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ABSTRACT: BACKGROUND: Contemporary educational approaches to professionalism do not take into account the dominant influence that the culture of academic medicine has on the nascent professional attitudes, beliefs, and behaviors of medical learners. This article examines formation as an organizing principle for professionalism in medical education. Virtue, the foundation to understanding professionalism, is the habits and dispositions that are fostered in individuals but that are embedded in learning environments. Formation, the ongoing integration of an individual, growing in self-awareness and in recognition of a life of service, with others who share in the common mission of a larger group, depicts this process. One model of formation considers a continuum from novice to more advance stages that is predicated on rules that must be applied in greater contextually shaped situations. Within medical education, formation is the process by which lives of service are created and sustained by learning communities that promote human capacities for intuition, empathy, and compassion. An imagined curriculum in formation would link the lived experiences of mentors and learners with an interdisciplinary set of didactic materials in an intentionally progressive fashion.
Family medicine 05/2011; 43(5):325-9. · 1.33 Impact Factor
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ABSTRACT: Spiritual care is increasingly recognized as an important component of medical care. Although many primary care residency programs incorporate spiritual care into their curricula, there are currently no consensus guidelines regarding core competencies necessary for primary care training. In 2006, the Society of Teachers of Family Medicine's Interest Group on Spirituality undertook a three-year initiative to address this need. The project leader assembled a diverse panel of eight educators with dual expertise in (1) spirituality and health and (2) family medicine. The multidisciplinary panel members represented different geographic regions and diverse faith traditions and were nationally recognized senior faculty. They underwent three rounds of a modified Delphi technique to achieve initial consensus regarding spiritual care competencies (SCCs) tailored for family medicine residency training, followed by an iterative process of external validation, feedback, and consensus modifications of the SCCs. Panel members identified six knowledge, nine skills, and four attitude core SCCs for use in training and linked these to competencies of the Accreditation Council for Graduate Medical Education. They identified three global competencies for use in promotion and graduation criteria. Defining core competencies in spiritual care clarifies training goals and provides the basis for robust curricula evaluation. Given the breadth of family medicine, these competencies may be adaptable to other primary care fields, to medical and surgical specialties, and to medical student education. Effective training in this area may enhance physicians' ability to attend to the physical, mental, and spiritual needs of patients and better maintain sustainable healing relationships.
Academic medicine: journal of the Association of American Medical Colleges 10/2010; 85(12):1897-904. · 2.34 Impact Factor
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ABSTRACT: To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST.
After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility.
The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states.
Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that.
Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034).
Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.
Journal of the American Medical Directors Association 01/2010; 11(1):42-51. · 4.64 Impact Factor
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ABSTRACT: To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP.
After-death interviews of family members of decedents and facility liaisons where decedents received care.
Stratified sample of 164 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina.
Family members and facility liaisons who gave 446 and 1014 reports, respectively, on 1015 decedent residents.
Reports of death/dying discussions, known treatment preferences, and reports and records of signed living wills (LW), health care powers of attorney (HCPOA), do-not-resuscitate orders, and do-not-hospitalize orders.
Family respondents reported a higher prevalence, compared with facility reports, of HCPOAs (92% versus 49%) and LWs (84% versus 43%). In family reports, non-white race and no private insurance were significantly associated with lower prevalence of LWs and HCPOAs; additionally, residing in nursing homes (versus assisted living facilities) and in North Carolina were associated with lower prevalence of reported LWs. In facility reports, non-white race, unexpected death, and residing in North Carolina or Maryland were significantly associated with lower prevalence of LWs, whereas high Medicaid case mix, intact cognitive status, and high family involvement were associated with lower prevalence of HCPOAs. Concordance of family and facility reporting of HCPOAs was significantly greater in facilities with fewer than 120 beds.
The prevalence of ACP in LTC is much higher than previously described, and there is marked variation in characteristics associated with ACP, despite moderately high concordance, when reported by the facility or family caregivers.
Journal of the American Medical Directors Association 06/2009; 10(4):243-51. · 4.64 Impact Factor
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ABSTRACT: The process of advance care planning (ACP) is often difficult to initiate and complete in minority populations, and African Americans are less likely to participate in ACP than non-Hispanic whites. We explored the perceptions of ACP among seriously ill African-American older adults.
