Religion and Spirituality: Why and How to Address It in Clinical Practice.

Religion and spirituality (R/S) have been influential in societies' history, daily life, and identity in the past and in today's society. From a sociological perspective, R/S contributes to family development and organization, influences culture, and often contributes to forming opinions, beliefs, and concepts about oneself, family, society, and the world. In addition, R/S help shape individuals, families, and communities' ethical and moral understanding, thus influencing their behavior. This review article aims to provide the clinician with tools to understand, assess, and provide interventions that consider the patients' and their families' R/S. A recent review of the topic focused on general aspects of the R/S but we are unaware of reviews that integrate attachment, moral foundation theory, and forgiveness. This review will integrate these additional features into our understanding of the role of R/S in the delivery of mental health.

Relationship between exercise intensity and stress levels among U.S. medical students.

BACKGROUND: Physical activity may protect the mental health of medical students, yet it is unknown which types and intensities of physical activity have the greatest potential to improve medical student well-being. OBJECTIVE: We characterize the relationship between exercise intensity and stress levels of U.S. medical students, thereby informing the design of future well-being interventions. DESIGN: Two cross-sectional validated surveys assessing stress and physical activity were administered one year apart at the David Geffen School of Medicine at UCLA. A total of 1,046 out of 1,392 medical students responded (75%). An ordered logistic regression was used to determine the association between stress and each level of exercise intensity (inactivity, moderate-activity, and health-enhancing physical activity [HEPA]). These exercise intensity groupings were compared to the CDC guidelines for aerobic exercise. RESULTS: While achieving either moderate-activity or HEPA is compliant with the CDC guidelines for aerobic exercise, the additional intensity of exercise required to achieve HEPA was associated with a 26% increase in the probability of being in the lowest stress quartile and a 22% decrease in the probability of being in the highest stress quartile. Medical student physical activity levels were on-par with the national average per the CDC exercise guidelines (65% vs. 58%), but medical student HEPA levels were significantly lower than the national average (27% vs. 64%; OR 0.21; 95% CI 0.12-0.37). CONCLUSIONS: There is a large disparity in rates of the highest intensity physical activity (HEPA) between medical students and the age-adjusted national average, which has previously been overlooked by the binary CDC exercise guidelines. The fact that HEPA levels are not optimized and more strongly associated with lower stress levels relative to less intense forms of exercise makes it a promising new target for future well-being interventions among medical trainees.

Engaging Latino Adolescent and Young Adult (AYA) Cancer Survivors in Their Care: Piloting a Photonovela Intervention.

Latino adolescent and young adult (AYA) cancer survivors represent a growing population given the changing demographics in the USA. They experience significant healthcare disparities and barriers that warrant age-specific and culturally appropriate interventions to improve their clinical and psychosocial outcomes. This single-arm pilot study evaluated a novel intervention - a photonovela - on its ability to educate Latino AYA survivors and their family members and engage them in survivorship care. Ninety-seven participants (Latino AYA survivors and their family members) were recruited for this study. Three surveys assessing survivorship care confidence, cancer stigma, and survivorship care knowledge were administered to families before they received the photonovela, after the intervention, and at a booster phone call session. Mixed effects models were used to evaluate differences in scores at the three time points while accounting for repeated measures and family clustering. Results show that the photonovela was effective in improving survivorship care confidence and knowledge of Latino AYA survivors and their families. This pilot study indicates that the photonovela has potential to be a useful intervention for improving confidence and knowledge regarding the need to seek survivorship care for Latino AYA cancer survivors.

The impact of caregiver post-traumatic stress and depressive symptoms on pediatric transplant outcomes.

