ABSTRACT
This case highlights the challenges both faculty and entering medical students face when faith-based practices collide with schedules. Specifically in this case, the faculty member ponders the balance between accommodation and avocation for an entering Muslim student attempting to maintain all religious holidays, fasts and prayer five times/day.
The first day of MS1 Principles of Clinical Medicine small groups, a respectful young man approached me to inform that he would be late each week because he needed to pray. He explained that his Muslim faith required he pray five times per day, and between the lecture and small group session was a time prayer needed to occur. I agreed. The weeks followed, and each week he would quickly drop his backpack off in the small group room, disappear for about ten minutes and discretely re-enter the room. The small group seemed ambivalent to his late arrival, yet we did not delay or repeat content. One time this resulted in this student not participating in an autogenic exercise, but generally he simply missed some of the early conversation related to the previous lecture.
Mid way through the term, the student respectfully emailed me to let me know he would miss school (and small group) the following day because it was a Muslim holiday. After that he wrote the following in his required reflections assignment:
- “I missed the last PCM, because of ‘Eid Al-Fitr’ which is one of two total Islamic holidays. It marks the end of the month of Ramadan and therefore, the end of a month of fasting from food and water during daylight hours. I found it sort of ironic that the topic of the PCM class that day was how to deal with stress while in school, and the different methods of stress release. This was ironic to me because I personally felt that adhering to my religious commitments serve as stress release. So, taking that day off from school to attend the traditional morning ‘Eid’ prayer was a manner of stress release.
Furthermore, I felt that as a Muslim, there are periodic times of stress release throughout the day. I am referring to the five daily prayers that are obligatory upon Muslims to fulfill. These prayers are spread throughout the day and night and typically last from between 5 minutes to 10 minutes. They serve as moments of stress relief, because one of the intentions of prayer is not only to strengthen one’s relationship with God, but also to detach themselves from this worldly life. In fact, the Prophet Muhammad (peace be upon him) told one of his companions to make the call for prayer so that we can be ‘relieved from the stress of this world’. So I think that the idea of consistent prayer or meditation for others, helps incorporate mechanisms for people to deal with the stress that is in their lives.”
Up until this point, this student has been the quietest in the group. His pale face and flat affect caused me to wonder if he was depressed. In the two sessions following this reflection paper (and the break of the fast of Ramadan), he has become animated, has a sense of humor, and is an active participant in the small group. He still arrives late each week. My dilemma as faculty and facilitator of the small group is how to advocate (or do I need to advocate?) for this student. Will every faculty accommodate his faith needs? What will happen when he does his surgery rotation or residency? What is my role as the first faculty to likely understand the depth of his faith commitment? Will medical education in our environment and his faith requirements result in a crisis of time versus values? Should I do nothing?
Student Response
Patients, physicians, medical students and their educators all must learn to negotiate the complicated intersections of the ideals of religious faith with the realities of medical practice. The student in this vignette is beginning to find his own path through these intersections, and there is little doubt he will face similar, likely more challenging dilemmas in the future.
As a clinical clerk in medical school, and as a member of a house staff team during residency, he may need to make adjustments to the strictness of his adherence to prayer times, or even to his manner of observing religious holidays. Most teams will not look kindly on requests to step out in the middle of a surgery, for example, to pray – especially if the patient is unstable. It is a matter for the student to discuss with himself, his family, his colleagues, his educators and his God, and I hope he can find a balance between prayer and clinical learning that is acceptable to all involved and allows him to provide excellent medical care.
This process of reconciling faith with medicine may not always be an easy one, and he may face insensitivity or even intolerance along the way. I am pleased that the author of this case is so sensitive to the student’s situation and is ready to advocate on his behalf. I think, however, that unless the student was to face an academic misunderstanding or obvious intolerance as a result of his religious practice, it is up to the student to look out for himself. The case author has already participated in the student’s growth in a meaningful way by providing a safe forum for him to reflect on his faith.
If the author would like to engage more fully with these issues, perhaps she or he could look into what the medical school official policies are with regards to the religious observances of students and residents, and investigate just how departments have handled such dilemmas in the past. In addition, it would be of value to examine the completeness of the school curriculum in its teaching about the many challenging intersections of faith and medicine.
Faculty Response
In response to the question regarding faculty advocacy I would say, yes, you need to advocate or educate the student as a faculty and facilitator of the small group.
Thinking about the question about the student’s situation during surgery rotation I would say that flexibility is needed. Once in a while we can accommodate his faith needs like – by allowing two restricted holidays in a year in order to fulfill his faith needs and definitely no faculty will accommodate his faith needs as you did in this particular case.
