The greatest challenge facing the academic health center community is to restore the marriage between humanistic concerns and scientific and technical excellence in health care delivery practices.
—R.J. Bulger, The Journal of the American Medical Association, 2000
I came across this quote from Bulger in his article “The Quest for a Therapeutic Organization” while teaching an undergraduate seminar at the University of Michigan, where I am currently a faculty member in the School of Medicine. Bulger’s words so moved me that his declaration has since become my professional mission statement. Bulger’s choice of words like "restore" and "marriage" invokes a sense of something sacred which has been broken. "Humanistic concerns" bring to mind a sense of the divine's presence in mankind, which has been long forgotten.
The undergraduate seminar I taught was called "Fearfully and Wonderfully Made: Themes of Medicine in the Old and New Testament." The title of the course was taken from Psalm 139 where David expresses awe for his maker, "For you formed my inward parts; you knitted me together in my mother’s womb. I praise you, for I am fearfully and wonderfully made; wonderful are your works." In developing the curriculum for and teaching this class over three semesters, I was able to explore and meditate upon what the scriptures reveal about health and disease in relationship to God and mankind.
The ancient near-eastern biblical view of sickness, as found in the book of Job, where man’s condition is dependent upon the divine, was contrasted with the modern western health care perspective, where the divine-human interplay is excluded from the purview. Topics discussed included the biblical view of health and wellness in relationship to that of disease and death. We explored preventative medicine under Mosaic Law, sexual health and wellness from a biblical-medical perspective, and circumcision as understood in the Old and New Testament and today. The role of healer and redeemer by the "Great Physician" was brought to light in the context of Jesus’s use of touch in human interactions in contrast to the declining use of touch within our modern healthcare system. We also explored medical journal and research articles, which showed that physicians today often neglect the spiritual needs of patients.
In 1964, Cicely Saunders, widely considered to be the mother of modern day palliative medicine, modeled a concept of "Total Pain" that recognizes that people experience wellness, health, disease and suffering in interconnected ways that encompass more than just the physical state. Her work gave voice to the picture of a person as more than just a physical being. She writes that people experience their health in four intersecting quadrants—physical, emotional, social, and spiritual. For physicians to deliver whole person-centered care, they must not see the patient as solely physical matter.
When we reflect upon the current state of medical education we notice that the majority of the emphasis is on the physical "quadrant" of the patient, thereby reducing medical education to a bio-reductionist, materialism-only type of education. In this narrow model, Dr. Rachel Remen M.D., author of The Healer’s Art, a groundbreaking curriculum for holistic medical education that originated at the UCSF School of Medicine, says, "We have traded mystery for mastery, and paid a great price. We have lost the ability to meet honestly with the unknown to wonder together with our patients on the deeper meaning of things, to share questions as well as answers." Thus, our current system leaves little to no room for mystery in the encounters with our patients and their diseases and leaves the physician learner uncomfortable when things cannot be "fixed."
In 1927 Francis Peabody emphasized in his article "The Care of the Patient" that science and the art of medicine are not antagonistic to one another. As we continue to advance scientifically, have we begun to ignore the art of medicine which incorporates what gives meaning to a person? Reflecting upon my training has led me to the realization that I was very well trained in diagnosing and managing physical suffering, marginally well trained in diagnosing and managing emotional suffering, and largely untrained in how to diagnose and manage social and spiritual suffering. In effect, I realized I had been seeing and treating only part of the patient in my encounters.
In 1999, the Association of American Medical Colleges (AAMC) released the "Medical School Objectives Project Report III, Contemporary Issues in Medicine: Communication in Medicine," which states that:
Students will be aware that spirituality, and cultural beliefs and practices are important elements of the health and wellbeing of many patients. They will be aware of the need to incorporate awareness of spirituality and cultural beliefs and practices into the care of patients in a variety of clinical contexts. They will recognize that their own spirituality, and cultural beliefs and practices, might affect the ways they relate to, and provide care to, patients.
Upon reviewing this report, in light of my changing perspectives on what holistic healthcare should encompass, I approached one of the medical school deans overseeing curricular changes and asked how we might better help our medical students develop what the AAMC calls "spiritual competencies." We discussed that the Joint Commission—the accrediting body that oversees health care organizations—requires that all patients admitted to an acute care hospital have a spiritual assessment performed by a health care provider. We also examined current research which shows that many patients want their spiritual and social needs addressed by health care professionals. We looked at how the Liaison Committee on Medical Education (LCME) highlights the need for developing "cultural competence" in health care disparities and that religion is often an underappreciated social determinant of health.
Specifically, the LCME writes that medical curricula need to include instruction regarding "the manner in which people of diverse cultures and belief systems perceive health and illness" and how to understand the "basic principles of culturally competent health care." My desire was to communicate that health care professionals and patients are intrinsically connected to cultural, mental, spiritual and societal aspects of wellness and disease. The medical communities throughout the United States should therefore be better able to provide culturally competent, relationship-centered health care that is holistic to the human person. We are not scientific technicians taking care of complex machines; we are humanistic physicians taking care of persons made in the image of God.
