Ben Frush, MD, was 3 years into medical school at the University of North Carolina when conversations with mentors about the intersection of theology and medical practice left him wanting more.
Frush, a Christian, determined that he needed more time and space to think about how his beliefs shaped him as a physician. He decided to take a year off of medical school and become a fellow at the Theology, Medicine, and Culture Initiative at Duke Divinity School.
"Physicians are taught implicitly and pretty powerfully that there's a stark division between the private and public," Frush told Medscape Medical News. "And if you have personal beliefs, leave them at the door when you don your white coat."
This conventional thinking feels reductive to Frush, whose moral intuition drove him to medicine because it was a way of serving others and caring for them in spaces of vulnerability and sickness. He didn't feel that one's faith, identity, or tradition should have to be left at the door.
"Since divinity school, I've been even more affirmed in my idea that faith can allow for a more fulfilling and flourishing professional life," said Frush, now an internal medicine-pediatrics resident at Vanderbilt University Medical Center in Nashville, Tennessee. "I also believe very firmly that in some tangible ways, it allows us to care for patients better."
There is data to support Frush's beliefs. A 2021 study found that medical students who consider themselves to be active participants of their religion — regardless of the faith they practice — may be at lower risk of developing burnout. And according to a review of studies on spirituality and medicine, "religious involvement and spirituality are associated with better health outcomes, including greater longevity, coping skills and health-related quality of life (even during terminal illness) and less anxiety, depression, and suicide."
Couple those findings with the fact that 65.2% of physicians report that they believe in God; 51.2% report themselves as religious and 24.8% spiritual; and 83% of patients actually want physicians to ask about their spiritual beliefs in at least some circumstances, and it begs the question as to why spiritual health is not treated as an essential component to a person's whole health.
Religion vs Spirituality
Howard Koh, MD, MPH, former US Assistant Secretary for Health in the Obama administration, has spoken and published at length on the subject of medicine and spirituality. He admits that a lot of people get turned off when they hear the word religion, which is why Koh emphasizes the importance of entering the conversation with a broader understanding of what is meant by spirituality. He points to a definition of spirituality that encompasses "ultimate meaning, purpose, and transcendence and in relationship with the significant or sacred."
"People discover what is meaningful or brings them a sense of purpose or connections to the significant and sacred in their own ways — in multiple ways," Koh told Medscape Medical News. "Sometimes it's formally through religious communities, but oftentimes it's informally through deep connections with family or friends, or even nature or music."
Koh, a professor of the Practice of Public Health Leadership at the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School in Boston, explains that health, religion, and spirituality are all part of what it is to be human for many people. "But over time, the way that people have been cared for has been broken up in such a fragmented way that currently most clinicians just overlook dimensions of spirituality when caring for patients, or when considering what health really means, or even when considering their own health," he said.
Koh predicts that a lot more attention will be paid to health, spirituality, and religion going forward, in part because the pandemic caused people to face a number of existential questions.
"During the time of COVID, issues of meaning and purpose are really front and center for a lot of people and these are very important themes," he said. With so many doctors getting ready to retire in the next 5 years because of exhaustion from COVID, Koh wonders if those who understand where their own spiritual support comes from can be re-energized quicker, or feel revitalized, or find a sense of support more than others who may not have that as a foundation.
Frush is clear that while his beliefs are the orienting framework of his life, he doesn't think anyone should prey upon a patient's vulnerability or try to proselytize to them. Nor does he believe that a physician should ever do anything against what is in the best interest of the patient, even if they believe their faith or religion calls them to do it — but this is often what conversations of faith and medicine turn to.
"Everything seems to boil down to praying with patients, abortion, and other controversial issues," Frush said. "And while some of those conversations are certainly important, what's much more compelling to me is what it means to practice medicine as a Christian. How does it affect the way you engage with patients?"
Frush explains how his faith helps him tend to difficult patients, especially when he's exhausted from a long night shift. "I've failed at this lots of times," he admits, "but if I have my wits about me, I take a step back and I think about Matthew [chapter] 25 where Jesus said, 'What you've done to the least of these, you've done unto me,' talking specifically about visiting people who are sick and in prisons."
Frush believes that taking a moment to reflect on the implications of that story prevents him from making medical judgment errors that could happen if he jumped to conclusions based on patient stereotypes. "Patients will benefit if I can step back and say, 'How do I care well for this patient in spite of all these barriers that are both systemic and the product of working at a job at night?' "
Should Medical School Focus on Spirituality?
Like Frush, Koh talks about how the church encouraged him to "live a life of purpose and service." While attending Yale College and Yale University School of Medicine, he recalls listening to the Rev. William Sloane Coffin, the chaplain at the time, preach on Sundays. Coffin would remind the medical students who were buried in a mountain of facts every day to work with intention and purpose. Koh recalls: "He would get up and say, 'Okay, you've got to ask yourself not just what are you doing, but why are you doing it? What's the goal here?' "
Koh and Coffin enjoyed a close friendship until his death in 2006 — a friendship Koh credits for shaping his successful career as a physician, public health advisor, and professor. "Having Rev. Coffin articulate those basic principles in his own unique way is something that's driven me my whole life," he said.
Koh and Frush were able to locate the spiritual guidance they sought, but many medical students might not. While 80% of US medical schools offer training in spiritual care, most students don't receive it because it's an elective. There is an increased focus on the biopsychosocial–spiritual model when assessing a patient's needs, but the intersection of faith and the practice of medicine is largely overlooked.
