The illness experience is chiseled by the search for meaning, for purpose, for greater understanding of existential suffering. This search is at the center of the spiritual journey. It is being recognized with greater prevalence that spirituality and illness are deeply intertwined, as the trials and tribulations of sickness and recovery prompt us to ask questions of deep significance. Physicians should be recognized as companions for patients through the treatment and healing process. It is often from the care and compassion of the clinician that patients can derive solace and healing. As medicine undergoes a paradigm shift towards care of the whole patient, it is important we recognize the deeply humanistic value of spirituality in the healing process and the physician as a key driver of it.
The Need for Spirituality in Medicine
For centuries, body and spirit were intimately linked by the work of traditional healers such as priests and shamans. When hospitals were established, they were often funded by religious organizations that emphasized health and healing as a means of intersecting with the increasingly diverse cultural and spiritual makeup of immigrating populations. But with the advent of the Flexner report, there was a newfound emphasis on scientific evidence-based medicine. Simultaneously, the high rates of illness and mortality disillusioned patients from religion. This led to the medical establishment slowly, but surely, de-emphasizing spirituality and turning to science.
Towards the end of the 20th century, there was a greater demand for a rejuvenation of holistic, spiritual care in medicine. Science has not cured all illness and pain. Suffering still remains a part of the illness experience and will continue to be. But an exclusive reliance on science has reduced the process of treatment and recovery to facts devoid of the richness inherent to each patient’s healing process. As more patients turn to alternative healing practices like rituals, prayer and meditation, it is apparent that patients desire more meaning and purpose to the healing process, even in the setting of suffering.
With patients growing more discontent with an exclusively cold, clinical and technologically-oriented system, palliative medicine has risen to the forefront of modern medicine. At the core of palliative medicine lies the distinction between curing, or treating the physical illness, and healing, which refers to a restoration of inner peace and purpose despite a terminal condition. As we palliate, we seek to address the spiritual, the existential and the faith-based components of care that undergird the “total pain” of the patient.. While a spiritual history might not initially seem relevant for routine appointments, the creation of a space to share spiritual needs beyond the formal problem list might provide a unique opportunity for coping and healing in the most unexpected of ways.
Valuing spirituality can be key in the inpatient setting, as clinicians seek to support seriously ill patients and family members. A scoping review by Ordons et al examined experiences of spiritual distress among critically ill adult patients and family members. Researchers found at least moderate spiritual distress in 10%-63% of patients and “conceptualizing spiritual distress” was a core theme among extracted articles. Studies like these make it increasingly apparent that sidelining the spiritual aspect of illness is “to ignore a significant dimension of the experience.” As such, the healing-centered approach of palliative care must be extended across the spectrum of patient populations and diverse settings of health care delivery if we are to truly heal in an era when treatments can result in prolonged suffering for patients.
The Dimension of Spirituality in the Care of the Whole Patient
The word “heal” stems from the root “baelan,” or the condition of being whole. At its core, to heal is to “make whole” again in relation to self, to body, to spirit. Illness and its accompanying suffering, however, fundamentally challenge our notions of being. Our awareness of self and body is sharpened by illness. It drives us to come to terms with a body that no longer seamlessly connects to our sense of wholeness. Illness, in itself, can be thought of as an intensely spiritual experience, as it compels us to ask questions of significant meaning about our sense of self and worldview.
As healthcare shifts towards care of the whole patient, or cura personalis, it becomes increasingly apparent that addressing patients’ spiritual needs is a core element of physician-patient encounters. The reciprocity of the physician-patient relationship creates a space for both healing and a partnership. Physicians act as knowledgeable guides for patients through the treatment process, while also serving as empathetic companions who create a safe space within the clinical environment.
By effectively creating a safe space, physicians can employ the immensely valuable tool of narrative to elicit the suffering and questioning that underlies the patient’s illness experience. When given the space and time to speak, patients can reframe their illness stories to better accept and even transcend suffering. Physicians can engage in the conversation by listening deeply and leveraging the power of storytelling to help patients discover meaning and purpose embedded within their stories. Simply by extending the encounter for a few minutes, it is possible to acknowledge and begin alleviating the deeper truths contained within narrative: the despondence of terminal illness, the loss of agency among the elderly, the pain of wear and tear. In his collection of writings chronicling his battle with cancer, essayist Anatole Broyard notes that what a sick man ultimately seeks from his healer is “empathetic witnessing,” simply deeply listening and critically grasping the patient’s situation. Without this simple acknowledgement, patients may feel abandoned despite access to the most state-of-the-art treatments that evidence-based medicine has to offer.
