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Is religion good for your health? What is spiritual health care? How is spirituality related to health? Why is spirituality important in health care? Is there a relationship between spirituality and health?

Our guest, Christina Puchalski, MD, professor of medicine and executive director of the George Washington Institute for Spirituality & Health, discusses the integration of spirituality into health care and shares her journey in developing medical school curriculum on spiritual care for patient health and well-being. AMA Chief Experience Officer Todd Unger hosts.

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Speaker

• Christina Puchalski, MD, professor of medicine and executive director, George Washington Institute for Spirituality & Health

Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about spirituality and health care. Our guest today is Dr. Christina Puchalski, a professor of medicine and executive director of the George Washington Institute for Spirituality and Health in Washington, DC. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Puchalski, welcome. 

Dr. Puchalski: Yeah, thank you for having me. I'm excited to talk about this work with you. 

Unger: Well, this is certainly something we've never covered before on the AMA Update. And it's great to have an international expert on this topic and a leader in the movement to integrate spirituality into health care, probably not something that everybody knows out there. So why don't you just start by giving us a little bit of background on yourself and your work? 

Dr. Puchalski: So my name is Christina Puchalski. I'm a physician and a professor of medicine at George Washington University. I was inspired, actually, as a medical student to look into the relationship between spirituality and health and to develop an elective, an elective for our medical school. 

So I was able to do that with the help of some very progressive faculty who were interested in this. And we have this curriculum to date at George Washington University. Since then, and with gratitude to the John Templeton Foundation, we've been able to work with many medical schools around the country to develop curricula. And then beyond that, we moved from curricula to spiritual care itself. 

How do we practice spiritual care as clinicians? And our vision, my vision in starting the George Washington Institute for Spirituality and Health was to develop models, education, training, clinical guidelines where clinicians, doctors, nurses and others address the spiritual health of patients as part of whole person care, working with board-certified health care chaplains as well as other spiritual care experts. 

Unger: Now, you really kind of developed this field. Am I understanding that correctly? 

Dr. Puchalski: Yes, but with lots of other people. I enjoy partnering with people. I learn from others. So I probably would need to take a whole day to thank everybody that's been part of this. But yes, I've taken the lead in it. And that's been a privilege and an honor, but there have been so many others. 

Dr. Betty Farrell, who is a leading nurse researcher at City of Hope, has been a partner. Many chaplains, Reverend Trace Haythorn, Anne Vander Hoek, others from U.S. and globally, and social workers and others who've been partners, I want to acknowledge their presence and their impact in being able to truly develop this as not just a field for physicians, but for nurses, for social workers and chaplains, and how we can provide whole person care, the biopsychosocial spiritual model together.

Unger: Now, just for clarification, when you say spirituality, do you mean religion? Is this something broader than that? 

Dr. Puchalski: Yeah, so we held two consensus conferences, one in the United States—and that was in the early part of this century—and then in Geneva, Switzerland, where we brought people from different parts of the world to have more of a global perspective. And our first task was exactly what you brought up. What is it? Is it religion?

When I first started this, there was a lot of caution from my colleagues around introducing "religion" into the curriculum, even though there is quite a bit of data that for people who are religious, it can impact their health. But there's also data that people who are spiritual. And we're seeing more and more of this, especially now with the data coming out on our population identifying more as spiritual, defined as meaning and purpose and connectedness. 

So the development of a definition was a key part of developing this field. And the definition briefly is the search for meaning, purpose and transcendence. So transcendence can be anything people see as outside of themselves. It can be theistic. It can be spiritual in other ways. It can be nature, et cetera, so meaning, purpose and connectedness, that sense of connectedness to a community. 

And again, that might be nature. It could be other people. It could be a faith-based community. It could be a spiritual community. It could be family. In a lot of our surveys, we find that people are identifying in many different ways of what that spiritual community is. 

And then it needs to be addressed. Research needs to be done to look at how spirituality is impacted. So it can be measured as how people understand spirituality in their life and what impact it may have on their health and well-being. 

