Medicine for the Soul

MARCH/APRIL 2002–It seems like common sense: When a person walks into a doctor's office, she brings much more than a headache or chest pain. Patients carry with them their ideas about alternative therapies, their parents' teachings, and their belief systems.

But for years, many medical educators say, physicians did not consider how such factors as spirituality and culture affected patients' health or their responses to medical treatment. They just weren't trained to, says M. Brownell Anderson, associate vice president for medical education for the American Association of Medical Colleges (AAMC) in Washington, D.C.

"Basically, we in the medical education profession were running the risk of having graduates who were technicians–very skilled at delivering medical care, but not skilled at dealing with the patient as a whole person," she says. "The recognition that there is art to medicine [and] that we need to treat the whole patient has strengthened enormously in the past five years."

Since the first few courses began in the early 1990s, a growing number–now more than seventy–of American medical schools have developed programs to teach students that patients are more than the sum of their vital signs. In 1999, the AAMC added cultural and spiritual competencies to its curriculum guidelines, thereby identifying those as skills that all medical school graduates should possess. By considering factors beyond the physical, educators say they are training doctors who deliver compassionate care to the whole patient.

In the long run, this push to reform medical education also may revolutionize health care, says Christina Puchalski, assistant professor in the division of aging studies at George Washington University Medical Center in Washington, D.C., and founder and director of the George Washington Institute for Spirituality and Health (GWish). The current system, with its Medicare cuts and profit-driven managed care, has left many physicians frustrated.

"A lot of doctors are burned out and finding a loss of meaning in their own personal and professional lives," she says. "They're finding this whole movement very encouraging. Because what it's saying, really, is we want to train compassionate and caring doctors, and they're saying, 'Yes, that's where we want medicine to be.' They're hoping that we can advocate for health care systems that will enable patients to receive compassionate care."

The new Program for Integrated Medical Education and Patient Health at the University of Michigan Medical School in Ann Arbor exemplifies the expanded educational model. The key word in this program, like many of the other programs, is integrative: It won't work unless it's woven throughout the curriculum, faculty members say.

"Let's say we're thinking about what you might use [to treat] heart disease," says Sara Warber, co-director of Michigan's Complementary and Alternative Medicine Research Center and a lecturer in the department of family medicine. "We teach things on an organ system basis, so it doesn't really help to have a course sitting someplace else in the curriculum about how to use alternative methods for heart disease. It needs to be there in that place where we talk about heart disease."

The Michigan program, formalized this year, brings together experts and projects in alternative therapies, spirituality, and end-of-life care that have been scattered throughout the medical school, some for nearly ten years. The school's goal is to build a thread of holistic topics throughout the four years of the medical curriculum.

"Students certainly need to know the biomedical sciences," says Casey White, Michigan's assistant dean for medical education. "But we need to give them more of a patient context, so they start thinking about the patient at the same time they're learning about the diseases."

Teaching these skills, medical educators say, can be challenging. "One of the hurdles is that students of medicine worship at the altar of science more than at any other altar," says Auguste Fortin, assistant clinical professor of medicine at Yale University Medical School in New Haven, Connecticut, and recipient of one of the 2001 John Templeton Foundation Spirituality and Medicine Awards. "They may not recognize that their patients may have much more spiritual belief than they do. That lack of sensitivity to the issue could lead to a lack of viewing any importance of it."

The distinction between spirituality and religion in these programs is vital, says GWish's Puchalski. Her institute directs the Spirituality and Medicine awards, which since 1995 have given grants of $25,000 to medical schools with courses or curricula integrating the two elements. Critics of this integration often focus on the dangers of doctors proselytizing.

"I think the resistance would come in if we were saying, the data definitely show that having a spiritual practice is better for your health, and therefore, physicians should be telling their patients to have a spiritual practice," Puchalski says. "We're not saying that. We're saying: 'Learn what's important to your patient, and go from there.'" As more medical schools develop these programs, faculty members have begun to create reliable teaching methods to help students focus on the whole patient. Standardized patients–actors trained to play patients–train and test students on how to approach subjects like spirituality in the examination room. In some programs, patients with chronic illnesses speak to students about what they value in a health care provider. In others, students participate in reflective activities, such as writing essays or poems, designed to put them in touch with their own value systems.

Modeling by faculty is also crucial, says Kevin Dorsey, interim dean and provost of the Southern Illinois University School of Medicine in Springfield. "If I, as a faculty member, am willing to talk about this openly and unabashedly, don't you think that sends a big message to the young, impressionable, beginning trainees in this profession? I'm not afraid to talk about my life experiences, whether they were personal or they occurred in my practice. I have to let them see inside my soul."

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