Dr. Christina Puchalski is familiar with death. The palliative care doctor and founder of the George Washington Institute for Spirituality and Health (GWish) has seen countless patients facing the end of life ― but there are still moments that shake her foundation.
Several years ago, Puchalski went into a checkup with a patient previously diagnosed with a terminal illness. Puchalski knew the appointment might take a while, and she was already running behind schedule. She was nervous.
“I felt the anxiety as I walked in the room,” Puchalski told The Huffington Post. “They started quibbling with each other. The husband was clearly anxious, and we were going nowhere. So I stepped out of the room for a minute because I felt myself getting sucked into the dynamic.”
In that minute, she continued, the veteran doctor took a deep breath and thought to herself: “I need to get out of that energy and be really present.”
“When I went back in, I sat down and just offered my love. That’s what I do. They had quieted down, and I asked them, ‘What are your deepest concerns?’ The husband started sobbing and said, ‘I think she’s going to die, and I don’t know what to do without her.’”
The wife, Puchalski said, expressed fear over how her death would come about and whether she would suffer at the end. “They just cried, and I sat with them. We’d gotten to the heart of the visit, and it wasn’t about the medication or the pain. The real issue was the bereavement and the fear of losing each other.”
Sometimes, Puchalski noted, the most crucial thing a doctor can offer a patient is their presence and a willingness to listen. With these tools doctors can attend not only to their patient’s physical needs but to their spiritual concerns as well, she said.
The definition Puchalski uses for spirituality at GWish, which marked its 15th anniversary this year, focuses less on religious affiliation and more on a person’s “search for ultimate meaning.” How patients make sense of their illnesses, and even their aches and pains, should be part of the “whole person model” doctors employ, she said.
That model isn’t always championed within the medical establishment. But Puchalski is among a host of doctors, medical students and chaplains working to change that.
“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug."”
Theologian and Harvard University psychiatry instructor Dr. Michael Balboni has dedicated his career to researching the spiritual dimensions of health care. His research has uncovered the profound impact religion has on patients’ medical decisions ― but he’s found that health care professionals are often socialized starting in medical school to “ignore or avoid spirituality and religion,” he told HuffPost.
The medical community skews slightly less religious than the general American public. But many doctors, like University of Chicago’s Dr. John Yoon, pursue medicine precisely because of their spiritual convictions. What awaits them, as a 2015 study found, is often disillusionment with the field.
“Once I started medical school it was a culture shock,” Yoon told HuffPost. “There really wasn’t any space for exploring the spiritual and religious aspect of medicine.”
Yoon graduated from medical school in 2005, having studied medicine in the middle of a 20-year period during which the medical field made greater efforts to incorporate spirituality into health care.
In 1995, Puchalski teamed up with The John Templeton Foundation to establish an awards program for medical schools that develop programs in spirituality and medicine. She was ahead of the curve.
In 1998, the Association of American Medical Colleges (AAMC) published a report called the Medical School Objectives Project, which included sections on spirituality. The learning objectives for students ranged from the ability to take a patient’s “spiritual history” to an understanding of how to collaborate with clergy and spiritual leaders as part of the patient’s care.
Several years later, The Joint Commission, which accredits most health care organizations, issued standards requiring that providers “receive training on the value of spiritual assessment.”
The AAMC’s MSOP reports are offered only as guidelines for medical schools. For accreditation, schools must comply with standards put forth by The Liaison Committee on Medical Education, which don’t refer to spirituality directly.
“Patients’ spirituality directly influences how they make medical decisions."”
Nonetheless, schools across the country including Duke University, Harvard University, Loyola University and the University of Chicago have developed programs on spirituality and health in the last two decades. The number of medical schools that incorporate some education on spirituality and health in their curriculum has increased from about 13 percent in 1994 to roughly 90 percent in 2014.
But Balboni, who co-directs Harvard’s Initiative on Health, Religion and Spirituality with his wife, Dr. Tracy Balboni, a physician, noted that such courses tend to be one-off lectures or electives.
“Those who most need training in this area are the least likely to receive that training because it’s all elective-based,” Balboni said.
A new generation of medical trainees is hungry for more. Aamir Hussain, a third-year medical student at the University of Chicago, is passionate about faith but said he hasn’t explicitly encountered topics of spirituality and health in his general medical training.
“I think it would be good to get a basic outline of what faith groups think about health and what practices faith groups have that might impact health care,” Hussain told HuffPost.
It’s “a missed opportunity,” he added, when doctors fail to take spirituality into account in their care. One such missed opportunity, said Norma Poll-Hunter, senior director of the Human Capital Initiatives at AAMC, comes in the form of patient compliance.
“For instance, if the doctor says, ‘Take this medication with food,’ the patient might not take it because they’re fasting for a religious observance,” she told HuffPost.
Fasting is just one of many religious practices that could impact medical outcomes. A medical student HuffPost interviewed said he once saw a surgery postponed at the last minute because the patient was a member of the Jehovah’s Witnesses and thus wouldn’t agree to a blood transfusion. The doctors reportedly arranged for an alternate procedure, called a “cell salvage,” which would recycle the patient’s blood back into their body with uninterrupted circulation. The miscommunication caused a delay in the surgery, the med student said, which the doctors might have avoided if they’d broach the subject of faith earlier.
Some doctors bristle at the thought of giving religion any airtime in health care ― and they have reason to. Faith, for them, has no place in medicine if it interferes with a doctor’s ability to provide optimal care. Consider the scenario of a medical student planning to become a family care physician but who is staunchly opposed to contraception for religious reasons. “Ask yourself, do you want your own health care provider to consider their own religious or personal beliefs first before offering you medical care?” wrote Dr. Jennifer Gunter who once encountered that very scenario while working as the director of undergraduate medical education at a Midwestern medical school.
On the flip side, some doctors worry that patients’ religious beliefs will predispose them to ignore their medical team’s recommendations on certain matters. One study conducted at London’s Great Ormond Street Hospital found that when child patients had no chance of recovery, highly religious parents often continued treatment against medical advice and hoped for a miracle.
“We use all too many words in health care."”
But Balboni and fellow researchers have found the opposite to be true ― at least in scenarios where doctors take time to attend to their patients’ spiritual needs. In their 2010 study, the researchers measured patients’ self-rated experiences of receiving “spiritual care” from their medical team. The more they received such care, the less they opted for aggressive ― and expensive ― end of life measures. “When the medical team is spiritually interacting with the patients it has an effect on medical outcomes and directly affects costs of care,” Balboni said.
The problem isn’t that doctors are resistant to incorporating spirituality into their care. In fact 40 percent of nurses and physicians say they provide less spiritual care than they’d like to, citing “lack of time” as the main impediment.
Doctors have too many patients to see and not enough hours in the day. Many medical students are similarly drowning under mountains of work. That’s why doctors like Puchalski and Yoon ― the same ones fighting for spiritual care training in medical school ― are also seeking ways to get medical students and doctors reflecting on their own spiritual and moral frameworks to cope with the stress associated with the field.
“Instead of throwing students in and giving them a moral stress test and having them recover 20 years later, why not inoculate them in medical school?” Yoon said.
Healing, for patients and doctors alike, goes much deeper than fixing a physical problem, Puchalski said. For patients, it can mean “finding a sense of coherence and hope despite facing end of life or chronic illness.”
To facilitate that kind of healing, Puchalski said, doctors need to “back away from the computer” and really listen.
“We use all too many words in health care,” she said. “Out of silence, patients can share what’s going on deeply. They can cry and feel they’re really deeply listened to without judgment. You can fix a fracture but it’s very difficult to fix suffering without that kind of compassionate care.”