Spirituality in Care: The Real Emergency in Medicine?

By Alina Lianne Wilson

Tears come to Dr. Bruce Feldstein’s eyes as he delivers the news. He adjusts the position of the stethoscope that hangs around his neck. He breathes deeply in an attempt to school his face into a neutral expression. 

His patient furrows her brow and nods. Dr. Feldstein speaks softly as he delivers her prognosis. The patient's breathing becomes choppier, and she digs her nails into her palms. When Dr. Feldstein pauses to ask if she has any questions, she collapses into herself. Tears stream down her face. Her family moves to hug her, to console her, but they too seem distraught. 

Dr. Feldstein grasps for the professionalism expected of him as an emergency room physician. He rushes out the rest of his assessment. He feels relief when the family has no follow-up questions. After 30 seconds of trying and failing to temper his own emotions while watching the family’s reaction, Feldstein feels tears well up in his eyes. He chokes back his own sobs and quickly says, “I’ll ask the nurse to come and be with you.” He turns on his heel and leaves the room. Not until he pulls the tan curtain into place behind him does he allow himself to cry. 

As an emergency room physician, Dr. Feldstein has experienced the conflict between professional composure and his own emotions many times over the years. He remembers learning that crying detracted from the doctor-patient relationship while in medical school. He was taught to avoid these emotional displays at any cost. Decades later, this concept of emotional detachment as professionalism continues to dominate the medical field. A 2009 study from Harvard Medical School found that about half of medical interns regarded crying in the work setting as a sign of weakness. The surveyed participants strongly felt that a crying physician is not fit for the job. Yet the study also revealed that 69 percent of medical students and 74 percent of interns said they had cried at least once in a medical setting. As crying becomes increasingly common for young physicians, questions of medical professionality emerge. Ultimately, the controversy over physician emotional displays forces us to engage with the critical question: What does it mean to be a physician? Dr. Feldstein had been mulling this question in his head when he sustained a career-ending injury. 

In August 1997, Dr. Feldstein felt an excruciating pain in his low back as he helped his friend lift a dresser. He made to stand and came up crooked, in the shape of a “three-dimensional question mark.” As he lay in bed that night, he felt deep in his bones that this was the beginning of the end of his career in emergency medicine. 

He stares at the MRI scan a few days later. His eyes linger on his bulging disks. L4-5, L5-S1. The radiologist in front of him sighs and says, “Okay, Doc. It’s time to consider slowing down at work.” 

When Dr. Feldstein recovered, he cut back his hours to part-time. Yet, the feeling that it was time for him to move on from emergency medicine remained. His mind often wandered to an encounter he had with a patient four months before his injury. 

At the time, Dr. Feldstein worked as a senior physician in a busy Emergency Department. During a morning shift, he walked into the room of Mrs. Martinez, an 86-year-old Hispanic woman with a history of colon cancer and recurrent nausea, vomiting, and dehydration. The nurses had rehydrated her, and she was on the cusp of discharge. Dr. Feldstein had just met her when she had entered the Emergency Department a few days ago, so he planned to let her long-time oncologist break the news: her head CT scan showed that her cancer cells had spread to her brain.

As Dr. Feldstein entered the room to discharge her, she asked him a question that stopped him in his tracks. “Doctor, what was the result of my brain test?” He froze slightly before telling her gently that the cancer had reached her brain. Mrs. Martinez turned pale, looked away, and declared that she had been handed a death sentence. 

At that moment, Dr. Feldstein acutely felt the limits of his role as a medical doctor. He had been trained to diagnose and cure. He had spent years studying organ systems and the diseases that afflicted them. Yet he had no treatments or medications to offer her. Upon Mrs. Martinez’s imminent release from the emergency department, her care and treatment would be left to her oncologist. His interaction with this patient would only last for the few minutes before her release from the ED. What was his role as her doctor in this moment? 

He noticed a cross hanging on a silver chain at the base of her throat. And suddenly he knew what he needed to do, although he had never done it before. 

He asked if she would like to pray. 

When she nodded, he gently took her hand and lowered himself onto the black stool beside her gurney. After sensing that she was waiting for him, he hesitantly began, “Oh, God, You Who are the Great Healer.” He stumbled at first but somehow found the right words, drawing upon his Jewish spirituality to deliver words of comfort to the Catholic woman beside him. After his improvised prayer, Mrs. Martinez grasped his hand tightly and recited the Lord’s Prayer in Spanish. She then looked deeply into his eyes and gave him a watery smile, “Thank you, doctor.” He nodded as tears filled his eyes. He didn’t wipe them away. 

