 Reverend John Simon and Dr. Daniel Aronzon, CEO of Vassar Brothers Medical Center, in the hospital's interfaith chapel |
Aronzon reflects that with today's shortened hospital stays, spiritual needs can more easily fall through the cracks. One concern is that time-crunched physicians may miss valuable opportunities to refer patients for pastoral care services. "Fifteen, twenty, or thirty years ago, hospital care was a different animal," says Aronzon. "Things weren't rushed. For example, a patient with a hernia could expect to be in the hospital for a week," compared to a much shorter stay today.
In a candid analysis of modern health-care culture, Aronzon draws a direct parallel between an increasingly fragmented and technologically dependent style of medical care, and a need for readily available spiritual aid. "As hospital care has become more complex, and patients' illnesses more acute, the number of physicians caring for a patient and the number of medications given each patient has increased tremendously," he says. "Physicians must react to patients' needs more quickly. So, it's ever more necessary that each patient have access, just as quickly, to spiritual care."
Yet with physicians squeezed to see more patients in less time, is it appropriate for health care organizations to require doctors to incorporate, as well, a "spiritual awareness" in their patients? In recent years, this question has stirred a great deal of controversy, as well as change, in both medical education and health care administration.
The Joint Commission on Accreditation of Health Care Organizations, the nation's predominant standards-setting and accrediting body in health care, began to address spiritual care in the context of patients' rights in 1998, when it required accredited health care providers to make spiritual care accessible to all patients. However, many health care providers find it difficult to secure adequate funding for such services, and nationwide pastoral care resources are frequently stretched to the breaking point. Many institutions are forced to rely almost exclusively on volunteer networks of both clergy and laypersons. When neither is available, doctors may be pressed to deal with difficult questions far beyond the scope of their medical training.
Historically, our earliest nurses and physicians drew deeply from religious teachings in caring for the sick. One of Europe's most celebrated healers, for example, was Hildegard of Bingen (1098-1179). Revered as a mystic, Hildegard founded the first convent of the Benedictine order along the banks of the Rhine in Germany, and was also an important author of both spiritual and medical texts, including treatises on the curative powers of natural objects and Christian doctrine.
But by the 20th century, with increased reliance upon medical science, spiritual care had become a discrete domain, attended primarily by community clergy. Such was the case with Vassar Brothers Medical Center. From its inception in 1887, pastoral care services were provided by the pooled resources of the Catholic parishes served by the hospital.
Last year, however, Vassar Brothers Medical Center joined a national movement in the health care industry to formally meld an interfaith spiritual care program into its services. Following an institutional review of the medical center conducted by the New York-based Healthcare Chaplaincy, Aronzon hired Reverend John Simon, a representative of that multifaith agency, to direct a new Department of Pastoral Care. Already Simon has organized a community chaplaincy program that trains local clergy, through a six-week training program based upon the national model of Clinical Pastoral Education, to minister to patients and family members in a diverse range of health care settings. According to Aronzon, bringing in Rev. Simon has very quickly advanced one of the institution's key objectives: to provide a holistic model of patient care, one that addresses the complex relationship of physical, psychosocial, and spiritual health. "Reverend Simon's work with the community chaplaincy program has literally been a Godsend," he says. "We're looking forward to expanding the program."
As Simon often says, "A medical crisis is a spiritual crisis." Difficult medical and end-of-life decisions are very often intrinsically linked to spiritual beliefs. To illustrate this point, he tells of a patient who was close to death. Medically, there was little that could be done, except to keep the patient as comfortable as possible. Gathered around the patient's hospital bed with Simon were family members, a nurse, and a physician member of the Palliative Care Consult Team, to assess the most effective means of pain management for the patient.
"Although he cannot talk, this fellow is lucid," Simon recalls. "Though ventilated, he can make eye contact and nod his approval to questions the medical team is asking. As the various medical options were being explained, the patient became emotionally unresponsive. At that point, I asked if it would be possible for me to meet with [only] the patient, his spouse, and the palliative care physician. After having the spouse introduce me, I shared with the patient concerns, which from my role as a husband and father, and as a man, I suspected he might have. I connected with him on a human level first, as a point of entry, and then helped him draw strength from his faith to make one of the greatest decisions of his life."
Simon goes on to describe how this conversation ultimately elicited a response from the patient that included affirmation (by nodding) that he was "ready to let go," which meant the eventual removal of the breathing machine, a decision about which there hadn't been an earlier family consensus. The patient also nodded to acknowledge fear that he would disappoint his family by "giving up too easily."
"The man had tears in his eyes" when finally able to convey these thoughts, says Simon, "and I felt that he had clearly reached a place of peace where he felt as though he was honoring both his own and his family's wishes."
A small but growing body of research supports Simon's real-world experience of the importance of a spiritual dimension to medical care, and calls for even greater integration of them. Dr. Harold Koenig, director and founder of the Center for the Study of Religion/Spirituality and Health at Duke University, where he is also associate professor of psychiatry and medicine, is one of the nation's leading experts on the intersection of spirituality and medicine.
