When Kristen Moser enrolled in the Stritch School of Medicine at Loyola University Chicago, she said she was "subconsciously searching for an outlet to explore what it means to be a Christian." Fortunately, she found one in the school's Physician's Vocation Program.
John Hardt, PhD, vice president of mission integration at Loyola University Health System, said that although the Jesuit Catholic university has a robust mission culture, about five years ago some medical students began asking for a bigger, more formal way in which to engage questions of faith and medicine.
The result was a four-year program run like a graduate seminar. In the third year, each student does the traditional Ignatian exercises of prayer, meditation and reflection under the guidance of a spiritual director. The program has enrolled students from a wide variety of Christian denominations. Moser, for example, grew up in an evangelical Protestant church.
"For me, where medicine and religion intersect is in the relationships you build, whether practicing medicine or whatever your vocation is," said Moser, now in family practice residency in suburban Chicago. Although the medical school taught communications skills, the vocation program "teaches why this is so important. It's really encountering Christ in another person," she said. And that encounter, both singly and multiplied across careers and systems, exemplifies the common good.
Although medical student formation programs as specific and deep as Loyola's are still rare, more than 75 percent of U.S. medical schools now include some recognition of spirituality in their curriculum or offer additional programming to students who are interested. Christina Puchalski, MD, director of the GW Institute for Spirituality and Health at the George Washington University School of Medicine and Health Sciences in Washington, D.C., and one of the pioneers in the field, said competencies around spirituality are now woven through many curricula — so that, for instance, students may learn to take a patient's spiritual history along with taking a medical history.
The concept of spirituality is not the same as religion, however. Puchalski's working definition is the search for meaning and purpose; the connection to others, self, nature; and the significant or sacred.
FAITH AND MEDICINE
Loyola's program "is not for doctors to evangelize patients," Hardt emphasized. "It's to integrate your faith as a Christian and your life as a practicing doctor." Witnessing to God's love through one's actions "cuts across any religious boundary." The only for-credit course in the program is a rotation in palliative care, which leads all other specialties in integrating spiritual care.
Notoriously, in medical school "altruistic motivation is quickly zapped," said Michael McCarthy, PhD, an assistant professor in Loyola's Neiswanger School of Bioethics, but the program's community can help insulate against the burnout, cynicism and gallows humor that often go along with medical school.
"All of my best friends at medical school were in that group," Moser agreed. "Sometimes we felt burned out already. But it helped keep that discussion alive — what does God have for us in this career? Seeing that big picture is one of the only ways to keep going."
The question of vocation butts up against the general social expectation that doctors can and should cure everything. "You're not always going to be able to cure," McCarthy said. "What is your obligation to people in the midst of suffering?"
In addressing those kinds of questions, the leaders of the program hope their students develop a relationship with God. "It's a hard thing to measure and prove," Hardt said, "but that would be the best outcome."
A somewhat similar program at Duke University in Durham, North Carolina, is being run under the auspices of the Duke Divinity School, which welcomes all Christian denominations but is affiliated with the United Methodist Church. Farr Curlin, the physician who in 2015 began Duke's Initiative on Theology, Medicine and Culture, said lowest-common-denominator spirituality programs are limited in the impact they can have on students, but Duke's one-year theology program offers formation for medical professionals. Most often, students take it either before enrolling in medical school or halfway through, but it also has attracted nursing students and practicing physicians. Duke's program asks students not just to think about faith, but to instill habits that will "form them into a different kind of person and clinician," Curlin said.
Curlin moved to Duke two years ago from the University of Chicago's Medicine and Religion Faculty Scholars Program because "I longed to consider more deeply what difference the Gospel makes to the way we practice medicine."
A formation program is not about teaching skills such as active listening. Spiritual depth can't be taught or controlled in the same way, Curlin said, but the expectation is that spiritually aware students will develop "habits that are skillful and wise."
BRIDGING THE DIVIDE
A decade ago, Curlin co-authored a study debunking the belief that doctors are less religious than the general population. His research found that physicians actually attend church more than patients do, but are less likely to ask God for help.
Although students who make the kind of committed faith journeys in the Loyola or Duke programs may be in the minority, a nonreligious doctor often will need to understand a religious patient. A mandatory second-year class at Northwestern University's Feinberg School of Medicine in Chicago is designed to, if not bridge the divide, at least make students aware of some patients' spiritual needs. Jeanne Wirpsa, a chaplain at Northwestern Memorial Hospital in Chicago, said the class gives students the language to talk to patients and families. The response is overwhelmingly positive.
"Some students have had little exposure to some of these issues," Wirpsa said. "Your own satisfaction as a physician is enhanced if you connect with patients."
The benefit of making the class mandatory, Wirpsa said, is that at some point in their careers, doctors will have to communicate with patients who put religion at the center of their lives. Making sure the nonreligious students are exposed to the concepts, she said, is exactly the point. If the course were about spiritual formation, she said, she could envision pushback from some, but, as it stands, it is explicitly about giving students tools with which to relate to patients.