Around the time these curricular changes were being discussed with the deans, a family approached the medical school and the development office with an interest in funding an initiative on religion and spirituality within the medical school. In response, the leadership at the medical school, in conjunction with the development office, invited a group of colleagues and I from the medical school to a dinner with the family. Over dinner, our group conversed on the importance of spirituality and religion to both our patients and colleagues. We brainstormed about what an initiative in this space might look like at our medical school. We left the dinner hopeful and encouraged.
Within the week, I received an email from the deans expressing their desire that I take the lead on the initiative around spirituality and religion at the medical school. I accepted and spent the first few months on a "listening tour" as we called it, sitting down with stakeholders at our institution and discussing what a program on this topic at our medical school could become. Colleagues across the country such as Dr. Christina Puchalski of George Washington University and Dr. Aasim Padela of the University of Chicago generously gave of their time to brainstorm with me about how the medical school might move forward.
The "listening tour" culminated in a proposal that our leadership team presented to the donors and the development office. Our proposal for the medical school consisted of a speaker series within this domain, core curriculum in religion and spirituality for all students, and funding for student and trainee research projects. The donors shared our vision and approved a generous gift of money to fund the program. We decided, after much discussion, to name the program “The University of Michigan Medical School Program on Health, Spirituality and Religion.” I became the director of the program and asked a colleague of mine, a physician with rabbinical training, to be the associate director.
In an effort to stimulate conversation and impact the culture at the medical school, we have successfully hosted a number of speakers who have given talks to our community on topics related to the intersection of religion, spirituality, and medicine. Speakers have included Dr. Charlie Camosy from Fordham University who gave a talk entitled "Should a Religious Physician Check Her Faith at the Door While Practicing Medicine?," Dr. Farr Curlin from Duke University who gave a talk on "What does Religion Have to Do with the Practice of Medicine?" and Dr. Tracy Balboni from Harvard who spoke on “Spirituality in Palliative Care: State of the Science.” In addition, we hosted a debate between two pediatric physicians on Conscience Protection that drew close to one hundred attendees. The sessions have been well attended by medical students, faculty, lay people from the community, chaplains, residents, and students from other UM professional schools. Medical student surveys of the talks have been overwhelmingly positive. For the current year we have scheduled Dr. Jeffrey Bishop of Saint Louis University who will give a talk entitled "Religion and the Birth of Osler’s Humanism," Dr. Ray Barfield of Duke University who will give a lecture entitled "I Wasn’t Trained for This: God, Miracles, and Medicine in Complex Decision Making," as well as Dr. Jonathan Crane of Emory University who will give a talk entitled "Disclosing Demise: Judaic Perspectives on Telling Dying Patients the Truth." Students attending the talks have told our team that the speaker series has been a tremendous source of support and joy for them.
As a result of generous support by many, we have been able to create curriculum for medical students and connect with colleagues at UM and across the country on this topic. We now have required curriculum on religion and spirituality for the pre-clinical and clinical medical students. We also run a senior medical student elective where students rotating through our ICU's may participate in didactics and patient care with members of our chaplaincy staff. We have also held a faculty development session on the spiritual needs of patients, presented a national workshop on this topic to colleagues and presented research the past two years at the Annual Conference on Medicine and Religion. My colleagues and I are committed to continuing to try to build a community around this topic at the University of Michigan and across the country.
Has there been some criticism and backlash against the program? Some, but not as much as we might have expected up to this point. Whenever this surfaces, I attempt to focus the discussion on three pillars that we hold in high esteem at our institution:
- diversity/equity/inclusion (DEI),
- and patient centered care.
Whatever our own bias may be, we know from research that spirituality and religion are of great importance to our patients. The president of the University of Michigan, Dr. Mark Schlissel, has elevated a movement around DEI to a place of prominence at the University. One of our goals is to continue to promote the inclusion and awareness of religion, spirituality and faith as under-represented, but essential components of DEI at the University of Michigan. We also believe that our program is an asset to institutional initiatives around trainee and physician wellness. Research shows that trainee and physician spirituality and religiosity can be helpful in maintaining personal resilience and well-being. We believe our institution should be able to support those who may have a spiritual or religious perspective as part of their integrated personal-professional identity even to the extent that these characteristics may be openly role-modeled here. Our medical students and trainees should not be made to think that faith, spirituality and religion must be checked at the door in their practice of medicine and patient care.
Ultimately, the primary goal of the program is to improve patient care. I recently read a devotional by Tim Keller that succinctly reflects the goal of our program. “Lord, raise up doctors and medical workers who don’t think of us just as flesh, but as a complex whole of soul and body.” Cultural change takes years to root itself, but I am grateful for the opportunities we have been granted thus far in the process and I look forward with hope and optimism to our path ahead.