Unger: I think that's really important context. And thank you for sharing that. And let's just get into what you were talking about right now, which is, how can spirituality affect health? And you talked about data. What's the evidence show? 

Dr. Puchalski: So two important papers—and I was privileged to be part of this—that came out of Harvard. One had to do with the ... what is the evidence that we have—using the strictest criteria of evidence, of scientific evidence—so what's called the Cochrane criteria—what is the evidence that we have that spirituality can impact health or health care decision making? 

And picking just those high-level studies, we found that spirituality and/or religious beliefs can impact practices as well, can impact a person's health. It can be the way that they cope with their illness. It can be the way that they understand their illness. And this is particularly relevant in serious and chronic illness, but also across all of health. 

So when I think of many of my patients—and again, changing the details of the patients. But I've had patients who identified as spiritual but not religious and who were struggling with meaning and purpose, and that when I asked about their spirituality, not really spiritual, what gives you meaning and purpose? I don't have that right now in my life. 

And it makes me flash back to what, five years ago now when COVID started. How many of us experienced that same thing of lack of meaning and purpose? And that can be negatively correlated with well-being. So conversely, spirituality can help us with overall well-being, positive mental attitude, et cetera. 

Unger: Now, I'm really interested in the answer to this question, which is when you talk with physicians about integrating spirituality into health care, number one, what's their reaction to that? Because there are about a thousand other things we're asking them to think about in providing health care. And second is, are they aware of these types of benefits that you're talking about? 

Dr. Puchalski: So we have a very, very interesting initiative going on now. It's our 10-year vision on how to advance this field of interprofessional spiritual care. So I'm going to answer your question by saying that so many people are interested in this. 

The initiative is based on forming partnerships. So we have people from around the world that are doing work now in this area, and we're working closely with them. Our second aim is to teach the workforce, being not just physicians, but all clinicians, in conjunction with chaplains. So clinicians are asked to bring a chaplain colleague and attend these courses. Our courses are very well received. 

Since we've started doing this work where we started teaching actively, we've trained almost a thousand people in this area from around the world, not just in the U.S. Predominantly U.S., but in other countries as well. So I would have to say there's a tremendous interest in this. 

Now, where is maybe the struggle, if you will, and why we are developing these models is that in today's health care system, as it's becoming more corporatized and physicians in particular, clinicians as well have less time with patients, I am hearing anecdotally from our attendees as well as my colleagues is that when you can establish a relationship with a patient where it's a relationship of trust, people are more likely to share really what's going on with them. 

And that's what this domain does. That's why it's such an important part of whole person care, because it indicates to us and to our patients even more so that when I ask, tell me, are you spiritual, is that something important to you, how does it influence your health care decision making, what's the spiritual community to you, that really recenters the conversation on, they're interested in me as a whole person, not just in my blood pressure or in my diabetes. 

Also, when people are suffering, spiritual distress is a real element. And it's been defined by the NCCN guidelines, Cancer Comprehensive Network guidelines, as well as in our consensus conferences. Spiritual distress is significantly high in many of our studies. It's more than 55% to 60% incidence of spiritual distress in the various populations of patients that have been involved. That's a high number. 

So the distress, the lack of meaning of purpose, lack of connectedness, that needs to be addressed. So I would say back in the '90s, when we recognized in palliative care that we had to address pain management, and that became required, I would like to see addressing spiritual distress and spiritual health as being required. And that's where a lot of clinicians are interested in being able to know how to do this. 

Unger: Very interesting analogy. You mentioned your 10-year vision. Talk to us a little bit about the role that spirituality is playing in health care today and where you would like to see that at the end of your 10-year vision. 

Dr. Puchalski: Great question. That's a great question. Certainly, since I started this, it's tremendous. I am moved every time I get an email or I'm in a phone call with someone who really wants to do this how much interest there is. 

But we have a ways to go. So there are spiritual histories. I developed a spiritual history tool called FICA that is integrated in Epic. But being integrated and using it are two different things. 

