%H\RQG5HOLJLRQDQG6SLULWXDOLW\ )DLWKLQWKH6WXG\ DQG3UDFWLFHRI0HGLFLQH William Ventres, Shafik Dharamsi
Perspectives in Biology and Medicine, Volume 56, Number 3, Summer 2013, pp. 352-361 (Article) 3XEOLVKHGE\7KH-RKQV+RSNLQV8QLYHUVLW\3UHVV DOI: 10.1353/pbm.2013.0023
For additional information about this article http://muse.jhu.edu/journals/pbm/summary/v056/56.3.ventres.html
Access provided by Carleton University Library (19 Jun 2015 17:54 GMT)
07_ventres 352–61.qxp_02_51.3schwartz 320– 12/3/13 6:20 AM Page 352
Beyond Religion and Spirituality faith in the study and practice of medicine
William Ventres * and Shafik Dharamsi †
ABSTRACT Discussions about faith in medicine traditionally have been linked to religion and spirituality. Faith, however, is also that sense of trust or confidence one has in someone or something. As such, it is a concept integral to medical education and practice. This essay explores several dimensions of faith that play significant roles in medicine. It reviews why developing an awareness of faith is important for medical students and practitioners alike, and concludes by suggesting it is by seeking such faith in the profession that medical students and physicians can nurture their personal and professional growth. AITH HAS BEEN,
F
is, and always will be a part of medicine.
We make this statement knowing full well there exists an intense debate about whether spirituality has any place whatsoever in the work physicians do (Curlin and Hall 2005; Lawrence 2002; Pembroke 2008; Post, Puchalski, and
* Master’s Program in Public Health, School of Medicine, and Institute for Studies in History, Anthropology, and Archeology, University of El Salvador, San Salvador; and Department of Family Medicine, Oregon Health and Science University, Portland. † Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver. Correspondence: William Ventres, Urbanización Buenos Aires III, Block H, Calle Los Maquilishuat, No. 3-A, San Salvador, El Salvador. E-mail: [email protected].
The authors wish to thank Carol Herbert for her thoughtful comments regarding the issues of faith in medicine. Perspectives in Biology and Medicine, volume 56, number 3 (summer 2013):352–61 © 2013 by The Johns Hopkins University Press
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Larson 2000; Robinson, Thiel, and Meyer 2007; Scheurich 2003). We also make it knowing there are those who see in the profession of medicine echoes of religious traditions that fulfill ceremonial rites imbued with deeply ingrained therapeutic meanings (Blumhagen 1979; Frank 1974; Goldberg 2007). These are concerns about faith from perspectives of religion and ritual, but our perspective comes from looking at faith in quite a different light. We use faith to mean the sense of trust and complete confidence one has in someone or something: one might call it little “f ” faith, as opposed to the big “F” Faith of religious tenets, that patients and practitioners bring to their mutual encounters. Seen through this lens, faith touches on almost every facet of medicine. Here we present our view that faith is a concept integral to medical education and practice. We explore several dimensions of faith that play significant roles in medicine and review why developing an awareness of this concept is important for medical students and practitioners alike. We suggest that it is through our conception of faith that physicians can look to create a union between the art and science of medical practice.
Faith: A Core Principle of Medicine Much in the practice of medicine is unknown, and medicine itself relies on a not insignificant amount of faith in its own right. There is an old medical school adage that 50% of what physicians know as fact today will in five years time be considered outmoded, only they don’t now know which 50% it is (Emanuel 1975). Physicians commonly come to rely on faith in biomedicine and the hierarchy of evidence that places randomized clinical trials at the pinnacle of what is considered trustworthy knowledge. Yet there are many other factors that influence the presentation, diagnosis, and treatment of disease (Engel 1977). Some of these factors are observable in the cosmos represented by the biopsychosocial model (Engel 1980; Stange 2009); others lie behind a veil of consciousness (what anthropologists, psychologists, or sociologists refer to as cultural, systemic, or structural). All play a part in the individual and collective construction of disease and illness (Cassell 1978; Eisenberg 1977), respectively the “abnormalities of the structure and function of body organs and systems” and the “subjective response of the patient to being unwell” (Helman 1981, p. 548). There is also growing recognition that social determinants (including how the institution of medicine responds to discrimination, social inequity, and poverty) play important roles in the causation and treatment of disease (Fort, Mercer, and Gish 2004; Kim et al. 2000). In addition, basic tenets of practice from even 20 years ago are currently in question, their reliability seemingly based more on market forces than on any scientific proof (Bleyer and Welch 2012; Dumit 2012; Healy 2012; McNaughton-Collins and Barry 2011; Newman 2008). We know these things, but it is faith (the sense of unwavering confidence in something) that helps us continue on our paths as trainees and clinisummer 2013 • volume 56, number 3
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cians—faith in the belief that what we are doing has, at its core, a beneficial value beyond simple monetary remuneration. For patients and their families, faith makes itself known in the implicit confidence they give their physicians, both generalists and subspecialists, to prescribe, order, and operate when needed—and even, on occasion, when not. To be sure, this faith is not absolute. Physicians know that many treatments are inefficacious or troubled with bothersome side effects, and also that the physician-patient relationship doesn’t always work well (ABIM 2013; Burcher 2012). Patients know this too, and they exercise this awareness most commonly by an often-undisclosed lack of adherence to medication regimens or by quietly seeking the care of other clinicians (Conrad 1985). Yet disease and illness make for a vulnerability that necessitates attention. They make for a sense of isolation that requires consolation. And they make for a role—transforming a “healthy” person into a “sick” patient (Segall 1976)—that all but demands the presence of someone to step in and try to help. Into that space enters the physician, who through professional commitment and social approbation is imbued with trust and respect (Wynia et al. 1999). And faith.