Response to questions about the responsibilities of the faculty member and the school to the student’s faith requirements – As the first faculty to face such types of problem you should be very clear with the rules and regulations of the academic institution and you should be in a position to explain the importance of the academics, you should help the student to realize the importance of that particular task if he misses that class / small group discussion. You should explain to the student clearly that he should not interlink the faith needs with academics and being a responsible faculty / academician we should not entertain such type of activities inside the academic institution and if we do so it will give a wrong message to the other students of the small group and the activity flourishes which leads to the collapse of the discipline and integrity of the students.
You should understand that the student needs some kind of help and support in such type of situations / circumstances. You can achieve this by Academic Counseling.
Academic counseling includes Information, Advice and Counseling.
- a)Information is about knowledge, which is largely independent of the student. Rules, Regulations, and similar things need to be informed. You need appropriate knowledge and communicating ability to be able to inform.
b)Counseling is letting the student decide for himself as to what is best for him regarding the choice of career and other points which need one path to choose out of many available. This is an entirely student dependent activity.
c)Advising is a mixture of the two – after clarifying the need, you offer several options, but recommend only one, especially for that particular student.</ulas a faculty of a medical institution i have faced the similar problem with some of the students regarding their faith needs
Finally it depends purely on rules and regulations of the medical institution since we have to work under the influence of the Dean or Principal of the medical institution.
Administrator Response
This case illustrates the challenge that students and institutions often face when navigating the complexities of special accommodations. While the title designates it as “a student’s dilemma”, it also becomes an institutional dilemma. Every institution has technical standards that it must adhere to in order to confer that its graduates have mastered the academic and clinical demands and the educational competencies required for residency and the ultimate practice of medicine. All students, including those who have special needs due to their personal religious beliefs or personal health issues must still meet the technical standards set forth by the institution.
It is standard for academic institutions to have policies that address observation of religious holidays. Students whose religious faith requires accommodations beyond those that are set forth in the existing policies should be proactive and request special accommodations at the time of matriculation. Proactively, a conversation between the student and the officers of the school, particularly Student Affairs, Medical Education and Academic Affairs should take place and the student’s needs will be fully explored, including the specific details of the accommodations requested. The school will then make a determination as to whether the student’s accommodation requests can be met and whether the accommodation compromises the student’s educational experience. In this case, it does not appear that this conversation took place; rather the student assumed that he was entitled to these accommodations. While the faculty member in question showed a great deal of sensitivity toward the student in wanting to advocate on his behalf, the issue is an institutional one and not just a student/faculty issue.
The student needs to balance the needs of his own religious faith with the needs of his patients and the requirements of the education to prepare him to care for patients. Accommodations that require frequent absences and the inevitable interruption in his education may be easy to accomplish in some situations, for example, missed lectures where technology allows the student to review the lecture later. In other situations, such as small group learning where participation is key to learning, or the clinical arena, where continuity of care is at stake, this becomes far more difficult, and in all likelihood, the student may need to identify activities that are core to his faith and see if there is any flexibility in the timing of his observances. Regarding his prayers as a means to be “relieved of stress of this world”, there may be times during the day or night that this can be accomplished that would not interrupt the integrity of his medical education. Stress relief is important for all students, and the student can be counseled on additional ways of relieving stress and coping strategies in addition to prayer.
Resolution of this issue requires a broad-based discussion between the student, a faculty advocate and key administrative officials. The discussion and ultimate decision regarding the requested accommodations should balance the personal needs of the student with the technical standards of the educational program. As part of that discussion, all parties should explore where there is flexibility within the confines of the curriculum and where there is flexibility within the confines of the student’s faith. In certain clinical situations, continuity of care may preclude the ability of a student to be absent at set times during the day, just as it would be for residents and practicing physicians. Where there is flexibility, however, an effort should be made to provide reasonable accommodations.
Respondents
Student Respondent
Taylor White, MS4, UMDNJ – Robert Wood Johnson Medical School, Piscataway, NJ
Faculty Respondent
Surapaneni Krishna Mohan MRSC,FAGE, Assistant Professor, Department of Biochemistry, Saveetha Medical College & Hospital, Saveetha University, Chennai – 600 077, Tamilnadu, India.
Administrator Respondents
Toni Ganzel, M.D., Associate Dean, Students and
David L. Weigman, Ph.D, Associate Dean, Academics University of Louisville School of Medicine, Louisville, KY, 40292