So we're finding more and more people are interested and are addressing it and are integrating it into care. But I would like to actually see this at the public health level. I would actually like to see spiritual health as an absolutely required domain, not just the fourth domain of whole person care, but actually, almost the essential one. 

Because if we approach—I think of the clinical space. When I see my patients, when I walk into the room, to me—and these are my words—that's sacred space. So I pause. I take a breath before entering into this space with the patient. 

I want to be fully present to them. I don't want to be distracted with computers or timelines or needing to move on. I want to be fully present for the time that I have. That is the beginning of spiritual care. So that breath is my reminder of what my call is to serve my patients and to be present for whatever might be there. 

And sometimes the visit is pretty much—my blood pressure. I'm following up on my blood pressure. But it might turn into, it's really high. It's been really high lately. What's going on in your life? Well, I'm stressed, so we'll start talking about stress. And you told me a few months ago that you used to meditate. Are you doing that? No. So then we integrate that. 

Or it could be a very serious spiritual distress. I had a patient who I could tell something was wrong. And we went through the physical, the emotional, the social in those areas. But I knew there was something else, and I actually wouldn't let him go. 

I said, I know there's something. Just tell me what's going on inside. And I sat there in silence, held that space. And he took a deep breath and said, I'm just trying to come to terms with never having hope again. I'm trying to come to terms with never having hope again. 

That is profound, and that requires our attention. And that's why I'm passionate. Because if we're not addressing spiritual distress, we are potentially causing harm to patients, at least not getting them the help that they need. 

So more and more of my clinician colleagues are passionate. I was on a call earlier today with a chaplain who's developing a standardized note that chaplains can use. We need more chaplains in health care. We need more chaplains in the hospital but in outpatient settings as well, because we as generalists can only go so far. 

I wish at that moment that I had a chaplain next door where I could say, listen, why don't we go over and see my colleague? My colleague, he'll be able to talk to you more about this. And I'll follow up with you on that deep sense of loneliness at our next visit. That's the way I'd like to see things. We're getting there, though. 

Unger: Gosh, that story is just so moving. And obviously, the answer to that question is not something they teach you in medical school. So there's a lot for physicians to learn. And we'll look forward to the resources that you provide. Dr. Puchalski, talk to us a little bit about how the AMA has been working with you on this in the realm of policy. 

Dr. Puchalski: Really grateful to the AMA. So just briefly, I started with the Association of American Medical Colleges, AAMC. And we did a consensus conference with them where we developed a definition, guidelines for teaching, et cetera. 

Many years later, when I was a physician having to take these exams, I noticed there were ethics questions, but nothing on spirituality. So I asked my colleagues there, and they said, well, that will take a resolution through AMA. 

So about 20 years later, I managed to have these amazing colleagues, Dr. Steven Mandel, Dr. Gary Gaddis, Dean Alma Littles and Rabbi Igael Gurin-Malous, who just appeared at a conference where I spoke. And we managed, through their passion, to be able to have a group at the Academic Physician Section, which I joined at the AMA, proposed a resolution. In this past June of last year, it was passed. 

And what does that resolution say? That patients should have access to spiritual care, all patients, and that the AMA recommended curricula in spirituality and health across the continuum, from medical school on to practicing physicians, which supports so much of the work that we at GWish and others are doing. So very grateful, because that resolution, I believe, is going to be the turning point for getting to the level, the hope I have, that spirituality and spiritual health is a truly equal domain of care. 

Unger: Well, Dr. Puchalski, that's just such an excellent example of how getting involved in the AMA and organized medicine can have a huge impact on patients. And the story you told is just so moving. And clearly, there's no answer to a question like the one that you talked about coming from medical school. So your resources, your thinking and the work that you're doing right now are going to be so valuable. 

Thank you so much for joining us and sharing all these insights. If you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/join. 

That wraps up today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care. 

Dr. Puchalski: Thank you very much. I really appreciated the conversation. 

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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