By Timothy P. Daaleman, DO, MPH, Department of Family Medicine, University of North Carolina at Chapel Hill
Albert Schweitzer once said that medicine is not only a science but also the art of letting our own individuality interact with the individuality of the patient. I thought of this aphorism after reading the qualitative study by Kuczewski and colleagues and the accompanying commentary on spirituality and health in the January issue of Academic Medicine. Spirituality has lost much of the luster and purchase that it had in health-related circles over a decade ago, and part of this decline is due to the lack of a clear understanding of how spirituality is operationalized in clinical settings among patients and physicians. For example, the wide range of themes identified by medical students in this exploratory study of spiritual care at the end-of-life—communication, patient care, compassionate presence, and personal and professional development—are not unique to spirituality and have been appropriated by other humanistic disciplines in medicine, such as patient-centered care, professionalism, and ethics. This is vexing for other health professions as well, particularly nursing, which struggle with placing spirituality within clinical care, research, and training contexts for similar reasons. The bottom line is that spirituality does not message well in contemporary academic health care centers and other clinical training environments, which are all moving to value-based paradigms. What will be the value proposition for spirituality in future health care systems and for physicians who are formed in these environments and communities?
The good Dr. Schweitzer shows us a way. To begin, my reading of the student narratives interprets a process of self-awareness and interior development that was not separately personal and professional but integrated. Fundamentally, such a process radically challenged and altered the students’ emerging self-identities as persons of care (i.e., their individuality). The texts, to me, also suggested that a profound shift occurred, not by way of coursework or adherence to clinical or educational guidelines, but through authentic relationships with patients who were facing death, encounters that lay bare the individuality of the patient, and probably the student. At the core of these encounters—if my clinical and research experience can be a trusted guide—are the spiritualities, that is, the beliefs, stories, and practices which are being worked out in response to human longing for meaning and purpose.1
This approach to spirituality can claim a unique space and offer a richer and more integrative framework for educational innovations in emerging value-based academic health centers, especially at a time when concerns are being voiced about professionalism in medical students and burnout in physicians. The authors of both the qualitative study and the commentary conclude with future directions that primarily target curricula, protocols, and competencies related to spirituality and health. Although I could not agree more with the overall goal and content within these recommendations, the well-recognized hidden curriculum has washed away many of the best developed and intended educational initiatives, and will do so with any spirituality initiatives that do not take into account the larger context of hospitals, medical homes, and other clinical learning environments. The “art,” which Dr. Schweitzer so rightly speaks, will be how the intersecting spiritualities of patients, doctors, and other care providers can be initiated, developed, and deepened in these clinical settings.2
1. Shea J. Spirituality and health care, reaching toward a holistic future. Chicago, IL: The Park Ridge Center; 2000.
2. Daaleman TP, Kinghorn WA, Newton WA, Meador KG. Rethinking professionalism in medical education through formation. Family Medicine. 2011;43:325-329.