PTSS as well as symptoms of depression have been reported in children who experience a serious medical adversity as well as their caretakers. The adverse effects of PTSS, when experienced by the patients, on medical outcomes have been clearly documented. However, the impact of those symptoms, if any, when experienced by the caretakers on child outcomes has not been investigated prospectively. We evaluated whether caregiver PTSS and depression symptoms predict adherence to medications and medical outcomes in a prospective multisite study. Four hundred children participated in MALT. Caretaker PTSS were assessed by the IES and depressive symptoms by CES-D. During 2 years of follow-up, the MLVI was used to determine adherence. Centrally read, biopsy-confirmed organ rejection was the primary medical outcome. IES scores were not associated with either adherence or rejection outcomes. In contrast, there were significant correlations between CES-D (depression) scores and lower adherence, r = .13, P < .001, and a trend toward higher scores on the CES-D among those whose children had experienced rejection, 12.4 (SD = 10.9) versus 9.1 (SD = 8.6), P = .077. Caregivers' PTSS were not a risk factor for poor child outcomes in this cohort, whereas depression symptoms were associated with non-adherence and possibly increased rates of rejection. Further study can validate if caregivers' depression as opposed to PTSS confers greater risk and should be a focus during the clinical care of medically ill children.

The use of mobile technology and peer navigation to promote adolescent and young adult (AYA) cancer survivorship care: results of a randomized controlled trial.

PURPOSE: Adolescent and young adult (AYA) cancer survivors experience unique barriers that compromise receipt of survivorship care; therefore, development of innovative educational interventions to improve rates of AYA survivorship care is needed. The efficacy of text-messaging and peer navigation interventions was compared to standard-of-care survivorship educational materials to increase AYAs' (1) late effects knowledge and (2) knowledge, attitudes, and self-efficacy towards seeking survivor-focused care. METHODS: This was a three-armed, prospective, randomized controlled trial with one control group and two intervention groups. The control group received current standard-of-care educational materials. One intervention group participated in a text-messaging program, and the second participated in a peer navigator program. Participants completed pre- and post-intervention questionnaires. Study outcome variables were quantified using Fisher exact tests, two-sample t tests, exact McNemar tests, conditional logistic regression models, and analysis of covariance. RESULTS: Seventy-one survivors completed the study (control n = 24; text-messaging n = 23; peer navigation n = 24). Late effects knowledge was high at baseline for all groups. The text-messaging group had increased survivorship care knowledge compared to the control group (p < 0.05); the peer navigation group had increased survivorship care self-efficacy compared to the control group; p < 0.05. Both intervention groups showed increased attitudes towards seeking survivor-focused care compared to the control group (text-messaging p < 0.05; peer navigation p < 0.05). CONCLUSIONS: Each intervention demonstrated significant benefits compared to the control group. IMPLICATIONS FOR CANCER SURVIVORS: Given the preliminary effectiveness of both interventions, each can potentially be used in the future by AYA cancer survivors to educate and empower them to obtain needed survivorship care.

Alcohol consumption behaviors and neurocognitive dysfunction and emotional distress in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.

AIMS: To estimate the level of alcohol consumption behaviors in adult survivors of childhood cancer and to test associations between alcohol consumption behaviors and symptoms of neurocognitive impairment and emotional distress. DESIGN: Retrospective cohort study with longitudinal follow-up of self-reported health outcomes. SETTING: Childhood Cancer Survivor Study (CCSS), a 26-center study of ≥ 5-year survivors of childhood cancer diagnosed ≤ 21 years of age between 1970 and 1986 in the United States and Canada. PARTICIPANTS: A total of 4484 adult survivors of childhood cancer [mean (standard deviation) age at evaluation = 34.8 (6.1) years; time from diagnosis = 24.8 (4.4) years] and 1651 sibling controls who completed surveys reporting on alcohol use, neurocognitive impairment and emotional distress. MEASUREMENTS: Survivor report of alcohol use included age at drinking initiation and quantity and frequency of alcohol consumption. Neurocognition was assessed using the CCSS Neurocognitive Questionnaire. Emotional distress symptoms were measured using the Brief Symptoms Inventory-18 and the Posttraumatic Stress Diagnostic Scale. FINDINGS: After adjustment for childhood cancer treatment exposures, including cranial radiation therapy, drinking initiation prior to 18 years of age was associated with 30% increased risk of subsequent memory problems [risk ratio (RR) = 1.3; 95% confidence interval (CI) = 1.1-1.5]. Younger age at drinking initiation was associated with future risk of depression (RR = 1.3; 95% CI = 1.1-1.5), anxiety (RR = 1.6; 95% CI = 1.3-2.1), and somatization (RR = 1.2; 95% CI = 1.1-1.4). Persistent heavy/risky drinking was associated with 80% increased risk of persistent psychological distress (RR = 1.8, 95% CI = 1.4-2.3). CONCLUSIONS: Drinking initiation during adolescence is associated with modest increased risk for memory impairment and emotional distress in adult survivors of childhood cancer.