Qualitative semistructured interviews and editing analysis of 10 community-dwelling African-American elders in North Carolina.
Three major themes were identified. First, participants had little to no familiarity with ACP; none reported that they participated in any substantive discussions regarding ACP. Inconsistent sources of healthcare information, in which there was little congruence in the information given and discordant of sources of information, were a second theme. Finally, participants denoted a deferred autonomy, in which they postponed involvement in future care decision-making but viewed themselves as active in their day-to-day living.
Seriously ill African-American elders report both individual-level and health systems-level barriers to ACP. Efforts to improve ACP need to take into account the differences between the current, autonomy-based model of ACP within biomedicine and the values of minority older adults approaching the end of life.
Journal of the National Medical Association 01/2009; 100(12):1457-62. · 1.16 Impact Factor
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ABSTRACT: Patients and palliative care experts endorse the importance of spiritual care for seriously ill patients and their families. However, little is known about spiritual care during serious illness, and whether it satisfies patients' and families' needs. The objective of this study was to describe spiritual care received by patients and families during serious illness, and test whether the provider and the type of care is associated with satisfaction with care.
Cross-sectional interview with 38 seriously ill patients and 65 family caregivers about spiritual care experiences.
The 103 spiritual care recipients identified 237 spiritual care providers; 95 (41%) were family or friends, 38 (17%) were clergy, and 66 (29%) were health care providers. Two-thirds of spiritual care providers shared the recipient's faith tradition. Recipients identified 21 different types of spiritual care activities. The most common activity was help coping with illness (87%) and the least common intercessory prayer (4%). Half of recipients were very or somewhat satisfied with spiritual care, and half found it very helpful for facilitating inner peace and meaning making. Satisfaction with spiritual care did not differ by provider age, race, gender, role, or frequency of visits. Types of care that helped with understanding or illness coping were associated with greater satisfaction with care.
Seriously ill patients and family caregivers experience spiritual care from multiple sources, including health care providers. Satisfaction with this care domain is modest, but approaches that help with understanding and with coping are associated with greater satisfaction.
Journal of palliative medicine 08/2008; 11(6):907-14. · 1.84 Impact Factor
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ABSTRACT: There is growing attention given to the spiritual needs of dying patients and long-term care (LTC) facilities are common settings in which patients receive care as they approach death.
To describe the sources of support, the structure and processes of spiritual care in LTC, and examine the relationship between these components and family ratings of overall care.
After-death interviews of family members of decedents.
Family members of 284 decedent residents from a stratified sample of 100 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina.
: Interview items included sources of spiritual support, processes of spiritual care, and the impression of overall care (4 = very good, 3 = good, 2 = fair, 1 = poor) for decedents. Facility-level data included demographics, counseling by clergy, on-site religious services, hospice services, and hospice unit.
Most decedents (87%) received assistance with their spiritual needs and those who received spiritual care were perceived by family members to have had better overall care (3.59 vs. 3.25, P = 0.002). Family ratings of care ratings were higher for those who received spiritual support or care from facility staff when compared with those who did not (3.76 vs. 3.49, P < 0.001) and better care was associated with the facilitation of individual devotional activities (3.87 vs. 3.53, P = 0.001).
Spiritual support and care are associated with better overall care at the end of life for LTC residents, and interventions to improve this type of care may best target interactions between residents and facility staff.
Medical Care 01/2008; 46(1):85-91. · 3.41 Impact Factor
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ABSTRACT: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions.
Retrospective study of family caregivers of persons who died in LTC.
Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities.
One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death.
Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96).
Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities.
Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.
Journal of the American Geriatrics Society 07/2007; 55(6):846-56. · 3.74 Impact Factor
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ABSTRACT: Although many studies have examined the relationship between religiosity and depressive symptoms in patient populations, there has been little work to understand and measure the effect of spirituality on depressive symptoms.
The purpose of this study was to examine the association of spirituality and symptoms of depression in primary care outpatients.
A cross-sectional analysis was performed of a dataset using 509 primary care outpatients who participated in an instrument validity study in the Kansas City (US) area. Patients were administered the Zung Depression Scale (ZDS) and the Spirituality Index of Well-Being (SIWB) in the waiting area before or after their appointment. Bivariate and multivariate analyses were performed to determine the relationship between the factors of interest and depressive symptoms.