Dimensions of Faith in Medical Education and Practice What are some basic dimensions of faith as they apply to the study and practice of medicine, and what is essential to know about these dimensions? Based on our lived experiences and reflective narratives born of our varied cultural, educational, and—indeed—religious backgrounds, we answer these questions by settling on four principles of faith that apply to medical training and practice: offering service, valuing relationship, fostering resiliency, and holding the unknowable. Offering Service
Medicine is a service profession that, as such, relies on confidence and trust. Physicians and other medical practitioners exist to attend to people in physical and emotional need. This has generally meant to work to save and extend life, to promote and maintain health, and to relieve suffering, all when feasibly possible (Cassell 1982). While there are discussions as to the viability of these traditional goals in our technologically and market-based society (Hastings Center 1996), it remains that the practice of medicine, at its core, has much to do with addressing to the concerns of others, both in sickness and in health. A major role of physicians is to ameliorate the effects of disease and assuage the concomitant challenges of illness through the course of people’s lives. Faith is made manifest in where, how, and ultimately why physicians practice their profession. Recognizing that medicine around the world is tied to particular models of funding and delivery—in Canada and the United States, for exam354
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ple, both the market and the state play significant, interconnected parts in the provision of medical care (Bodenheimer and Grumbach 2012; Fierlbeck 2011)— we suggest that physicians have definite choices in these matters. How is it that they extend their daily work into the realm of social responsibility? Is it in areas of need, attending to those who suffer disproportionate levels of disease burden due to social determinants (Hart 1971)? Is it with compassion and care, offering empathy at the same time expertise and skill (Spiro et al. 1993; Wallace 1997)? Is it with a sense of profession, knowing that with respect received also comes responsibility: to learn with practice, to contribute with conscience, to give as one is able to a greater good beyond the economic and social remuneration that comes with the work (Bernat 2012; Dharamsi et al. 2011)? Fostering Resiliency
Part of faith is the belief, often without much contributing evidence, that one can manage in spite of all the challenges disease presents. Medical practitioners skilled in the uses of persuasion can lessen the isolation these challenges provoke by building therapeutic relationships with their patients, encouraging a sense of shared hope (Frank 1974). In the face of demoralization, fear, and the nagging limitations that are commonly part and parcel of the illness experience, faith is the confidence that we—patient and physician together—can overcome and survive. From faith is born the almost universal knowledge, across divisions of geography, culture, and language, that we can and will find a path through suffering (remembering that physicians, too, invariably face infirmity, disability, and death). Even when the prospect of death looms, faith can transform adversity into transcendence and help when biomedical innovation and new technologies reach their limits of effectiveness. In medical practice, by helping create this sense of hope, physicians can offer a bridge for patients from worse to better, from dependence to functioning, from resignation to coping, and, on occasion, to actualization. At various moments in time, that shared hopefulness suggests protection, nurturance, guidance, and an expectation of realistic recovery (Penson et al. 2007; Renz et al. 2009). There may come a time—perhaps while listening to a patient’s story, hearing a review of systems, examining an abdomen, or prescribing a medication—when physicians might even suggest that the power to become and live healthier comes from within, that the patient is the true healer (Glasser 1976). Thus pointing the way to resiliency, toward a capacity beyond what one believes is possible, is a potent force in physicians’ therapeutic armamentarium. Valuing Relationship
Patient- and relationship-centered care have long been key theoretical components of medical practices (Stewart et al. 1995; Tresolini and Pew-Fetzer Task Force 1994). There is growing evidence that physicians can significantly influence patient outcomes for the better when they figuratively meet patients where summer 2013 • volume 56, number 3
