Patients, especially those with serious illness, have always reckoned with existential matters of life, death, and what's to come.
But when COVID-19 unleashed ubiquitous uncertainty, particularly in health care, both patients and physicians had to cope with stress, ground themselves, and find some peace in a changing world, said Christina Puchalski, MD, FACP.
“I think COVID has offered this opportunity to really recognize that the spiritual part is so important. All of us have been faced with uncertainty about the future. Just as our patients face deep uncertainty when diagnosed with a serious illness, we all have been facing uncertainty in the face of this pandemic,” she said. “It is a wake-up call to address spiritual issues in our own lives as well as those of our patients.”
In contrast to the changes that the pandemic continues to cause, faith and spirituality can serve as a constant, said Dr. Puchalski, who is executive director of the George Washington University's Institute for Spirituality and Health (GWish) in Washington, D.C.
“I hear this over and over, and I feel it myself: Spirituality, broadly defined as how we search for meaning, purpose, and transcendence, is the one part of our lives where there can be some certainty,” she said.
Experts explained why now is an important time for internal medicine physicians to address the spiritual health of both their patients and themselves.
Spiritual health and patients
Many physicians feel uncomfortable when dealing with metaphysical matters, said Kristin M. Collier, MD, FACP, a clinical associate professor of internal medicine at the University of Michigan Medical School in Ann Arbor, where she also directs the program on health, spirituality, and religion.
“We are often more comfortable with what we can see and what we can measure,” she said. “And therefore, what happens is that many health care providers avoid these questions with their patients, and this is only to their detriment.”
While the biopsychosocial-spiritual model of whole-person care has been discussed since the mid-1900s, medicine has long ignored the spiritual domain, said Dr. Puchalski. “In fact, when I was in medical school, we talked about the biopsychosocial model, and the spiritual domain got dropped.”
Since then, however, the concept of spiritual health has grown, she said. Recommendations from consensus conferences in the U.S. and Geneva in 2009 and 2013 discussed how the medical team should address spiritual distress and other spiritual issues in both palliative care and whole-person care, respectively.
The consensus group broadly defined spirituality (inclusive of religion) as the “aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.”
In contrast with religion, spirituality describes one's relationship with the transcendent questions that confront one as a human being and how one relates to these questions, noted Daniel P. Sulmasy, MD, PhD, MACP, during the “Spirituality in End-of-Life Care: Cases That Clarify the Physician's Role” session at Internal Medicine Meeting 2022, held in April in Chicago. ACP's Ethics, Professionalism, and Human Rights Committee sponsored the session.
“There's a sense in which spirituality is, on the one hand, wider than religion, in the sense that many people can describe themselves (and do) as spiritual but not religious,” he said. “There's another sense in which spirituality is narrower than religion because within every religion, each individual has their own particular way of living out that religion and addressing spiritual questions for themselves.”
In a 2017 Pew Research survey, 48% of U.S. adults reported that they are both religious and spiritual. Twenty-seven percent said they think of themselves as spiritual but not religious, an 8% increase in five years.
“We know that many of our patients come to us with either a spiritual or religious identity, and it behooves us to recognize and incorporate these commitments in their health care plan if we are to truly be patient centered,” said Dr. Collier.
Whether spiritual, religious, or neither, most U.S. adults (90%) believe in God or some kind of higher power, according to another Pew Research report, published in 2018. About half (48%) said they believe God or a higher power determines what happens to them most or all of the time, and nearly 80% said they believe God or a higher power has protected them.
“The reason that this matters for us in health care is that our patients who have these beliefs are going to view their illness in a way in which God is involved,” Dr. Collier said. “We know that because illness can threaten meaning in patients' lives, and because spirituality is rooted in meaning, we know that therefore illness can cause what is referred to as spiritual distress.”
Illness can conjure questions of meaning, such as “Why is this happening to me?” and “What will happen when I die?” “It is important to realize this type of distress and have this addressed, ideally with a chaplain or other spiritual or religious person trained to manage this type of suffering, in our goal to provide whole-person care,” Dr. Collier said.
To screen for spirituality, a single-item tool often used in palliative care is, “Do you have any pain in the soul?” Dr. Puchalski said. “If the person says yes, then that should trigger more exploration, either by the physician or the nurse. … I would explore that through the FICA tool.”
The FICA Spiritual History Tool, developed in 1996 by Dr. Puchalski in collaboration with Dr. Sulmasy and two other primary care physicians, helps physicians invite patients to share about their spirituality and what matters most, as well as the role spirituality plays in their lives in the context of their whole health. It can also help physicians identity and diagnose spiritual distress, she noted.
An updated version of the tool inquires about patients' faith, beliefs, or meaning; the importance or influence of these views in caring for themselves; the community to call upon; and how they would like the physician to act on or address these issues in their care, Dr. Puchalski said. The A also stands for assessment, which would be the spiritual part of a clinical note (e.g., “patient is spiritually distressed, currently struggling with why this cancer diagnosis is happening to her, especially at such a young age”), she explained.
The FICA tool can be a jumping-off point to a deeper conversation where clinicians ask broader questions, then follow the patient's lead, Dr. Sulmasy said. “Eventually you ask, I think, more open-ended questions, and the one I like to ask my patients in routine general internal medicine is, ‘What role does spirituality or religion play in your life?’”