In bivariate analyses, less insurance coverage (P < 0.01) and greater spirituality (P < 0.01) were associated with less reported depressive symptoms. In a model adjusted for covariates, spirituality (P < 0.01) remained independently associated with less symptoms.
Primary care outpatients who report greater spirituality are more likely to report less depressive symptoms.
Southern Medical Journal 01/2007; 99(12):1340-4. · 0.83 Impact Factor
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ABSTRACT: Communication in the delivery of health care services occurs along 2 axes: between providers and patients and among several providers. In primary care, a principle objective in the provider-patient relationship is facilitating whole-person care, which is care provided in the context of family and community. In addition, primary care emphasizes communication between the primary care physician and other providers with the goal of integrated care, or care provided in the context of a patient's overall health care needs. However, considering both the U.S. health care delivery system and medical education programs, several obstacles interfere with the necessary processes of communication. This paper addresses those obstacles with a conceptual framework for effective communication in primary care. Recommendations propose formalizing requirements for the exchange of information among providers, enhancing communication training, disseminating information technology, and mitigating external factors that disrupt communication in primary care.
Annals of internal medicine 05/2005; 142(8):709-14. · 16.73 Impact Factor
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Research on Aging - RES AGING. 01/2005; 27(5):556-577.
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ABSTRACT: Communication studies suggest that patient sociodemographic factors are embedded within medical encounters and impact patient expectations, judgments, and outcomes, such as satisfaction. Physician chatting has been suggested as one way to enhance patient satisfaction; however, little is known about chatting within the context of the clinical encounter or of the interaction of chatting with patient sociodemographic factors and patient satisfaction. The study's purpose was to determine the prevalence and patterns of chatting, and to examine the association of chatting with patient sociodemographic factors and patient satisfaction with their physician. A convenience sample of adult outpatients from an urban family practice underwent an exit interview. A total of 105 patients participated; 63 (61%) reported chatting from their recent encounter. No sociodemographic differences were observed between patients reporting chatting and those reporting no chatting. Chatting behavior pertaining to the patient's family or friends was the predominant topic, and more nonwhite (30%) than white (13%) patients reported this activity (p<0.001). There was no significant difference in satisfaction scores between patients that reported chatting behavior and those that did not (23.73 vs. 22.79, p=0.076). In addition, there was no difference in patient satisfaction scores for physician personal manner, technical skill, visit explanation, time spent with the physician, and overall visit between the chatting and nonchatting groups.
Journal of the National Medical Association 05/2004; 96(5):666-70. · 1.16 Impact Factor
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ABSTRACT: To evaluate the reliability and validity of the Spirituality Index of Well-Being (SIWB) Scale in a patient population.
Cross-sectional survey.
Community-dwelling elderly individuals (n = 277) recruited from primary care clinic sites in the Kansas City metropolitan area.
Internal consistency, concurrent construct validity, discriminant validity, and factor analysis with Varivax rotation.
The initial version of the SIWB contained 40 items: 20 from a self-efficacy domain and 20 from a life scheme domain. Factor analysis yielded 6 items loaded most strongly on factor 1 (intrapersonal self-efficacy) and 6 other items loaded strongly on factor 2 (life scheme). The Self-efficacy subscale had an alpha of.83 and the Life Scheme subscale had an alpha of.80; the total 12-item SIWB Scale had an alpha of.87. The SIWB had significant and expected correlations with other quality-of-life measures related to subjective well-being: EuroQol (r =.18), Geriatric Depression Scale (r = -35), the Physical Functioning Index from the Short Form 36 (r =.28), and the Years of Healthy Life Scale (r = -.35). Religiosity did not correlated significantly with the SIWB (r =.12, P =.056).
The 12-item SIWB Scale is a valid and reliable measure of subjective well-being in an older patient population.
