to our survey (despite repeated contacts) probably had even less interest in and possibly less curricular content on S/H.
What are some possible explanations for such findings? First, only a few studies on S/H were published in Brazilian medical journals prior to the year 2000. For example, in one of the most prestigious Brazilian medical databases, called Scielo (Scientific Electronic Library Online – http://www.scielo.br/), using the search word “espiritualidade”/“spirituality” we found 0 articles in 1999, 7 articles in 2005, and 18 articles in 2010. Second, there is resistance to the introduction of these courses due to the view that medicine should be kept secular and therefore avoid addressing religious/spiritual issues because this may be experienced as coercive by some patients [13]. Third, few Brazilian medical conferences addressed S/H before the year 2000, university research departments seldom investigated S/H, and only one post-graduate program on S/H exists in the entire country.
We also found a notable difference between private and public medical schools. Private schools were more likely to have required courses that focused on theological issues related to culture and religion (Table 1), whereas public medical schools were more likely to have elective courses that focused on connections between spirituality and health from a broader perspective (Table 2). According to the Association of American Medical Colleges, medical curricula should provide students with an understanding of the role that spirituality plays in the care of patients in different clinical situations and the effect their own spirituality has on their ability to provide compassionate care that involves the spiritual aspects of patients’ lives [8].
These objectives are more attuned to the courses provided by public medical schools than private ones in Brazil. Some knowledge regarding different religions, however, is important for ethical and legal reasons, as well for addressing the religious needs of patients which often surface when patients become ill (particularly in a country as religious as Brazil). A spiritual history, then, should inquire about the specific religious beliefs, practices, and needs of patients, as well as about the broader spiritual aspects of patients lives and needs that arise from them.
A key objective of AAMC is that all students should be able to take a spiritual history as part of the medical history [8]. Unfortunately, in our study, only two schools included hands-on practice on how to integrate spirituality into patient care, and only three taught how to conduct a spiritual history. These findings are in line with S/H courses in UK [11], where only a few medical schools teach students how to take a spiritual history.
The small proportion of Brazilian medical schools that teach spiritual history taking and provide hands-on training should be emphasized, since doing so is important to achieve a better understanding of how spirituality influences the patient’s health [6, 10, 19]. There are several instruments which can guide the physician in taking a spiritual history [20] and which can help overcome the barriers to addressing spiritual issues (lack of knowledge, lack of training, fear of imposing religion) [5]. Nevertheless, the lack of hands-on training may leave the medical student without practical skills when encountering real patients.
Another concern is the lack of uniformity in S/H curricular content. Some courses are dedicated exclusively to religious issues (“Jesus Christ and the Trinity”, “the contribution of religious manifestations in the construction of cultures and society,” etc.); others focus on complementary and alternative medicine (CAM) practices such as Reike, ayurvedic medicine and hypnosis; and still others emphasize the interface between quantum physics and connections to health (through Kirlian photography, bioelectrography, near-death experiences, etc.). All of these topics are considered “spiritual.” This situation reflects a lack of specific training for faculty, a lack of consensus between faculty on what should be included in the curriculum and lack of a national policy with regard to S/H in medical education.
It is also possible, however, that the medical deans we surveyed may not have always been aware of courses that included S/H content, since they may not have been involved in those courses and instead relied on what their often large and diverse faculty shared with them. In a recent consensus conference on palliative care, spirituality was considered a fundamental component of palliative care [21]. Likewise, CAM courses often include aspects of S/H in their content, which respondents to our survey may not have been aware of [22].
Interestingly, the majority of medical directors (54%) believed that this issue is important for their schools and none reported that it was not important. These results are even more positive than those from a study of US medical school deans [12], of whom less than 40% felt that introducing S/H contents into the curriculum was important and only 10% indicated their faculty valued S/H content as “very valuable.” We should note that there is a clear difference between medical school deans’ opinions and their medical school's actual practices. While medical school deans in Brazil believe this issue is important, they often do not integrate it into the curriculum. We understand that a major barrier to doing so involves the intense competition for time in the curriculum, the lack of research on S/H in Brazil, and lack of qualified faculty to teach such courses.
Despite the limited space in the curriculum, addressing spiritual issues related to clinical care should be given more attention.
There is a general agreement that spiritual/religious beliefs can impact physical and mental health as well as affect ethical, legal and medical decisions [3, 15]. There is also agreement that physicians should not prescribe religious activities that patients are not already doing [23]. There is no consensus, however, on whether physicians should pray with patients [24], what kind of issues should be taught in S/H course, and how these courses should be evaluated [10].
Our study has a number of limitations. First, despite substantial efforts to achieve a high response rate (sequential emails, phone contacts, expanded deadlines), we received responses from only about half of Brazilian medical schools. As noted earlier, this may represent a lack of interest by some schools in the topic. Nevertheless, our response rate was similar to Neely et al. [11] who evaluated UK medical schools. Second, some medical directors/representatives may not have been aware of S/H initiatives conducted by their faculty and therefore chose not to respond. Third, the questionnaire did not include a number of factors that could affect the inclusion of S/H in the medical curriculum, such as curricular time, funding, training support, questions about curricular competencies, methods to evaluate these competencies, and type of teamwork available within the school. In order to maximize the response rate, these questions could not be included.