He also recommended following visual clues, such as seeing Shabbat candles, the Bible, the Quran, or an amulet sitting on the table while in a patient's room on rounds. “Those may be there to say something from the patient's perspective about who they are and what is important to them. And if you ignore it, you are actually ignoring something deep—very deep and important to that patient,” said Dr. Sulmasy, who is director of the Kennedy Institute of Ethics at Georgetown University in Washington, D.C.
When starting a conversation with a patient about spirituality, it is important to use the two Ps of purpose and permission, as one would with any potentially sensitive line of questioning, Dr. Collier added. “This would include explaining the purpose of why you are wanting to inquire about their spiritual and/or religious beliefs and then asking for permission to do so.”
Once patients' spiritual needs are identified, there are regimented approaches to addressing them. In a clinical framework described by the consensus group, spiritual health is addressed through a collaborative generalist-specialist care model, where the generalists (clinicians and social workers) refer patients to and consult with specialists (board-certified chaplains), said Dr. Puchalski, who was lead author of both consensus reports. “That was the beginning, and then that started a lot of education courses,” she noted.
To train clinicians and chaplains in this model, GWish developed the Interprofessional Spiritual Care Education Curriculum, inviting pairs to attend so they can then train their colleagues. Hundreds of people have attended these courses since their 2018 launch, Dr. Puchalski said.
“There's a movement now that's developed in trying to really build these holistic models of care, and not just in palliative care but across all of care,” she said. Advancing Spiritual Care in Everyday Clinical Practice, a 10-year initiative launched in 2022 by GWish in partnership with City of Hope and ACPE, plans to bring clinicians and chaplains together as a team to address patients' spiritual needs and promote interprofessional spiritual care. “It is a human right to have spiritual distress addressed, so we have to be prepared to do that as clinicians,” Dr. Pulchaski said.
But addressing spirituality in a patient's care doesn't have to be complicated or take a lot of time, Dr. Sulmasy noted. “And all you have to say is, ‘Is that the Quran?’ Because what it says is, ‘I recognize what you have put forth is important to you, and I want to respect that and address it in your care.’”
He added, however, that physicians are not expected to provide the specialized spiritual care of chaplains and that proselytizing of any sort is unethical within the setting of the doctor-patient relationship. “MD does not stand for ‘medical deity.’ I don't want to make all of you into the persons who do the spiritual care,” he said. “But I think you do have a role.”
Burnout as spiritual distress
Spiritual health goes beyond the physician-patient relationship and into the doctor's own beliefs, concerns, and burnout. “The pandemic has only intensified the workload on physicians and brought them into situations where they have seen and faced the depths of despair that are hard to describe,” said Dr. Collier.
Some scholars have divided burnout into two categories: circumstantial and existential, she noted. “We know that in the ‘existential burnout’ category lies the concept of loss of meaning at work.”
Burnout is a spiritual health issue because it relates to meaning, said Dr. Puchalski, who is also a professor of medicine and health science at the George Washington University School of Medicine and Health Sciences.
“Burnout has aspects of spiritual distress to it. … What is it that gives us meaning? For most of us, we went into medicine to have relationships with people, to help patients, to care for them, to serve,” she said. “And yet, when we get into systems that don't honor that, or that all of a sudden it becomes so stressful that we get detached from our meaning, that is when burnout goes on.”
Religious and spiritual practices can be a source of meaning for many clinicians but aren't always appreciated in medicine, Dr. Collier said. “We know that many physicians come into medicine in part because of their religious or spiritual commitments,” she said. “But then, often, physicians are made to feel like they must check their faith at the door to be considered a legitimate scientist, and this can be very counterproductive for those individuals.”
Part of treating burnout and fostering professional development is bringing clinicians back to that sense of meaning, said Dr. Puchalski, who also appeared on a June Core IM podcast episode on the topic of spirituality (ACP members can earn CME/MOC points for listening).
“I would love that leadership in hospitals in clinical settings and academic centers would say, ‘Are you still working from that place of meaning’?” she said. “‘When we're talking about spiritual health, we're also talking about meaning. Why did you become a doctor?’”
To help medical students tap into this inner life, George Washington developed GWish Templeton Reflection Rounds, which encourage learners to reflect on their calling, Dr. Puchalski said. “Many times, the suffering of our patients can be so intense that we just want to run, but they need us,” she said. “They need us to at least listen to them … but if we're not grounded, it's going to be hard for us to do that.”
In addition, supporting colleagues and staff members who have deep spiritual commitments both addresses burnout and abides by the tenets of diversity and inclusion, Dr. Collier noted. “This type of work may have even more importance given the crisis of the pandemic and the resultant loss of meaning that has been shown to promote burnout.”
In a June 2021 perspective in the Journal of General Internal Medicine, Dr. Collier and colleagues called for medicine to make space for clinicians and trainees who have a religious or spiritual commitment, allowing for prayer and respecting dietary needs of those who keep kosher or who prefer halal offerings.
Ultimately, physicians who address their own spiritual health will be better equipped to help others, Dr. Sulmasy said. “The way we address questions about meaning, value, and relationship in our own lives, our commitment to doing that, and the kind of self-care that's involved in that, as well as growth as human beings ourselves, will be really significant in our ability to help patients who are struggling with those sorts of questions.”
To illustrate this point, he closed his talk at Internal Medicine Meeting 2022 with a quote from Abraham Joshua Heschel, a 20th-century Jewish philosopher and theologian, speaking at a meeting of the American Medical Association: “To heal a person, you must first be a person.”
“I think all of you are committed to being persons,” Dr. Sulmasy said. “And the more you are committed to being persons as physicians, the more you will be able to recognize patients as persons.”