The Soul of Medicine: Spiritual Perspectives and Clinical Practice

14. Teaching and Learning at the Interface of Medicine and Spirituality

CHAPTER FOURTEEN Teaching and Learning at the Interface of Medicine and Spirituality Marta D. Herschkopf, M.St., M.D. As the preceding chapters indicate, interest in the traditionally important role of spirituality in medicine waned with the 20th-century development of a scientific approach to medicine and scientific dominance of the biomedical model. This chapter explores the recent resurgence of interest in spirituality in medicine , primarily at the level of medical school training. Historically, medical school training has been a critical force in determining the type of practitioner that physicians become. Highly regulated, it institutionalizes social values and attitudes in the form of the core competencies demanded of every practicing U.S. physician. While the role of spirituality in individual practices naturally reflects personality, specialty, patient population , informal learning experiences, and other variables, there is a growing consensus that all physicians would benefit from a minimal level of what might be termed spiritual competence, to serve their patients’ needs as well as possibly their own. After reviewing 20th-century medical education and the educational reform movements that anticipated the reintroduction of spirituality, I discuss what has come to be a movement toward spirituality in medicine, identifying 238 Implications and Applications its supporting institutions and advocates, including Christina Puchalski, of the George Washington Institute for Spirituality and Health (GWish). I then use the historical development of the Harvard Medical School curriculum as an example of one attempt to incorporate spirituality into formal medical education , as well as the challenges encountered in doing so. Historical Considerations Modern U.S. medical education began with the Flexner revolution, a series of reforms that standardized admissions requirements and curricula for American medical schools. Abraham Flexner, headmaster of a private high school in the Midwest, was appointed by the Carnegie Foundation for the Advancement of Teaching to survey the contemporary state of medical education. His report, Medical Education in the United States and Canada, published in 1910, thrust the need for reform into the public sphere. Flexner’s report criticized the lax admissions requirements and minimal training offered by U.S. medical schools. Many schools would certify any applicant who could afford their fees as a licensed physician if the applicant merely attended a few months of lectures. Through the reforming efforts of Flexner and others, by the end of the 1920s medical schools had developed stringent admissions requirements as well as a four-year curriculum divided into preclinical and clinical years, with required instruction in basic sciences and clinical clerkship experience (Ludmerer 1999, pp. 3–6). The first major changes to follow Flexner’s revolution were a series of experimental educational programs in “comprehensive medicine” developed in the 1940s and 1950s. The corpus of medical knowledge had grown so exponentially after World War II that increasing specialization was becoming necessary to maintain competence. As a result, medical school faculties became concerned that their students were losing sight of the psychosocial and environmental factors that were as important to understanding and treating patients as the scientific details. Particularly worried that the physician-patient relationship was suffering, Cornell and the University of Colorado introduced new courses for fourth-year students in the early 1950s, and Case Western Reserve attempted a revision of its entire curriculum. These reforms emphasized environmental and preventive medicine as well as communication skills. Ultimately , however, they were discontinued because of budgetary concerns and a lack of philosophical consensus (Kendall and Reader 1988). Teaching and Learning at the Interface 239 The next major change began in the late 1970s, when it became increasingly acknowledged that medical education in particular, and the health care system in general, had developed a number of fundamental flaws. Among these was the sense that modern mainstream medicine had, for lack of a better term, “lost its soul.” While soaring costs and systemic barriers to care were part of the problem, the public also increasingly began to express dissatisfaction with the quality of the physician encounter itself. Patients felt that their doctors did not listen to them, did not understand them, and most important, seemed uninterested in them as people. Instead, doctors focused on laboratory results and procedures. Physicians began to recognize that, despite excellent scientific training, they were often unable to satisfy their patients’ concerns. Summarizing these attitudes in a 1977 article in Science, psychiatrist George Engel scathingly assessed the current biomedical model as “no longer adequate for the scientific tasks and social responsibilities of . . . medicine” (p...