Self-Management Measurement and Prediction of Clinical Outcomes in Pediatric Transplant.

OBJECTIVE: To further refine a measure of self-management, the Responsibility and Familiarity with Illness Survey (REFILS), and to determine if this score predicts medication adherence and, thus, fewer instances of allograft rejection among pediatric liver transplant recipients. STUDY DESIGN: Participants were 400 liver transplant recipients and their parents recruited for the Medication Adherence in Children Who Had a Liver Transplant study, from 5 US pediatric transplant centers. The REFILS was administered to participants (ages 9-17 years) and their parents at enrollment (n = 213 completed dyads). The REFILS scores, and a discrepancy score calculated between patient and parent report of the patient's self-management, were used to predict Medication Level Variability Index (MLVI), a measure of medication adherence (higher MLVI = more variability in medication levels) and central pathologist-diagnosed rejection over a 2-year follow-up. RESULTS: When patients reported greater self-management, their adherence was lower (higher MLVI, r = 0.26, P < .01). Discrepancies between patient and parent report (patients endorsing higher levels than parents) were associated with lower adherence (r = 0.20, P < .01). Greater patient-reported self-management and higher discrepancy scores also predicted rejection. CONCLUSIONS: We found that when patients endorse more responsibility for their care, clinical outcomes are worse, indicating that indiscriminate promotion of self-management by adolescents may not be advisable. A discrepancy between patient and parent perception of self-management emerged as a novel strategy to gauge the degree of risk involved in transitioning care responsibilities to the child.

Recruiting a representative sample in adherence research-The MALT multisite prospective cohort study experience.

Medication adherence is an important determinant of transplant outcomes. Attempts to investigate adherence are frequently undermined by selection bias: It is very hard to recruit and retain non-adherent patients in research efforts. This manuscript presents recruitment strategies and results from the MALT (Medication Adherence in children who had a Liver Transplant) multisite prospective cohort study. MALT sites recruited 400 pediatric liver transplant patients who agreed to be followed for 2 years. The primary purpose was to determine whether a marker of adherence, the Medication Level Variability Index (MLVI), predicts rejection outcomes. The present manuscript describes methods used in MALT to ensure that a representative sample was recruited, and presents detailed recruitment results. MALT sites were able to recruit a nationally representative sample, as determined by a comparison between the MALT cohort and a national sample of transplant recipients. Strategies that helped ensure that the sample was representative included monitoring of the outcome measure in comparison with a national sample, drastically limiting patient burden, and specific recruitment methods. We discuss the importance of a representative sample in adherence research and recommend that future efforts to study adherence pay special attention to sample characteristics.

Medical Student Perceptions of the Learning Environment in Medical School Change as Students Transition to Clinical Training in Undergraduate Medical School.