Months later, Dr. Feldstein took his last shift as an emergency department physician. His winding path led him in a seemingly vastly different direction: chaplaincy. Walking into the Stanford Medical Center Emergency Department with a badge saying “Bruce Feldstein. Chaplain,” he felt like he was coming home. 

When physicians leave the room, chaplains enter. In our 15-minute-per patient-model for health care, physicians and nurses simply do not have the time or resources to sit with their patients through the most difficult moments. Physicians provide medical care by giving diagnoses, sewing wounds, and handing patients treatment lists. Chaplains help patients of all (or no) faith backgrounds find meaning in their illnesses through spiritual care. 

Originally, religion and medicine were tightly intertwined. Religious organizations founded many of the first hospitals. For centuries, retired clergy provided spiritual care for hospitalized patients in religiously affiliated health care systems. Only in the 1920s did chaplains emerge as a distinct subset of the clergy with their own training requirements. After 1925, Protestant clergy members first founded clinical pastoral education (CPE) programs to provide further training to spiritual care professionals. Today, the majority of chaplains have completed a bachelor's degree, a theological degree, and CPE training. 

In the past two decades, nearly a quarter of theological schools have started degree programs for aspiring chaplains. Even as religious congregations have slowly declined in the United States over the past 20 years, the number of people engaging with chaplains and spiritual-care providers has been steadily rising. In a society afraid of death and illness, chaplains quietly support the dying and their loved ones through the hardest parts of being human. 

Father Hector pulls the curtain back and steps into the room. He comes face to face with Mary Simmons, a woman in her thirties. Pulmonary hypertension is devastating her lungs, and a lung transplant is her only chance at survival. In minutes, nurses will load her onto a gurney and take her into the operating room.

Crammed into the small room are nearly ten people: sisters, brothers, parents, and friends. Father Hector asks, “So what’s your situation?” He nods and listens as Mary and her family fill him in. When they finish, he asks the patient’s loved ones to gather in a circle. They push stools out of the way and make one as best they can. They reach out to hold each other’s hands. “Let’s all share one thing we appreciate about Mary. How do we love her? What do we hope for her? If we have any regrets let’s mention those too,” Father Hector says. 

When the last person finishes sharing, Father Hector speaks again, “Let’s have a prayer.” Father Hector begins to lead the prayer, and every family member has tears flowing from their eyes. Then Father Hector himself has tears spilling out over his cheeks, silently coming down over his nose. 

This display of tears might elicit feelings of discomfort in some outside observers. But the family members gaze at Father Hector adoringly. When he finishes, he reverently makes the sign of the cross. Even as Father Hector stands wordless with a bowed head, his actions speak for him. I am here with you. I am here for each of you in this moment. 

As a patient in our healthcare system, it is easy to feel as if your humanity is being intentionally ignored. In preparation for being seen by the doctor, you are stripped of your clothing and reoutfitted in a personality-less gown. You are weighed. You are poked, prodded, and pressed against. At some point in a visit, a patient’s personhood takes a backseat to their identity as a patient. The patient becomes a machine to be examined by an overworked mechanic. Is the lymphatic system working? Is the immune system online? Do you need an oil change? 

Spiritual care humanizes an increasingly sterile and disorienting health care experience. Chaplains may be a catalyst of this change, but widespread change becomes possible when physicians join them. Doctors such as John Peteet at Harvard Medical School have been injecting spirituality into their practice for decades. 

On a Friday evening, a male cancer patient sits down across from Dr. John Peteet at the outpatient clinic of Brigham and Women’s Hospital. The man has cancer. He was once spry and full of energy, but now he’s constantly fatigued from the battle his body is fighting. Other psychiatrists might go ahead and prescribe this gentleman Modafilin, a stimulant to keep his energy up throughout the day. Dr. Peteet asks him how long it’s been since he went to church. In response, the man visibly lets out a breath and smiles as if a weight has been lifted from his shoulders. “My religion is the most important thing to me,” he declares with a smile. He states that his religious beliefs have given him the strength to get through his illness, but none of his providers have ever asked him about it.

