AMA Journal of Ethics®

July 2018, Volume 20, Number 7: E655-663

MEDICINE AND SOCIETY

Training Physicians as Healers
Aparna Sajja, MD and Christina Puchalski, MD

Abstract
Spirituality is increasingly recognized as an essential element of patient
care and health. It is often during illness that patients experience deep
spiritual and existential suffering. With clinicians’ care and compassion,
patients are able to find solace and healing through their spiritual beliefs
and values. This article chronicles a history of spirituality and health
education, including the development of consensus-based clinical
guidelines and competencies in health professions education that have
influenced the curricular development.

Need for Spirituality in Medicine

Spirituality is defined as a search for meaning, purpose, and transcendence and a
connection to the significant or sacred.1,2 Illness, because it raises questions regarding
meaning and value, can be described as a spiritual event. As Hebert et al. note, “To ignore
the spiritual aspect of illness, then, is to ignore a significant dimension of the
experience.”3 Yet medical training falls short of preparing physicians to help patients with
the metaphysical needs of their illnesses.4 It is interesting that spirituality is not yet
routinely addressed in clinical care, as most US adults believe in God or a universal spirit,5
patients can discover strength and solace in their spirituality, and data demonstrate the
prevalence of spiritual distress.6 In this article, we chronicle the history of the field of
spirituality and health, with its challenges, evolving definition, and integration into
medical education.

Changing Roles of Spirituality in Medicine

Medicine, religion, and spirituality share a long history—as evidenced by the roles of
healers such as priests and shamans. In the US, many hospitals were founded by
religious organizations and espoused values of compassionate service. For centuries,
medicine was a profession attending to both body and spirit, with patients often viewing
physicians as “secular priests” who helped them grapple with the spiritual aspects of
their illness.7 As medical science emerged, contemporary physicians no longer saw it as
their role to care for patients’ spirits. In 1910, the Flexner report sought to put medical
education on a firm scientific footing by exposing its deficiencies.8 While the subsequent
grounding of medical education in science resulted in tremendous advances in medicine,
it also resulted in eliminating the humanistic and spiritual aspects of patient care. By the

AMA Journal of Ethics, July 2018 655

late twentieth century, there was a greater outcry from the public for more holistic and
spiritual approaches to medical care.1

While more physicians are beginning to recognize that spirituality is a core patient need
and has beneficial influences on health, some in the medical community think it
“conflicts” with medical science.9 A major challenge in incorporating spirituality as a
dimension of health stems from the difficulty in defining it. In attempting to define
spirituality, one is discussing ways in which people view the purpose of their existence.
Efforts have been made by consensus conferences on compassionate care to elucidate
this concept.10 According to the 2013 International Consensus Conference on Improving
the Spiritual Dimension of Whole Person Care, spirituality is defined as “A dynamic and
intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and
transcendence, and experience relationship to self, family, others, community, society,
nature, and the significant or sacred. Spirituality is expressed through beliefs, values,
traditions, and practices.”11 By this definition, spirituality is an inseparable aspect of
humanity.

As we have entered an era in which patients suffer longer, traditional medicine’s goals of
healing and relief from suffering become more pressing. As Egnew writes, “Suffering fills
the chasm of meaninglessness that opens when the patient’s previously held meaning
structures are destroyed.”4 Saving and prolonging life incur a duty to “accompany
patients on their illness journeys, to care for their souls as well as their bodies.”4 This
duty aligns with the World Health Assembly’s palliative care guidelines, which states that
all healthcare professionals have an ethical obligation to address all suffering of
patients—psychosocial and spiritual.12

George Washington University’s Spirituality and Health Course

The senior author (CP) recognized the need for addressing spirituality as part of whole
person care while a medical student at George Washington University. CP and colleagues
at George Washington University started the first fully integrated elective course on
spirituality and health in 1992 as a way to begin to broaden our understanding of
patients from a holistic viewpoint, and in 1996 spirituality became integrated into the
required GW School of Medicine curriculum. In collaboration with the Association of
American Medical Colleges (AAMC), we held a consensus conference in 1999 to develop
a definition of spirituality, learning objectives aimed at improving whole person care and
facilitating professional growth (see table 1), and methods for developing courses on
spirituality and health. This conference issued in a report published as part of the AAMC’s
Medical School Objectives Project (MSOP).13 Subsequently, in 2001, the George
Washington University started the first university-charted Institute for Spirituality and
Health (GWish).14