Phenomenon: The learning environment is the physical, social, and psychological context in which a student learns. A supportive learning environment contributes to student well-being and enhances student empathy, professionalism, and academic success, whereas an unsupportive learning environment may lead to burnout, exhaustion, and cynicism. Student perceptions of the medical school learning environment may change over time and be associated with students' year of training and may differ significantly depending on the student's gender or race/ethnicity. Understanding the changes in perceptions of the learning environment related to student characteristics and year of training could inform interventions that facilitate positive experiences in undergraduate medical education. APPROACH: The Medical School Learning Environment Survey (MSLES) was administered to 4,262 students who matriculated at one of 23 U.S. and Canadian medical schools in 2010 and 2011. Students completed the survey at the end of each year of medical school as part of a battery of surveys in the Learning Environment Study. A mixed-effects longitudinal model, t tests, Cohen's d effect size, and analysis of variance assessed the relationship between MSLES score, year of training, and demographic variables. FINDINGS: After controlling for gender, race/ethnicity, and school, students reported worsening perceptions toward the medical school learning environment, with the worst perceptions in the 3rd year of medical school as students begin their clinical experiences, and some recovery in the 4th year after Match Day. The drop in MSLES scores associated with the transition to the clinical learning environment (-0.26 point drop in addition to yearly change, effect size = 0.52, p < .0001) is more than 3 times greater than the drop between the 1st and 2nd year (0.07 points, effect size = 0.14, p < .0001). The largest declines were from items related to work-life balance and informal student relationships. There was some, but not complete, recovery in perceptions of the medical school learning environment in the 4th year. Insights: Perceptions of the medical school learning environment worsen as students continue through medical school, with a stronger decline in perception scores as students' transition to the clinical learning environment. Students reported the greatest drop in finding time for outside activities and students helping one another in the 3rd year. Perceptions differed based on gender and race/ethnicity. Future studies should investigate the specific features of medical schools that contribute most significantly to student perceptions of the medical school learning environment, both positive and negative, to pinpoint potential interventions and improvements.

Assessing the Learning Environment for Medical Students: An Evaluation of a Novel Survey Instrument in Four Medical Schools.

OBJECTIVE: A practical, reliable, and valid instrument is needed to measure the impact of the learning environment on medical students' well-being and educational experience and to meet medical school accreditation requirements. METHODS: From 2012 to 2015, medical students were surveyed at the end of their first, second, and third year of studies at four medical schools. The survey assessed students' perceptions of the following nine dimensions of the school culture: vitality, self-efficacy, institutional support, relationships/inclusion, values alignment, ethical/moral distress, work-life integration, gender equity, and ethnic minority equity. The internal reliability of each of the nine dimensions was measured. Construct validity was evaluated by assessing relationships predicted by our conceptual model and prior research. Assessment was made of whether the measurements were sensitive to differences over time and across institutions. RESULTS: Six hundred and eighty-six students completed the survey (49 % women; 9 % underrepresented minorities), with a response rate of 89 % (range over the student cohorts 72-100 %). Internal consistency of each dimension was high (Cronbach's α 0.71-0.86). The instrument was able to detect significant differences in the learning environment across institutions and over time. Construct validity was supported by demonstrating several relationships predicted by our conceptual model. CONCLUSIONS: The C-Change Medical Student Survey is a practical, reliable, and valid instrument for assessing the learning environment of medical students. Because it is sensitive to changes over time and differences across institution, results could potentially be used to facilitate and monitor improvements in the learning environment of medical students.

Medical Student Perceptions of the Learning Environment: Learning Communities Are Associated With a More Positive Learning Environment in a Multi-Institutional Medical School Study.