Speaking at a 2003 symposium titled "Is Prayer Really Good for Your Health?," Koenig referenced a study conducted a few years earlier at the Hospital of the University of Pennsylvania, in which researchers concluded that "66 percent of medical patients indicate that religious beliefs would influence their medical decisions should they become seriously ill." Koenig presented an additional study that asked whether patients with end-stage lung cancer should receive chemotherapy. "Family and patients ranked 'faith in God' as second in importance" in their decision-making about treatment, "even ahead of whether or not chemotherapy would effectively treat the cancer. [The oncologist's recommendation was ranked first.] When 300 oncologists were asked this question, they ranked 'faith in God' dead last among seven or eight other important influential factors."
His take-home message to colleagues is clear: "End-of-life decisions relate to religious beliefs and can cause serious conflict" with medical treatment options. He asks, "With religious beliefs having such a profound influence on medical decisions, how can doctors practice good medicine without communicating about these issues with their patients?" He recommends that doctors "respect, value, and support the beliefs and practices of the patient, and orchestrate the meeting of spiritual needs." Further, Koenig is an avid proponent of training doctors to take a "spiritual history" of each patient, in the context of conducting a medical exam.
In opposition to that idea at the symposium was Dr. Richard Sloan, professor of Psychiatry at the College of Physicians and Surgeons at Columbia University. "Should we be spending time exploring patients' religious beliefs when we already know that, even today, not enough physicians ask about smoking? About diet and nutrition? With a limited amount of time, what do we want physicians to spend their time on?"
Dr. Aronzon believes there is, indeed, a need for physicians "to develop sensitivities to the spiritual and psychosocial needs of patients." But he concedes, "It's sometimes difficult to teach old dogs new tricks." On the positive side, he points out that "newer graduates are much more understanding of the value of pastoral care and will seek referrals for their patients much more easily." He adds, "The time for inculcating the importance of a spiritual component of patient care is in the first years of medical school." Health care administrators like Aronzon are finding this view increasingly supported by contemporary changes to medical school curricula.
Indeed, as health care delivery has become more fragmented and cost-driven, the push for a more humanistic approach to medicine is gaining momentum among a constituency that, even some 20 years ago, would have seemed highly unlikely. Until quite recently, the Association of American Medical Colleges (AAMC) had little inclination to endorse courses designed to teach doctors to assess the spiritual, emotional, and psychosocial needs of patients. Yet a nationwide trend among medical schools to integrate courses focusing on topics such as spirituality in medicine, cultural competency, and (in a more general sense) humanism is clearly under way.
The results of a 2004 survey of the nation's medical school curricula, published in the Journal of the American Medical Association, found that in 1994 only 17 of the 126 accredited US medical schools offered courses in spirituality in medicine. By 1998, this number had increased to 39 and by 2004 to 84 schools.
What are some of the factors that have fueled this surge? Dr. Christina Puchalski, founder and director of the George Washington Institute for Spirituality and Health in Washington, DC, believes that the trend stems from consumer demand for a more humanistic approach to patient care. She characterizes traditional American medical schools as the breeding ground for recent cadres of physicians ill-equipped to treat patients holistically. She underscores that, while "so much of the impetus in [medical] education and the way that our physicians, myself included, were trained, is to want to cure and fix the problem," it has its downside. "The public has responded negatively to that, with comments in the press and elsewhere that doctors are 'overtechnologicalized,' so to speak—that they focus too much on the disease and not enough on the person."
Puchalski reflects that in 1992, George Washington University Medical Center, where she is Associate Professor of Medicine and Health Care Sciences, offered one of just three courses on spirituality then available nationwide. She points out that an initiative spearheaded by the AAMC, titled the Medical School Objectives Project, came "in direct response to the public outcry about training physicians and the fact that physicians are becoming too cold, too technical, and that people wanted a warmer, closer relationship with physicians." That initiative called for expanding medical school curricula to include courses that encourage a more holistic approach to patient care.
Closer to home, Dr. Rita Charon, Professor of Clinical Medicine at the College of Physicians and Surgeons at Columbia University, directs the Program in Narrative Medicine, an innovative model that she founded. Medical students are required to choose electives from a host of courses offered through the Humanities and Medicine Seminar Series. "The long-range goals of the seminars are to enable P & S graduates to practice medicine with their full selves, using all their gifts toward the health of the patient," she wrote in a 1999 issue of the College's student newsletter. Today the seminars are immensely popular.
One such seminar is Father Daniel Morrissey's "Faith in the Face of the Practice of Medicine." As a Roman Catholic priest and Ivy League professor, Morrissey helps new doctors to bridge two worlds: that of the spiritual/religious and that of the traditionally secular realm of academic medicine. His course addresses some of the challenges faced by members of both the medical and pastoral care communities as their roles intersect—and sometimes even blur—within hospital walls.
Morrissey equates the uncertainty of his medical students when they are faced with patients' questions of faith to his own cautious responses in discussing medical conditions with patients. He recounts that one medical student was asked by a patient, "Does God love me?" Morrissey understands that student's concern: "What if I say the wrong thing?" Yet these are exactly the kinds of difficult questions that warrant further pondering as modern medical education and health care evolve.
Morrissey cautions, however, "When you talk to a patient and they say 'God,' they can have a very different meaning than the one the doctor or medical student might have. We all have to be aware of this. There is absolutely no place for proselytizing a particular religious belief system in the practice of medicine."