The Journal of family practice 12/2002; 51(11):952. · 0.61 Impact Factor
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ABSTRACT: Spirituality has become a construct of interest in American health care; however, there remains a limited understanding of how patients themselves describe spirituality and view its impact on their health and well-being. The purpose of this study was to identify and describe elements of patient-reported, health-related spirituality. A qualitative study utilized focus group interviews of 17 women with type 2 diabetes mellitus and 18 women with no self-identified illness. Purposeful sampling of participants who had prior experiences in healthcare settings, with or without a chronic illness, guided the sampling strategy. Editing analysis of the interview transcripts were coded into conceptual categories. Participant narratives were grouped into eight general categories: (1) change in functional status, (2) core beliefs, (3) medical/disease state information gathering and processing, (4) interpretation and understanding, (5) life scheme, (6) positive intentionality, (7) agency, and (8) subjective well-being. A change in functional status was the catalyst for two process-oriented categories; medical/disease state information gathering and processing, and the higher-order interpretation and understanding, or meaning making of life events. Core beliefs were sources that grounded and maintained an interpretative structure through which participants viewed their life events and positively framed their experiences. Life scheme described a heuristic framework through which all life events were viewed. Positive intentionality was participant belief in the capacity to execute a specific action that was required for a desired outcome. Participants tied the attitudes and practices of positive intentionality with agency, or the use or exertion of power through belief, practice, or community. Participants outlined both a positive affective and cognitive component of subjective well-being. Patients describe several interrelated elements and a process of events in their depiction of spirituality in healthcare settings. Patient-reported spirituality is predominantly a cognitive construct incorporating the domains of life scheme and positive intentionality.
Social Science & Medicine. 01/2001; 53(11):1503-1511.
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Timothy P Daaleman
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ABSTRACT: Family medicine is currently undergoing a transformation and, amid such change, the medical home has emerged as the new polestar. This article examines the medical home through the lens of philosopher Alasdair MacIntyre and offers a perspective, informed by Hubert Dreyfus and Peter Senge, about medical homes as practical sites of formation for family physicians. The intellectual past of family medicine points to contextually sensitive patient care as a practice that is particular to the discipline, with the virtue of "placing patients within contexts over time" as a commonly held virtue. Dreyfus provides a model of knowledge and skill acquisition that is relevant to the training of family physicians in practical wisdom. In this model, there is a continuum from novice to more advanced stages of professional formation that is aided by rules that not only must be learned, but must be applied in greater contextually informed situations. Senge's emphasis on learning organizations-organizations where people are continually learning how to learn together-presents a framework for evaluating the extent to which future medical homes facilitate or retard the formation of family physicians.
The Journal of the American Board of Family Medicine 21(5):451-7. · 2.05 Impact Factor
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ABSTRACT: Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members.
Our study was based on qualitative research using key informant interviews and editing analysis with 12 clinicians and other health care workers nominated as spiritual caregivers by dying patients and their family members.
Being present was a predominant theme, marked by physical proximity and intentionality, or the deliberate ideation and purposeful action of providing care that went beyond medical treatment. Opening eyes was the process by which caregivers became aware of their patient's life course and the individualized experience of their patient's current illness. Participants also described another course of action, which we termed cocreating, that was a mutual and fluid activity between patients, family members, and caregivers. Cocreating began with an affirmation of the patient's life experience and led to the generation of a wholistic care plan that focused on maintaining the patient's humanity and dignity. Time was both a facilitator and inhibitor of effective spiritual care.
Clinicians and other health care workers consider spiritual care at the end of life as a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.
The Annals of Family Medicine 6(5):406-11. · 5.36 Impact Factor
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ABSTRACT: A unique characteristic of family physicians is that they seek to understand individual patients within the context of their families and larger social environments. Unfortunately, the intellectual development of family medicine is hampered by the reliance on epidemiologic, health service, and biomedical paradigms that are limited in their contextual perspectives on patients' lives. However, another paradigm, that of the life course, represents an interdisciplinary framework that views persons in context over time. It provides an ecological understanding of individual people by examining phenomena at the nexus of social pathways, developmental or health trajectories, and social change. A life course paradigm provides a way of thinking about patients in both proximal (eg, lived lives and family) and distal (eg, health care system) contexts over a life span. Five core principles define the life course as a paradigmatic framework: (1) human development and aging as lifelong processes, (2) human agency, (3) historical time and place, (4) the timing of events in a life, and (5) linked lives. At the individual level, the life course orients physicians to the opportunities and constraints that frame the health care choices, plans, and initiatives of people who maintain health and also face illness. At the organizational level, the life course offers an intellectual infrastructure for the New Model of Family Medicine by depicting an idealized delivery system that may be longitudinally integrated. It also emphasizes health and illness trajectories by linking health and other service organizations that assist individuals at different stages of their lives.