PURPOSE: Many medical schools have implemented learning communities (LCs) to improve the learning environment (LE) for students. The authors conducted this study to determine whether a relationship exists between medical student perceptions of the LE and presence of LCs during the preclerkship years. METHOD: Students from 24 schools participating in the American Medical Association Learning Environment Study completed the 17-item Medical Student Learning Environment Survey (MSLES) at the end of their first and second years of medical school between 2011 and 2013. Mean total MSLES scores and individual item scores at the end of the first and second years in schools with and without LCs were compared with t tests, and effect sizes were calculated. Mixed-effects longitudinal models were used to control for student demographics and random school and student effects on the relationship between LC status and MSLES score. RESULTS: A total of 4,980 students (81% of 6,148 matriculants) from 18 schools with LCs and 6 without LCs participated. Mean [SD] MSLES scores were significantly higher in LC schools compared with non-LC schools at the end of year one (3.72 [0.44] versus 3.57 [0.43], P < .001) and year two (3.69 [0.49] versus 3.42 [0.54], P < .001). The effect size increased from 0.35 (small) at the end of year one to 0.53 (medium) at the end of year two. CONCLUSIONS: This large multi-institutional cohort study found that LCs at medical schools were associated with more positive perceptions of the LE by preclerkship students.

Implementation of interprofessional education (IPE) in 16 U.S. medical schools: Common practices, barriers and facilitators.

BACKGROUND: Enhanced patient outcomes and accreditation criteria have led schools to integrate interprofessional education (IPE). While several studies describe IPE curricula at individual institutions, few examine practices across multiple institutions. PURPOSE: To examine the IPE integration at different institutions and determine gaps where there is potential for improvement. METHOD: In this mixed methods study, we obtained survey results from 16 U.S. medical schools, 14 of which reported IPE activities. RESULTS: The most common collaboration was between medical and nursing schools (93%). The prevalent format was shared curriculum, often including integrated modules (57%). Small group activities represented the majority (64%) of event settings, and simulation-based learning, games and role-play (71%) were the most utilized learning methods. Thirteen schools (81.3%) reported teaching IPE competencies, but significant variation existed. Gaps and barriers in the study include limitations of using a convenience sample, limited qualitative analysis, and survey by self-report. CONCLUSIONS: Most IPE activities focused on the physician role. Implementation challenges included scheduling, logistics and financial support. A need for effective faculty development as well as measures to examine the link between IPE learning outcomes and patient outcomes were identified.

Chaplain rounds: a chance for medical students to reflect on spirituality in patient-centered care.

OBJECTIVE: This study assesses the perceived impact of a required half-day with a hospital chaplain for first-year medical students, using a qualitative analysis of their written reflections. METHODS: Students shadowed chaplains at the UCLA hospital with the stated goal of increasing their awareness and understanding of the spiritual aspects of health care and the role of the chaplain in patient care. Participation in the rounds and a short written reflection on their experience with the chaplain were required as part of the first-year Doctoring course. RESULTS: The qualitative analysis of reflections from 166 students using grounded theory yielded four themes: (1) the importance of spiritual care, (2) the chaplain's role in the clinical setting, (3) personal introspection, and (4) doctors and compassion. CONCLUSIONS: Going on hospital rounds with a chaplain helps medical students understand the importance of spirituality in medicine and positively influences student perceptions of chaplains and their work.

Relations between posttraumatic stress and posttraumatic growth in long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.

OBJECTIVE: Contemporary models of trauma suggest that posttraumatic stress and growth should be related and that symptoms of stress resulting from a perceived trauma (e.g., childhood cancer) are prerequisite for posttraumatic growth (PTG) to occur. However, empirical data regarding the relationship of posttraumatic stress and growth have been equivocal. The purpose of this study is to examine the relationship between posttraumatic stress symptoms (PTSS) and PTG among adult survivors of childhood cancer. METHODS: Survey methods were used to collect data from 6,162 survivors participating in the Childhood Cancer Survivor Study (CCSS). Nonparametric correlation was examined pairwise between PTG and PTSS using Spearman's correlation coefficient with 95% confidence intervals, with nonlinear canonical correlation analysis being conducted to examine relationships between subscales. A multivariable partial proportional odds model was also fit for PTG total quartiles focusing on associations with PTSS total quartiles while adjusting for sociodemographic and medical variables. RESULTS: Examination of unadjusted PTSS and PTG total scores revealed a Spearman correlation of 0.11 (p < .001), with coefficients ranging from 0.03 to 0.17 between total and subscale scores. The nonlinear canonical correlation analyses resulted in two dimensions with eigenvalues of 0.15 and 0.14, resulting in a fit value of 0.30 and evidence that little variability in the data (15%) was explained by the weighted combinations of the variables. CONCLUSIONS: Although statistically significant, these results do not indicate a robust relationship between PTSS and PTG among adult survivors of childhood cancer. Theories suggesting that PTSS is a prerequisite for PTG should be reconsidered.

