Whole Person Care in Medicine (and Beyond)
Addressing the spiritual in the day-to-day
Mill Creek, San Bernardino National Forest
*I attempt to minimize how much I write about myself in these posts because there are far more interesting and meaningful subjects to write about than me. However, I do think that there are some subjects that are so subjective that the best way I can write about them is through the use of myself as a case example. Whole person care in medicine seems to be one of those topics and I hope you will find this post helpful despite (and hopefully because of) the inclusion of my personal experience.
My understanding of whole person care: Holistic patient-centered care which encompasses all dimensions of a patient’s needs, including but not limited to spiritual and emotional needs, in addition to their physical concerns for which they are seeing a physician. I also think that whole-person care need not be restricted to the medical profession. Broadly, I think “whole person care” is just an expression of an understanding that considers all of a person’s dimensions. This may be just as applicable for a teacher or for a shopper talking with their grocer.
While my textbook definition has remained largely unchanged in my mind since the time I began my medical training, my ideal of its implementation has evolved substantially. I entered medicine primarily because I felt (and still do) that a physician is uniquely positioned to address the spiritual and emotional needs of individuals in addition to their physical needs. I was inspired by books like Gray Matter by neurosurgeon David Levy in which physicians described praying with patients and speaking with them about forgiveness. I saw the physician as both a physical healer and a chaplain, knowing that many of those with spiritual questions would never see a chaplain. Additionally, medical problems, especially crises or terminal diagnoses, tend to prompt serious spiritual reflection and often persons are “looking for answers” that extend beyond the physical when they see a physician.
Upon entering medical school, I was struck by the vulnerability of the patients I met. Despite being a still-wet-behind-the-ears first-year medical student, there was a difference in the power I wielded as a member of the medical community and that of my patient. Donned in the bright new vestments of my profession, namely a stethoscope and a short white coat, I was a representative of the medical establishment and all the good (and bad things) for which it stood. My patients did not focus on the length of my white coat or my anxiously-held notebook and view me as the student I was. They saw a member of their medical team and in many of their minds prior to my introduction, I was a physician. Even after my introduction as a student, they cared about my opinion. Additionally, a physician’s power could easily be abused and the position of doctor and the patient’s sick role could be leveraged for the physician’s personal gain or agenda. There was a lot more nuance to this whole-person care thing than what I had naively once assumed.
A few experiences with a group that taught medical students how to practice whole-person care galvanized my initial impressions. In addition to the inspiring experiences I had as part of this group, one day I was asked to download an app that was effectively a religious tract. I was to go to the oncology unit with phone in hand and share the gospel with a patient I had not previously met (“Lord willing”), using God’s guidance as I selected a patient room. When I introduced myself to the patient, I was to make clear that I was not a member of the patient’s treating team but instead wanted to talk with them about their experience in the hospital.
The instructions were given gently and with encouragement to follow God’s leading and discernment about whether it would be helpful to share the tract. I spent that afternoon discussing the ethics of this task with a senior medical student and I ultimately declined to participate.
Writing about this years later I still feel uncomfortable with this idea. I cannot justify this practice of proselytizing in my work. It is grotesque to go to a cancer floor with a religious tract in hand as a medical professional with the hope of converting a patient. In my mind, there are several glaring issues with this practice:
I would be using my patient’s medical illness as leverage to proclaim my own religious/spiritual beliefs
I would be proselytizing without considering the ramifications of demolishing someone’s pre-existing philosophical/theological framework and associated sources of support and community
Most importantly, the act of proselytizing would be grounded in my own needs rather than those of the patient, akin to knocking on stranger’s doors.
When a patient provides informed consent for treatment, it is my duty as physician to discuss all reasonable possibilities and therapies or interventions that may be indicated as well as their risks. If attempting to convert my patient to a specific faith were part of my routine practice of medicine, it would be unethical to engage in this practice without first discussing my intentions openly with my patient as I would any other intervention
This feels egregious. If my plumber gave me a religious pamphlet under the pretense of fixing my toilet I would be irritated and I would probably find a different plumber. How is a medical provider any different?