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Table 1. MSOP III Learning Objectives Relevant to Spirituality and Cultural
Issues
The ability to elicit a spiritual history
The ability to obtain a cultural history that elicits the patient’s cultural
identity, experiences and explanations of illness, self-selected health
practices, culturally relevant interpretations of social stress factors, and
availability of culturally relevant support systems
An understanding that the spiritual dimension of people’s lives is an avenue
for compassionate care giving
The ability to apply the understanding of a patient’s spirituality and cultural
beliefs and behaviors to appropriate clinical contexts (e.g., in prevention,
case formulation, treatment planning, challenging clinical situations)
Knowledge of research data on the impact of spirituality on health and on
health care outcomes, and on the impact of patients’ cultural identity,
beliefs, and practices on their health, access to and interactions with health
care providers, and health outcomes
An understanding of, and respect for, the role of clergy and other spiritual
leaders, and culturally-based healers and care providers, and how to
communicate and/or collaborate with them on behalf of patients’ physical
and/or spiritual needs
An understanding of their own spirituality and how it can be nurtured as
part of their professional growth, promotion of their well-being, and the
basis of their calling as a physician
Reprinted with permission of the Association of American Medical Colleges.13

The Evolution and Growth of Spirituality in Medicine Courses

The content and the basis of spirituality in medical courses have changed from 1992 to
the present. Initially, courses responded to patient need as demonstrated in surveys. For
example, McCord et al. found that 83% of patients in a family practice setting “wanted
physicians to ask about [their] spiritual beliefs in at least some circumstances.” Among
those who wanted to discuss spirituality, 87% indicated “the most important reason for
discussion was desire for physician-patient understanding.”15

As research demonstrated the relevance of spiritual and existential distress and

guidelines for physicians attending to all aspects of patient suffering were developed,
courses began to emphasize the clinical aspect of spirituality.10,16,17 These courses, which
became widespread, now teach patient need for spirituality, diagnosis of spiritual and
existential distress, and development of spiritual treatment plans. More recently,

AMA Journal of Ethics, July 2018 657

courses began to integrate the spirituality of the clinician as a way to help students
identify with their role as healers.18 These courses also started integrating spirituality as
a part of student wellness,19 particularly in response to the growing crisis of physician
burnout, depression, and suicide.20

From 1996 to 2008, the senior author (CP) and GWish led a medical school and residency
Spirituality and Health Curricular Awards program, which contributed to the increase in
the number of US medical schools incorporating spirituality in their curriculum from 13%
in 1994 to 90% by 2014 and to spirituality curricular integration in psychiatry and family
medicine residency programs.21-23 To date, a total of 49 medical schools have received
John Templeton Foundation funding for curricular development in spirituality and
health.24

Based on these courses, the National Initiative to Develop National Competencies in

Spirituality for Medical Education (NIDCSME), convened by GWish in 2009 through a
consensus process, established spirituality-related competency behaviors, teaching
methods, and assessment strategies for medical schools.25 The framework used was
based on the existing Accreditation Council for Graduate Medical Education (ACGME)
competencies.26 The concepts of compassionate presence—a subset of compassionate
care—and student wellness were determined to be essential to these courses.
“Presence” refers to the contemplative aspect of our relationship with patients. While
compassionate care can involve empathy, forming connections, helping patients with
issues, and being respectful and caring, presence calls upon a unique set of skills in which
the clinician moves to a more reflective and contemplative space with the patient.10,16,17
Accompaniment, discussed earlier, is the outgrowth of presence.

The NIDCSME recommendations led to the development of a national program

in professional development called GWish-Templeton Reflection Rounds (G-TRR). G-TRR
is a mentored small group program that “aims to integrate meaning, purpose and
connectedness into the continuum of medical education” by nurturing physicians’ inner
growth through an interdisciplinary reflection process.27 These features relate to
spirituality, broadly defined as finding meaning and purpose and experiencing
connectedness to the sacred. Of the 33 participating medical schools in the G-TRR, 11
reported teaching more than 60% of competency behaviors,25 with the highest
prevalence in the compassionate presence domain. However, there are also barriers to
implementing these behaviors in practice. Physicians’ most commonly cited barriers to
initiating a spiritual history have been lack of an adequate framework during the clinical
interview and perception of inability to offer time for such conversations.28 In many
ways, a spiritual history may not seem relevant in a routine appointment, but offering
the space through genuine care beyond a problem list may provide an opportunity to
heal in the most surprising of moments.