Relationship between medical student perceptions of mistreatment and mistreatment sensitivity.

BACKGROUND: National statistics reveal that efforts to reduce medical student mistreatment have been largely ineffective. Some hypothesize that as supervisors gain skills in professionalism, medical students become more sensitive. AIMS: The purpose of this study was to determine if medical student perceptions of mistreatment are correlated with mistreatment sensitivity. METHOD: At the end of their third year, 175 medical students completed an Abuse Sensitivity Questionnaire, focused on student assessment of hypothetical scenarios which might be perceived as abusive, and the annual Well-Being Survey, which includes measurement of incident rates of mistreatment. It was hypothesized that those students who identified the scenarios as abusive would also be more likely to perceive that they had been mistreated. RESULTS: Student perceptions of mistreatment were not statistically correlated with individual's responses to the scenarios or to a statistically derived abuse sensitivity variable. There were no differences in abuse sensitivity by student age or ethnicity. Women were more likely than men to consider it "harsh" to be called incompetent during rounds (p < 0.0005). CONCLUSION: This study provides preliminary evidence that challenges the hypothesis that medical students who perceive mistreatment by their superiors are simply more sensitive.

Improving child and adolescent psychiatry education for medical students: an inter-organizational collaborative action plan.

OBJECTIVE: A new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the long-standing dearth of CAP training for medical students. METHOD: The CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP's CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies. RESULTS/CONCLUSION: The authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

Perceived positive impact of cancer among long-term survivors of childhood cancer: a report from the childhood cancer survivor study.

OBJECTIVE: Investigations examining psychosocial adjustment among childhood cancer survivors have focused primarily on negative effects and psychopathology. Emergent literature suggests the existence of positive impact or adjustment experienced after cancer, as well. The purpose of this study is to examine the distribution of Perceived Positive Impact (PPI) and its correlates in young adult survivors of childhood cancer. METHODS: 6425 survivors and 360 siblings completed a comprehensive health survey, inclusive of a modified version of the Post-traumatic Growth Inventory (PTGI) as a measure of PPI. Linear regression models were used to examine demographic, disease and treatment characteristics associated with PPI. RESULTS: Survivors were significantly more likely than siblings to report PPI. Endorsement of PPI was significantly greater among female and non-white survivors, and among survivors exposed to at least one intense therapy, a second malignancy or cancer recurrence. Survivors diagnosed at older ages and fewer years since diagnosis were more likely to report PPI. Income, education and marital/relationship status appeared to have varied relationships to PPI depending upon the subscale being evaluated. CONCLUSIONS: The existence and variability of PPI in survivors in this study suggest that individual characteristics, inclusive of race, gender, cancer type, intensity of treatment, age at diagnosis and time since diagnosis, have unique and specific associations with different aspects of perceived positive outcomes of childhood cancer.

Psychiatric issues in pediatric organ transplantation.

Solid organ transplantation has become the first line of treatment for a growing number of life-threatening pediatric illnesses. With improved survival, research into the long-term outcome of transplant recipients has become important to clinicians. Adherence to medical instructions remains a challenge, particularly in the adolescent population. New immunosuppressant approaches promise to expand organ transplantation in additional directions. Extension of transplantation into replacement of organs such as faces and hands raises complex ethical issues.