Until Dr. Peteet. 

Dr. Peteet–a psychiatrist who has been teaching courses on spirituality in medicine at Harvard for over 20 years–is quick to admit that not everyone directly connects with the questions he asks about meaning and spirituality. He’s even had a few patients who were suspicious of him because of his research into religion and healing. He recalls more than a few patients sitting nervously on the edge of their seats as if waiting for him to deliver an unwanted sermon. 

“[Connecting with patients’ religion as a means to support their healing] is not something that happens every day,” Dr. Peteet admits, “but when it does happen, it’s an incredibly rewarding thing to tap into.” 

Either way, in the moments when Dr. Peteet asks about a patient’s faith, he gives them permission to exist in his clinic as more than just a list of symptoms or disordered behaviors. He encourages them to bring their full humanity to their sessions. And because of this, he has the opportunity to build truly meaningful relationships with his patients. 

Dr. Peteet and other distinguished physicians are changing the way that medicine is taught and practiced. As a result, the new generation of doctors has access to a more compassionate, open-minded medical field. Medical schools are finally recognizing that acknowledging patient religious beliefs is integral to whole-patient care. About half of medical schools currently offer courses explicitly on spirituality and health, and about 90% indicate that they include the topic of spirituality in health in other courses, such as ethics courses. 

Trailblazers like Dr. Feldstein are challenging medicine’s traditional definition of professionalism and patient care. In the required seminar that he co-teaches at Stanford University School of Medicine, Feldstein teaches medical students to shift their view of the doctor-patient relationship, from one based on the patient’s chief complaint to their chief concern. A patient encounter Dr. Feldstein had five years into his career as an emergency medicine physician exemplifies this distinction. 

Dr. Feldstein pulled the curtain back and entered the patient room. “So what seems to be the problem?” The patient placed her hand over her heart and described the chest pain that had been plaguing her for the past week. After asking a few diagnostic questions, Dr. Feldstein said to her, “You seem worried. What is it about the pain that really matters to you?” 

She paused. “It’s the kind of pain my uncle said he had before his heart attack.” Dr. Feldstein lowered himself to sit on a stool across from the patient and continued the visit in the context of what was meaningful for the patient.

Addressing a chief complaint is about providing the correct medicine or treatment. On the other hand, the concept of a chief concern encourages physicians to take care of what really matters for each patient. 

Dr. Feldstein hopes to re-establish the human connection between physicians and patients. He teaches his medical students a different way to conceive of medicine–from encouraging them to allow themselves to show emotion when dealing with family members to reminding them to ask what matters most to the patient and why. With this deeper connection to and understanding of the patient, physicians can use evidence-based medicine to care for the patient as a human, and not just as a set of malfunctioning systems. 

“That’s one of the differences between providing spiritual care and medical care. Medical care is oriented toward curing and fixing,” says Dr. Feldstein. “When doctors are coming through and poking here and looking there, they're missing the part of connecting the person back with who they are. When I come into the room that's what I aim to do.” 

Preparing himself for his rounds at Stanford Hospital, Dr. Feldstein wears a shirt and vest, rather than a white coat. With a yarmulke on his head, he steps to a sink. He turns on the faucet and starts to say a prayer in Hebrew. As the water runs over his hands, he imagines the stress of the day flowing from his hands into the sink. He completes his ritual with a blessing: I lift up my hands. May I be of service. 

As the attending physician shuts the curtain behind her, she nods at Dr. Feldstein. After taking a breath, he enters the room.

---

Works Consulted List 

Spirituality in medical school curricula: findings from a national survey. 

https://pubmed.ncbi.nlm.nih.gov/21391410/ 

Crying: experiences and attitudes of third-year medical students and interns. https://pubmed.ncbi.nlm.nih.gov/20183336/ 

Training Healthcare Chaplains: Yesterday, Today, and Tomorrow 

https://chaplaincyinnovation.org/wp-content/uploads/2019/12/Cadge-et-al-2019.pdf 

Rise of the Chaplains 

https://www.theatlantic.com/ideas/archive/2020/05/why-americans-are-turning-chaplains-during pandemic/611767/ 

Spirituality and health in the curricula of medical schools in Brazil 

https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-12-78 

Doctor-turned-chaplain helps students address spiritual side of practicing medicine https://news.stanford.edu/news/2001/may30/chaplain.html