"Students aren't taught how to think through their own spiritual belief or spirituality and how that informs their care," said Frush. "They should think about what difference it makes that they are Jewish, Muslim, Buddhist, secular humanist, or whatever their faith tradition. What does that tradition say about what it means to care for the sick?"
Katy Moretz, MD, a pediatric neurologist with Memorial Health in Savannah, Georgia, doesn't think this kind of training is necessarily needed in medical school. Moretz was raised Presbyterian, attended Catholic school, and is a member of a church (though she hasn't attended in a few years). Moretz considers herself as "not very religious" and admittedly doesn't give much thought to how faith may inform her practice.
"What my beliefs are have nothing to do with how I treat my patients," she said. Like many physicians, Moretz would never pressure religion on anybody. And although she doesn't inquire about her patients' spirituality in her private practice, she does look for cues that a patient's faith might be important to them and responds accordingly.
"If religion comes up, it's usually in the hospital setting when there is a critical situation," she said. "It came up quite a few times when I covered adult neurology and was trying to help the families come to peace with end-of-life decision making." Moretz admits that sometimes saying, "It's in God's hands now," can take the burden off of their shoulders. "It's a measure of comfort," she said.
Spirituality as Part of the Whole Patient
But there's also evidence that many patients want their physician to inquire about their religious beliefs and in so doing could positively affect the patient–practitioner relationship.
Debbie Stremler, 59, said she's never had a doctor ask about her spirituality, but it would have had a real impact — first, as a young woman addicted to drugs, and second as a patient facing end-of-life care.
After stints at approximately 18 treatment centers, Stremler eventually got clean. "God changed everything about me," she said. A woman of deep faith, Stremler has overcome a number of medical issues throughout her adult life until she was admitted into the hospital 2 months ago, having difficulty breathing. Stremler's doctors diagnosed her with COPD and determined that the situation was very serious. They told her adult children that she might have just 3 months to live.
Stremler found it surprising that none of her physicians inquired about her faith or spirituality since it's an obvious part of her identity. "You could not meet me and not know I was a believer," she said with a laugh. When asked if she thinks it would have made a difference, Stremler replies, "I would have been so receptive. I would have loved that. But it comes down to the fact that we live in a world that is very confused spiritually."
Stremler finds her health journey sadly ironic. "When I was caught in my addiction and seeking opiates, I needed the same thing from my doctors then that I need today," she said, "and that is for doctors to talk with me about the health of my soul." She acknowledged that this will require some physicians to step into new territory and have conversations that might feel uncomfortable. "But in the end, I think doctors will find that it's more comfortable," Stremler said. "Because ultimately they're dealing with souls, not just a human body with arms and legs."
Stremler's take on the importance of spirituality echoes the words of the Rev. Coffin years earlier — words that Koh still quotes today. "He would say, 'Physicians shouldn't treat a patient like an uninteresting appendage to an interesting disease,'" Koh recalls. "Every patient can tell you that they feel absolutely dehumanized going through the healthcare system when the doctor is focusing on their disease and not them. Tending to their soul, their concerns about who they are, and how this is going to affect their well-being in the broadest sense."
It is why Stremler said that when hospice from a faith-based hospital came into her home, "God came in." The hospice workers asked about how she was doing spiritually, and if she had any questions about life or death. "They're vulnerable in a way that a regular doctor in a medical setting is not," she said. "Until we are willing to be vulnerable with one another, we will remain sick."
Stremler fully believes that her faith and health are connected, and that God and her church family have a profound impact on her well-being and the quality of her end-of-life experience. "I so believe that people of faith do better," she said.
Although Stremler's experience is anecdotal, Koh believes more robust research surrounding faith and medicine might be the catalyst needed to elevate the discussion out of informal conversation.
In 2013, Michael Balboni, PhD, ThM, MDiv, Tracy Balboni, MD, MPH, and Tyler VanderWeele, PhD, launched Harvard University's interfaculty Initiative on Health, Spirituality and Religion, of which Koh is a co-director.
According to the university's website, "the Initiative aims to be a research catalyst for an integrated model of spirituality, public health and patient care, one that fosters collaboration across Harvard University, and dialogue with spiritual communities." The program is oriented around the question: "How may religion and spirituality in concert with public health and the practice of medicine alleviate illness and promote human well-being?" The co-founders and team members have already conducted a number of studies and have published multiple articles based on this inquiry, driving interest.
For example, one study finds a strong link between regular religious service attendance and positive health outcomes. "When VanderWeele and his colleagues published that study, it made big news," said Koh. "It wasn't anecdotal. It was based on a study. This has the best science supporting it."
In answering the question posed by their article "Do Spirituality and Medicine Go Together?", authors and spouses Michael and Tracy Balboni conclude by saying "we must follow the evidence." And with more and more empirical research confirming what many people of faith have long experienced anecdotally, it's clearly worthy of conversation and further investigation.
"At the very least, these are issues that are hugely important to a vast majority of patients," said Koh, "and if you're going to be a good doctor who truly practices patient-centered care, you've got to be aware of this."
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Image 1: Dr Ben Frush
Image 2: Dr Howard Koh
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Cite this: Spirituality and Medicine: A Surprising Pairing - Medscape - Mar 21, 2022.