Under Puchalski, George Washington University's medical school has introduced reflection rounds, in which students consider the impact of patients' cases upon their own spiritual lives. Like almost all medical schools in the United States, GWU is secular, but it always has supported Puchalski's work.
Traditionally, Puchalski pointed out, medicine tried to heal the whole person. But the technological advances of the 20th century, as beneficial as they were, emphasized biological treatment and neglected psychological, social, and spiritual dimensions.
Medical interest in spirituality has gone in cycles over the past century, Curlin said. He noted that as recently as the 1970s, the American Medical Association had a department of religion. It fell by the wayside, but interest has renewed.
"The fact that it never fully goes away reflects the fact that our patients are spiritual beings," he said. But the dominant emphasis on biology is "the endemic problem for all modernity — what science can't know."
If doctors are aware of spirituality, both patients' and their own, Puchalski said, it can be a tool to reduce stress, burnout and even suicide in the medical profession.
"All of us want to provide good care," she said. "All of us want to serve the patient," and reflection rounds provide a conscious reminder of that sense of calling. Taking a patient's spiritual history, she said, "doesn't consume a lot of time and can help build trust, which makes the visit more efficient."
Mimi McEvoy, co-director of the Introduction to Clinical Medicine program at Albert Einstein College of Medicine in the Bronx, New York, said that when she meets a patient, she will ask something like, "What do you want me to know about your spirituality that would help me treat you?" Although Einstein is no longer formally Jewish-affiliated, it integrates spirituality into the medical school curriculum at several points.
Recognition of the importance of spirituality has increased in recent decades, McEvoy said, but "we need to do a lot more of this in faculty development. We don't have a lot of models on how to teach it." Students who take an elective on the subject at Einstein develop "the comfort and language skills to ask what gives meaning to their own lives. That's a question they should think about," she said.
Most of the new programs being developed are aimed specifically at doctors — but Curlin said that nursing schools have a long tradition of weaving spiritual matters into the curriculum. At Northwestern Memorial Hospital, Wirpsa also runs spirituality and ethics training sessions for new oncology nurses and social workers.
Of course, the potential for conflict exists if the patient's and doctor's values are not aligned, which means that students must be actively taught to be aware of their own biases, try to set them aside, and acknowledge the power difference in the relationship. But, Puchalski pointed out, that also applies to attitudes toward sex and other cultural issues. "Spirituality is no different," she said. "People make it so mysterious."
THE HEALER'S ART
A shorter and more general course, but one with much wider reach, is The Healer's Art, which is taught in more than 70 U.S. medical schools and has reached more than 17,000 students over the past two decades. Developed by Rachel Naomi Remen, MD, a pioneer of holistic medicine, the five-session course covers subjects like grief and loss, mystery and awe, and service as a way of life.
"We are all learners in this course. Everyone is equal," said Evangeline Andarsio, MD, a retired OB-GYN who now directs The Healer's Art. Lecture mingles with small-group discussion during which faculty and practicing physicians model compassionate presence.
The Healer's Art works with students of every faith, or no faith, to teach resilience and self-care. Andarsio said that Remen considers medicine to be its own spiritual path. Many Healer's Art graduates start small "meaning of medicine" discussion groups in residency or practice to find and offer support for the sense of mission in their work.
"The capacity to see meaning becomes a powerful form of self-care," Andarsio said.
In forming contemplative, resilient, grounded physicians, "how could that not lead to the greater good of all, not just the patient but the whole health care system?" Andarsio asked. Systems change slowly, of course, but she sees more acknowledgment now of physician stress and burnout, and less of the "John Wayne attitude."
The Healer's Art "is not a panacea," Andarsio cautioned. "It's only a piece of how this can happen. We need to acknowledge that some of the system is broken and needs to be fixed. Change is coming. Physicians are speaking out, and students are speaking out."
In the same way Loyola's program emphasizes Jesuit spirituality, a new program at Marian University's college of osteopathic medicine in Indianapolis emphasizes Franciscan spirituality. John Shelton, the campus minister for spiritual formation, said one reason the university started an osteopathic school was because of osteopathy's emphasis on treating the whole person — and the vocation program will introduce students to Franciscan spirituality as it relates to medical practice.
Teaching effective communication is part of it, Shelton said, and goes along with spiritual formation. "It's a both-and situation — their wellness and the patients' wellness. You can't have one without the other." The Marian program also is open to Protestant and Orthodox Christian students, and the medical school sponsors faith-based clubs for Jewish and Muslim students.
Successful spirituality education "transforms health care and transforms relationships," Puchalski said — which also enhances the common good. "Spirituality is transformative. We are connected to each other. If we can get out of our silos and talk about it with each other, make that kind of connection … it goes beyond being an essential element of health care to the essential element of health care."
The common good involves both the doctor and the patient, Curlin said. As an example, he suggested that if a patient with advanced cancer said she was depending on God for healing, it could be the cue for "a skilled and wise clinician" to begin an honest conversation about the limits of technology and where hope resides.
And from there it is but a short step to the idea of love. Going into an examining room, Puchalski said, "as stressed as I might be, I let all of that go, because I have the intention to love that person."
DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.
Copyright © 2016 by the Catholic Health Association of the United States
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