For physician Lester Ruppersberger, being a doctor is more than a job. It’s how he lives out his faith. An OB/GYN for more than three decades, Ruppersberger is the president of the Catholic Medical Association, a community of health care professionals that inspires its members to uphold Catholic principles.
He serves as a family life medical advisor and is a certified instructor of natural family planning for the Archdiocese of Philadelphia.
Because Ruppersberger believes a person’s faith can have ramifications on their health, he’s not afraid to mention it in conversation with his patients.
“When the body isn’t the issue and emotions aren’t the issue, the spirit could be,” Ruppersberger says. “Our job as doctors is to start out with the physical portion of health care—taking their temperature, ordering CT scans, etc. If everything comes back negative and the patient still has symptoms, then we need to start looking into their emotional and spiritual health. If the patient doesn’t have anything going on emotionally, then there’s usually something that’s not right spiritually.”
When Ruppersberger was in medical school, he studied holistic health care—the idea that the mind, body, and spirit are all linked.
“Western medicine takes care of the body and, sometimes, the mind. However, it quite frequently fails to take care of the spirit,” he says. “Physicians need to be comfortable in their own shoes to know where they’re coming from and to recognize the spiritual brokenness in their patient.”
For Ruppersberger, talking about faith and spirituality with his patients doesn’t mean talking about any specific religion. Instead it can be as simple as discussing stress and advising patients to turn over things they can’t control to “a master controller, whether you call him God or Jesus or whatever else.” Other times Ruppersberger will share stories from his own life, such as how he had a stroke at age 41 due to stress and how the lingering effects led him to turn back to his faith.
Because he knows many patients don’t expect to hear that conversation or don’t want to discuss spirituality, he always waits for them to open the door.
“You have to have the patient give permission, and you can’t come at it from a totally aggressive point of view,” he says. “Don’t go there first. Go there finally. What I do essentially is give patients food for thought and let them do with it as they will.”
Ruppersberger believes this approach allows patients to feel seen and heard as people instead of simply as medical problems to be solved. And he’s not wrong. Several studies show that a significant number of patients would like to have discussions of faith with their physicians, but many do not have the opportunity to do so.
A 2003 study of 456 outpatients at six academic medical centers found that, in the ambulatory setting, 33 percent wanted their physician to inquire about religious beliefs and 19 percent wanted their physician to pray with them. Among dying patients, the numbers rose. Seventy percent wanted their physician to know their beliefs and 50 percent wanted their physician to pray with them.
Similarly, a 2011 study of data from the University of Chicago Medical Center revealed that 41 percent of inpatients wanted to talk about religion or spirituality with their physicians while hospitalized, but only half of those reported having such a conversation. Overall, only 32 percent of inpatients reported discussing their religious or spiritual concerns with their physicians. However, those who did were more likely to rate their care at the highest level of patient satisfaction.
This data suggests that patients think religion is important enough to warrant discussion, but that it is not seen as a regular part of medical practice.
Medical ethicist and physician Daniel Sulmasy, head of the Program on Medicine and Religion at the University of Chicago, believes the lack of focus on spirituality in patient care is “a real deficiency in health care.”
“Spirituality is something that has become taboo in medicine,” he says. “We are able to talk with patients in incredible detail about their sexual lives, drug use, or illegal activities, but we can’t talk with them about religion.”
Often, Sulmasy says, facing an illness can lead patients to deep spiritual questions or a need for reconciliation. While chaplains are available to offer specific advice, he thinks doctors should be ready and willing to acknowledge spiritual issues, which can lead to physical or mental health ramifications.
“All of this comes up and we aren’t addressing any of it,” he says. “People are biological and spiritual at the same time. . . . When you neglect the spiritual, you are neglecting the whole person.”
Why bring it up?
Though the link between medicine and faith may seem tenuous, research has shown that a person’s spiritual beliefs or practices can make a difference in their physical health, affecting their quality of life, their willingness to take positive action, and the way they make health decisions.
A 1981 Medical and Pediatric Oncology study found that patients with advanced cancer who sought comfort in their religious beliefs were more satisfied with their lives and had less pain. A 1998 study of 90 HIV-positive patients revealed that those who were spiritually active had less fear of death and less guilt. And a 1995 study of recent heart transplant recipients found that those who regularly participated in religious activities had better physical and emotional well-being and fewer health worries by the final 12-month assessments.
Christina Puchalski, a 20-year practicing physician in internal medicine, geriatrics, and palliative care, is the founder of the George Washington University’s Institute for Spirituality and Health (GWish). She first became interested in the link between spirituality and health before she was in medical school, while working at the National Institutes of Health (NIH). Seeing seriously ill patients come in for treatment, she was often impressed by their reserves of inner strength and hope.