The knee-jerk response is to not broach spirituality with patients at all for fear of violating their trust or otherwise rupturing the therapeutic relationship. However, people aren’t quite that simple. Research done by Michael and Tracy Balboni out of Harvard (husband-wife theologian and hematologist/oncologist duo) as reported in their book Hostility to Hospitality: Spirituality and Professional Socialization within Medicine has found that actually a majority of patients not only want their doctors to talk about spiritual matters but would even like their doctors to pray with them. Most patients appreciate talking with their physician about spirituality and have their spirituality be considered in their medical care. In fact, in their research there were times when a member of a patient’s medical care team such as a nurse or physician was able to positively impact medical care of the patient through addressing spiritual needs, especially in the realm of end-of-life care.
So on one hand, there are numerous ethical landmines on the field of whole-person care and on the other I have empirical evidence that suggests most of my patients would like me to attempt to navigate that minefield because it is really important to their care.
While there are many responses to this quandary, I have found two guiding principles to be quite helpful in navigating spiritual care with my own patients:
Humility and Allocentrism
Although I have data on schizophrenia response rates to antipsychotic medications or stroke outcomes after receiving tissue plasminogen activator, I don’t have the same sort of data on questions of faith. We don’t have randomized controlled trials investigating the problem of evil or the origin of the universe and I’m not sure where we’d even begin to investigate those questions. I do have specific spiritual and religious beliefs, but I interact with them differently than I do with recommendations to get my yearly flu vaccine.
However, these questions are integral to human existence and nearly all persons wrestle with them. And most of us hunger for meaning and many long to connect with Someone or Something that transcends our own existence. And despite my many doubts and uncertainties, I feel I have connected with Someone outside of myself, namely the person of Jesus. If someone is genuinely searching for answers and I feel I have found some, would it not be appropriate in some circumstances to share those “answers” with them in a meek and transparent way?
If a patient mentions that their faith is important to them or if when I ask about their sources of strength they mention faith/spirituality, then I will often follow that up with curiosity and genuineness. I ask them about their relationship with their beliefs and if they believe in God, what that relationship is like for them. If they are an atheist or agnostic, do they have a community of like-minded individuals who support them and are there other sources of transcendence in their life? If at some point in our conversation I get the sense that my patient is searching for existential answers or is looking for spiritual support, then I might even offer to pray with them. However, I only offer prayer as a means of supporting them, not of advancing my own beliefs. I often ask by saying something like, “You know, I am a praying man and at times I find prayer helps when many other things do not. Would it be at all helpful if I prayed with you?” If they say “no” (and this has rarely happened), then I thank them for telling me so and look to other sources of strength that I might be able to utilize to support my patient. If they give me permission to pray, then I do so quietly and as my patient’s equal before God.
When I was beginning my medical training, on several occasions I entered patient’s rooms intending to pray with them. I regret that. These encounters went poorly, largely because the offer of prayer was not in response to an expressed need by my patient, rather my own needs. I wouldn’t begin all patient interviews with the intention of starting an antidepressant medication or antibiotic. How is spiritual care any different?
While my practice of whole person care continues to mature, I have found that the judicious use of it has enriched my work as a physician and has led to many opportunities for connection and compassion with my patients. Many of the patients with whom I pray often remark “You know, a doctor has never prayed with me before; thank you so much…” or some variation on that theme. Often the prayer moves my patient or their loved one to tears and they begin to express the difficulty of their current situation. When practiced with the patient’s best interests at its center, spiritual care is a sacred experience. Loud emergency department hallways or quiet medical wings are briefly transformed into holy ground. The Kingdom of God becomes palpable, if only for an instant, and the physician becomes a fellow sojourner with their patient along the road of life, equals while they both journey with God.
Thoughtful and very well written. Thank you for your experience.
What a good way to start my day by reading this thought-provoking post. Thank you!