Spirituality in the Education and Training Process
Although we have mastered the care of acute illness, modern day medicine struggles with chronic illness 一 arthritis, cancer, diabetes, heart disease. Physicians are often trained as scientists who refine their expertise on diagnosis, treatment and prevention. The focus is on the cure, rather than the care. As such, spiritual health has been isolated to the peripheries of medical care.
Most medical school curricula include little, if any, instruction on addressing spirituality. While most hospitals are equipped with chaplains to help with the intimacies of the process, there is value found in the physician who is able to elicit the patient’s spiritual needs at the onset of their care and/or track it during outpatient follow-ups. A few medical schools have integrated spirituality in medicine courses into their curricula centered on spirituality-related competencies developed by the National Initiative to Develop National Competencies (NIDCSME). George Washington University launched the first integrated elective spirituality and health course in 1992 and has since built on its goal of broadening medical students’ ability to understand patients from a holistic viewpoint, through exercises like eliciting a spiritual history.
One of the major concepts emphasized by the NIDCSME is the development of “compassionate presence.” This includes establishing a connection, being empathetic and helping patients with their needs. It also emphasizes self-awareness and creating a non-judgmental atmosphere open to patient affirmation and reflection. These courses encourage students,residents and clinicians to attune to their own spirituality in terms of inner life focus, authenticity, purpose/call to serve and compassionate presence as a part of their professional development as healers. As medical schools expand in number and enrollment, it is important to establish and strengthen courses in spiritual care skills.
Two major barriers to translating these learned skills to the patient encounter cited by clinicians are the absence of a framework during the clinical interview for a spiritual history and the lack of time for conversations of deep meaning. Thus, it remains a challenge to integrate spirituality with care, particularly in the end of life. Although the National Consensus on Palliative Care developed eight required domains of care covering spiritual, religious and existential concerns, how these were to be implemented in care was subject to interpretation. Since then, national consensus conferences have emphasized the inter-professional distribution of responsibility, with physicians serving as generalist spiritual care professionals and chaplains as the specialized experts. In this way, clinical components of spiritual care like taking a spiritual history, diagnosing spiritual distress, identifying spiritual resources and embedding spiritual care into the assessment and plan can be regularly enforced. Treating spirituality not only as a component of pain and suffering, but as a part of preventative care warranting regular assessment is now being more widely emphasized across palliative and critical care specialties.
Spirituality Within the Art of Medicine
Spirituality transcends the divisions of religion as an intensely human experience that underpins our collective reality. We, as humans, are frequently prompted to reflect on the nature of our bodies and our existence. Our life stories may lead us to diverse conclusions in our search for meaning, but by no means do we lose the ability to connect with one another over the shared experience of illness. Illness can be described as an intensely spiritual event as it unearths a process of probing deeper and gaining a deeper understanding of the machinery that makes up who we are.
It is widely agreed that the practice of medicine is the art of applied science, but many hesitate to describe it as a spiritual practice. But as noted earlier, the word root of healing is baelan, the state of being whole. And that is what we seek to do at the core of medicine — to restore our patients wholly. It is important to recognize that spirituality can exist beyond the realm of faith or religious belief. To be human is to be spiritual as all of us will be touched by the events of illness and death, making suffering an inevitable part of the human experience. As patients ask questions of hope, meaning and purpose, the physician-healer can be uniquely equipped to accompany them in that journey for meaning, if we choose to re-infuse humanity in our innate work as healers.
Image courtesy of Mili Dave.
Pulses of Connection is an attempt at delving into mind-body connections in medicine. This column will strive to emphasize how mobilizing the deep connections between our mind and physical bodies can enhance our sense of oneness, health, and well-being. Through narrative and exposition, I will explore how practicing physicians, medical students in training, and premedical students can integrate mindfulness in their lifestyles, as well as how such approaches can be crafted to bring healing to our patients.