“I saw the importance of spirituality in their lives,” she says. “When I went to medical school, I was amazed that the focus was mostly on the physical instead of the whole person.”
According to Puchalski, the most important thing about a spiritually integrated approach to medicine is simply allowing the physician to become more engaged with the patient—finding out who they are, what makes them tick, and what they really need. Otherwise, she says, a physician may treat a patient’s pain but not address their deeper suffering.
Sulmasy says patients who are in the midst of a health crisis often find themselves doubting their beliefs or becoming angry with God. Others may begin pondering spirituality in a new way.
“Illness raises spiritual questions in patients in a very real way—questions about meaning, about value: ‘Does anyone care about me if I’m no longer a productive member of the workforce?’ ” Sulmasy says.
For some, this spiritual distress can result in physical manifestations of pain.
In one instance, Sulmasy says, he treated a woman for insomnia not by offering sleeping pills but by providing a referral to the hospital chaplain. After discussing with her chaplain concerns that were keeping her awake, the patient was able to sleep without medication.
Even if they are not in crisis, Sulmasy has seen patients make important health decisions because of their spiritual beliefs. He’s heard of patients refusing treatment for certain illnesses, like HIV, because they believe they are being punished for their actions.
“A skillful doctor may be able to find this out by inquiring about their religion and can enable the patient to get the resources they need to better cope with the illness,” he says. “Religion can have good or bad influences in that way. Ignoring it altogether can ignore significant parts of the patients’ lives.”
With data pointing to the benefits of engaging patients on a spiritual level, why aren’t more physicians having these conversations?
Sulmasy believes physicians may be hesitant to take on these conversations, in part because of how they’ve been trained.
“[Between] increasing time pressures on physicians and a higher emphasis on outcomes . . . anything that is not scientific has been dismissed as fluff,” he says.
He believes a valuable way for medical students to learn the importance of spirituality in health care is by shadowing a chaplain for a day. He also advises physicians to pay attention to signals patients provide about their spiritual beliefs. If a patient has Shabbat candles, a Bible, or rosary beads by their bedside, Sulmasy advises physicians to ask about them.
“This could be an expression of something of ultimate importance to the patient,” he says. “Physicians need to be able to ask a patient about the ways in which these beliefs are going to be involved in their health care decisions.”
As part of her work with the George Washington University’s Institute of Spirituality and Health (GWish), Puchalski encourages physicians to take a whole person approach to health care by paying attention to and addressing the totality of their patients’ relational existence, from their physical and psychological needs to their social and spiritual ones.
To help physicians do this, Puchalski developed the FICA Spiritual History Tool, a method that encourages physicians and other clinicians to ask questions about a patient’s spirituality just as they would their physical lifestyle. The acronym (which stands for faith and belief; importance and influence; community; and address and assess) recommends physicians ask what a patient’s spirituality is (or where they draw meaning in life), how important it is in their life, what they consider a spiritual community, and how they would like their spirituality to be addressed in care.
After engaging patients in these conversations, Puchalski works with patients to co-create a treatment plan addressing the physical, emotional, social, and spiritual aspects of their health. Research, Puchalski says, has shown that patients who experience fully integrated spiritual care have less depression and anxiety. In her own work, she believes these conversations build patient trust.
Still, Puchalski and Sulmasy agree that there should be limits to how far conversations of spirituality go between physicians and patients. While Sulmasy encourages clinicians to discuss spirituality with their patients, he does not advise doctors to act as a spiritual leader. Instead, he encourages them to offer referrals for chaplains, meditation centers, or other resources.
“I think there are things patients probably want to tell their clergy but not their doctor, and vice versa,” he says. “I’m advocating the reintegration of spirituality into medicine, but I’m not advocating neoshamanism . . . I don’t want to be the guru, the priest, or the rabbi for my own patients.”
“You can’t impose your belief or even your lack of belief on another person,” Puchalski says. “There’s a power differential between a patient and a physician, and you need to be careful not to impose that in any circumstances.”
That power differential is one reason why mixing faith and medicine can be dangerous, says Ann Neumann, a visiting scholar at the Center for Religion and Media at New York University and author of The Good Death: An Exploration of Dying in America.
“My concern is that when doctors take their faith or some sort of judgment about faith into the examination room, they are probably more likely to make judgments about their patients,” Neumann says. “Regardless of what faith we aspire to, it is always incredibly personal . . . When a doctor approaches a patient and that patient says, ‘I am Muslim,’ or ‘I am Catholic,’ it is far too easy given our lack of religious fluency to assume that self-identification means particular things.”