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Despite these initiatives, physicians and trainees struggle with integrating spirituality
into care, particularly into care near the end of life. In 2004, the National Consensus
Project (NCP) for Quality Palliative Care developed 8 required domains of care, including
spiritual, religious, and existential issues.29 In this document, assessment of patient
spirituality is required; however, there were no guidelines on how to assess patient
spirituality or how to choose the clinical team member who should make the
assessment. Thus, in 2009, Puchalski and Ferrell co-led another national consensus
conference that emphasized interprofessional spiritual care (with clinicians functioning
as generalist spiritual care professionals and trained chaplains as the experts on the care
team). The conference addressed regular assessment by all members of the health care
team and integration of spiritual issues into the medical plan as a fundamental
component of quality palliative care.17 The guidelines motivated by this conference
recognized spirituality not only as essential to care of the suffering but also as a
fundamental aspect of preventative health. Spiritually-centered compassionate care
should be key to any health delivery system.10

Last, the first global spiritual care train-the-trainer program—the Interprofessional

Spiritual Care Education Curriculum (ISPEC)—will be launched in July 2018, led by GWish
and the City of Hope in partnership with the Fetzer Institute.30 This training program for
teaching interprofessional spiritual care was developed by the senior author (CP), Betty
Ferrell from the City of Hope, and colleagues. The program contains a level 1 online
component and a more advanced level 2 leadership train-the-trainer component for
clinician-chaplain pairs of leaders to use at their clinical settings.

Based on the above consensus conferences, 22 years of curriculum development in US

medical schools, and the professional development program (G-TRR), the GWU
components for a spirituality and health curriculum fulfill both clinical and professional
development components (see table 2). The clinical component includes taking a spiritual
history, identifying patient spiritual resources, diagnosing spiritual or existential distress,
and integrating spirituality into the assessment and treatment plan of patients. These
objectives are intended to provide all medical students with training in how to address
the spiritual concerns of patients, especially those with chronic and serious illnesses.
Essential to this component is recognizing how to refer to and work with trained spiritual
care professionals such as chaplains. In G-TRR, students experience their own spirituality
in the context of their professional development as healers, as they reflect on themes of
accompaniment and presence.

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Table 2. Components of Spirituality and Health Curriculum at GWU

Patient care

Spiritual history
Spiritual distress diagnosis and treatment
Biopsychosocial spiritual assessment and treatment plan
Compassionate presence to persons’ suffering

Student/resident/clinician formation

Inner life focus

Meaning, purpose, call to serve
Authenticity
Compassionate presence—to self
Reproduced from C. Puchalski.31

Conclusion
Medical educators are increasingly recognizing the need to bring the art of
compassionate care back into the curriculum.32 We must move away from asking
whether spirituality should play a role in health care to examining ways this dominant
force already functions in health care today. Given that (1) spirituality is associated with
reduced mortality and risk for certain diseases,33 (2) there is a growing number of
patients with chronic conditions and suffering, and (3) physician burnout is increasing,20
addressing spirituality is both relevant and timely. Requiring spirituality as an integral
component of medical education would bring medicine closer to the World Health
Organization’s longstanding definition of health as “a state of complete physical, mental,
and social well-being and not merely the absence of disease or infirmity,”34 updated with
spirituality in the World Health Assembly’s palliative care resolution in 2014.12 We cannot
serve our patients well if we only focus on the physical aspects of their illness, and
neither can we rely on others on the team to take care of the psychosocial and spiritual
issues as ancillary luxuries. The core element of the healing relationship is our ability to
adequately address all the concerns of our patients and their families—psychosocial,
spiritual, existential, and physical—and to work in partnership with experts in each of
these domains. Anything less than this is both inadequate and unethical in meeting our
professional obligation to our patients and their families.

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Aparna Sajja, MD, is an internal medicine resident at Johns Hopkins Hospital in Baltimore
and a recent graduate of the George Washington University School of Medicine. She is
interested in the intersection between spirituality, religion, ethics, and medicine.

Christina Puchalski, MD, is the founder and director of the George Washington Institute
for Spirituality and Health (GWish) and a professor of medicine at the George Washington
University in Washington, DC. Board certified in palliative medicine and internal medicine,
she directs an interdisciplinary outpatient supportive and palliative care clinic and is a
medical hospice director. Her scholarship focuses on palliative care, interprofessional
spiritual care, and compassionate care as part of whole person health.

Citation
AMA J Ethics. 2018;20(7):E655-663

DOI
10.1001/amajethics.2018.655

Conflict of Interest Disclosure

The authors had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not
necessarily reflect the views and policies of the AMA.

Copyright 2018 American Medical Association. All rights reserved.

ISSN 2376-6980

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