The Journal of the American Board of Family Medicine 20(1):85-92. · 2.05 Impact Factor
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ABSTRACT: Religion and spirituality remain important social and psychological factors in the lives of older adults, and there is continued interest in examining the effects of religion and spirituality on health status. The purpose of this study was to examine the interaction of religion and spirituality with self-reported health status in a community-dwelling geriatric population.
We performed a cross-sectional analysis of 277 geriatric outpatients participating in a cohort study in the Kansas City area. Patients underwent a home assessment of multiple health status and functional indicators by trained research assistants. A previously validated 5-item measure of religiosity and 12-item spirituality instrument were embedded during the final data collection. Univariate and multivariate analyses were performed to determine the relationship between each factor and self-reported health status.
In univariate analyses, physical functioning (P < .01), quality of life (P < .01), race (P < .01), depression (P < .01), age (P = .01), and spirituality (P < .01) were all associated with self-reported health status, but religiosity was not (P = .12). In a model adjusted for all covariates, however, spirituality remained independently associated with self-appraised good health (P = .01).
Geriatric outpatients who report greater spirituality, but not greater religiosity, are more likely to appraise their health as good. Spirituality may be an important explanatory factor of subjective health status in older adults.
The Annals of Family Medicine 2(1):49-53. · 5.36 Impact Factor
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Timothy P Daaleman
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ABSTRACT: A major challenge for the US health care system during coming years will be the financial viability and reorganization of Medicare--a program in which over 90% of family physicians participate. Although chronic illness constitutes a trajectory characterized by long-term patterns of health and functional states, fee-for-service Medicare is largely directed to the treatment of acute, episodic illness. Beyond the prescription drug benefit, there were several provisions in the Medicare Prescription Drug Improvement and Modernization Act of 2003 that were designed to improve the quality of care and reduce costs for chronically ill beneficiaries, an important first step in the reorientation of Medicare to chronic illness care. Quality is the foundation of Medicare's movement to a chronic care program and paying physicians for quality care is on the horizon. Family physicians will need to be actively engaged in Medicare's reorientation by articulating and promoting a quality of care that effectively integrates evidence-based medicine with a person-centered focus.
The Journal of the American Board of Family Medicine 19(3):303-9. · 2.05 Impact Factor
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ABSTRACT: Despite considerable interest in examining spirituality in health-related quality-of-life studies, there is a paucity of instruments that measure this construct. The objective of this study was to test a valid and reliable measure of spirituality that would be useful in patient populations.
We conducted a multisite, cross-sectional survey using systematic sampling of adult outpatients at primary care clinic sites in the Kansas City metropolitan area (N = 523). We determined the instrument reliability (Cronbach's alpha, test-retest) and validity (confirmatory factor analysis, convergent and discriminant validation) of the Spirituality Index of Well-Being (SIWB).
The SIWB contains 12 items: 6 from a self-efficacy domain and 6 from a life scheme domain. Confirmatory factor analysis found the following fit indices: chi2 (54, n = 508) = 508.35, P < .001; Comparative Fit Index = .98; Tucker-Lewis Index = .97; root mean square error of approximation = .13. The index had the following reliability results: for the self-efficacy subscale, alpha = .86 and test-retest r = 0.77; for the life scheme subscale, alpha = .89 and test-retest r = 0.86; and for the total scale alpha = .91 and test-retest r = 0.79, showing very good reliability. The SIWB had significant and expected correlations with other quality-of-life instruments that measure well-being or spirituality: Zung Depression Scale (r = 0-.42, P < .001), General Well-Being Scale (r = 0.64, P < .001), and Spiritual Well-Being Scale (SWB) (r = 0.62, P < .001). There was a modest correlation between the religious well-being subscale of the SWB and the SIWB (r = 0.35, P < .001).
The Spirituality Index of Well-Being is a valid and reliable instrument that can be used in health-related quality-of-life studies.
The Annals of Family Medicine 2(5):499-503. · 5.36 Impact Factor