Neumann believes there is a long history of medical practitioners bringing morality and religious judgment into the medical world to disastrous effects. Although she thinks it’s acceptable for patients and doctors to speak about spiritual matters or even to pray together, Neumann believes it should always be patient-led and that physicians should never act as spiritual advisors.
“A doctor’s role is to abide by the law and standard medical practice, give a patient all their medical options, and provide a realistic understanding of what their body and mind may expect,” she says. “Putting responsibility in their hands that really belongs to the patient or the patient’s spiritual leader is an error.”
For these reasons, Sulmasy believes physicians should be trained to recognize their own biases and not be influenced by them. He also thinks one way to overcome bias is by learning more about what patients believe and why.
“It’s always possible for people to be biased, but it may be that right now we’re operating under the bias that medicine has nothing to do with religion and vice versa, which is alienating the vast numbers of people to whom those issues matter,” Sulmasy says. “We need to guard against all biases, but that doesn’t mean we should avoid engaging in discussions of religion and medicine with our patients.”
Comfort and connection
Mary McCarthy Hines, a parishioner in the Diocese of Arlington, can speak firsthand to the role spirituality plays in health care. Hines chose to attend Tepeyac Family Center in Fairfax, Virginia specifically because of its holistic, Christian approach to health care.
“I’ve gotten better spiritual direction from Dr. Fisk than I have from some priests,” Hines says. “The first time I went to a priest to talk about infertility and trying to deal with our first miscarriage, I was told that our baby probably died for a good reason . . . and to try to relax and take care of myself and count my blessings. In the moment, the advice was very frustrating because I was hoping for someone to help explain things, not dismiss them.”
When she spoke with her doctor, he looked for a medical explanation but also spoke from the heart about certain things outside of human control.
“His heartfelt empathy and understanding meant so much more than the platitudes I’d received from other people,” Hines says.
After Hines became pregnant and her baby was stillborn, she was grateful to have nurses who also “happened to be Catholic.” They referred to her baby by name, instead of using medical terms. And as soon as they knew her daughter, Virginia, was stillborn, the nurse asked if she could call a priest. Thanks to that conversation with her priest, Hines received spiritual support before the difficult birthing process and she was able to begin thinking about plans for her daughter’s burial.
In his own practice, Ruppersberger has been in similar situations. “Whether it’s a family member or a baby who has died, sometimes there are no answers … but it always goes to the spiritual,” he says. He says he prays for strength every time he goes into the operating or delivery room, reminding himself that his work is more than a nine-to-five job. It’s a vocation.
“Health care and medicine in and of itself is a ministry,” he says. “You deal with life, you deal with death, and everything in between. Since we’re all made in the image of God, it’s the responsibility of a health care provider to recognize God in the other person through their brokenness.”
According to a study from the British Journal of Psychiatry, physicians are more than twice as likely to commit suicide as non-physicians. Puchalski believes the high suicide rate is because physicians lose their “sense of call” for what they’re doing, as they are inundated with insurance demands and stacks of paperwork. In her research, she has found that physicians who incorporate spirituality into their patient care are less likely to experience stress and burnout, even with the same workloads. By talking with patients about matters of faith, Puchalski believes physicians can reconnect with the deeper meaning behind their work.
That’s certainly been the case for Ruppersberger. Though many of his patients have been surprised by his faith-forward approach to medicine, he says he’s never had someone get angry or become upset.
“It has amazed me how many will come back and say, ‘I went home and thought about what we talked about last time,’ ” he says. “The majority of what I see, if nothing else, when I go to let go of the patient’s hand, they’ll start to break down in tears . . . They’ll walk out of there with their labs for their bloodwork, their ultrasound, and they’ll think, he’s gonna pray for me.”
By acknowledging his own spiritual beliefs and those of his patients, Ruppersberger says he has found deeper meaning in his work. In discussing spirituality, he has found great peace and grown in his own faith.
“It fills me up and gives me great confidence to know that this is what I’m called to do,” he says. “I pray every day and I offer everything to God, saying, ‘This is not about me, it’s about you, and use me as your instrument.’ ”
“If you forget that part, then you’re relegating medicine to nothing but science and nuts and bolts and sutures,” he says. “You need to know how to do all those things, but you don’t get those skills naturally. You get them because you were called, and those are the skills and directions you were given.”
This article appears in the April 2016 issue of U.S. Catholic (Vol. 81, No. 4, pages 27–31).
Image: Flickr cc via Alex Proimos