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they are and work to develop relational connections (Roter 2006; Stewart 1995; Stewart et al. 2000). These connections mean much more than the easily quantifiable metrics of satisfaction and access. While these two metrics are increasingly part of performance measurements, they function only as proxies for the actual interpersonal work of physicians and do not accurately portray the depth of physician involvement with their patients. This is where faith enters the picture. Faith suggests that when physicians are open to patients, something more therapeutic happens than when they simply attend to biomedical concerns (Sulmasy 1999; Ventres 2012a). We are not suggesting that physicians should ignore biomedicine. Yet when they allow their research and practice environments to devolve into techno-centric hubs of throughput and outcomes (in which either randomized controlled studies or return on investment become the sole models for success), something is lost in the process. What is lost is engagement: on a basic level simply contributing to human interaction, on a higher one touching the human spirit. Engagement is a social capital that nurtures patients’ capacities to mend when healing is feasible and to manage when it is not (Friedenberg 2003). From a community perspective, engagement gives recognition to the work of medicine in the world beyond laboratory, clinic, and hospital. From the point of view of patients, it promotes adherence to shared treatment plans and fosters acknowledgment on a path toward resolution. From that of physicians, maintaining an engaged stance vis-à-vis patients may mean the difference between contentment and burnout (Bascuñán 2005). Holding the Unknown
In its fourth dimension, faith is the capacity to carry all that is unknown in medicine with equanimity and sensibility. In the face of prognoses that are unclear, procedures whose outcomes are in question, and what lies beyond, faith gives physicians the age-old ability to be present and attendant when uncertainty and anxiety reign. For patients, these are times when questions arise: why me? will I be okay? what is my fate? They want to know: will my physicians be there as I go through this process? will they keep faith with me and serve my best interests, given the ordeals I may face? For physicians, responding to these uncertainties is a matter of harnessing faith in times of trouble, of suggesting they are present to hold their patients’ concerns. Yet there is another face to the coin of faith: how do physicians hold their own worries? Guidelines and algorithms only go so far to reassure physicians that what they are doing is good practice. Tests and more tests sometimes provide relief, as do consultations with subspecialists (for primary care clinicians) and limits to practice (for subspecialists); however, these frequently offer only temporary comfort. Many times there is no one ideal answer to a presenting problem. Not only is the practice of medicine full of nuance, it is also full of the unknown (Fox 1980; Ghosh 2004). Faith is the practiced belief that by know356
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ing their patients, knowing their practices, and knowing themselves, physicians can not only get through demanding situations, but do so responsively and with compassion, giving and receiving with trust and respect along the way (Stephens 1975; Ventres and Gobbo 2005).
Challenges to Faith in Education and Practice We hold faith—including its dimensions of offering service, valuing relationship, fostering resiliency, and holding the unknowable—to be a self-evident part of the practice of medicine. That it has not been frequently discussed in this way is due, in part, to a predominately reductionist view of medical practice, which postulates among other things that only through empiricism can a better practice of medicine be created (Brody et al. 1993; Engel 1992; Ho 2011). We believe that many subjective and interpretive forces cannot be seen under this microscopic paradigm (Dharamsi and Scott 2009). The prevailing perspective in medicine focuses predominately on a world of increasingly particularized knowledge that can be quantified, reported, and used for evaluation of performance. To a great extent, this gaze guides our actions as both trainees and practitioners. Medical students and residents become prey to the so-called hidden curriculum, which suggests that it is better to attend to areas of endeavor in which knowledge can be theoretically mastered than it is to explore the existential vagaries inherent in patient care, as exemplified by the above dimensions of faith in medicine (Hafferty and Franks 1994; Michalec 2012). The overt quality of its not-so-subtle message—issues of faith are too hard, too confusing, too ambiguous, and too frightening—moves many a trainee away from types of practices in which patient contact is valued toward more highly remunerative subspecialties of limited scope that focus on technocentric procedures for diagnosis and treatment. In practice, there are constant pressures that make it challenging for physicians to pay attention to faith and have confidence in their capacities to work amid the dimensions we have mapped. As one example, whereas once expert opinion and personal experience were the only media by which physicians could be reassured of doing a good job, now an array of performance criteria determine whether or not we measure up to our peers. Yet it is not at all clear that these criteria lead to better health outcomes; neither is it obvious that they are of sustainable value (Campbell et al. 2009; Gillam, Siriwardena, and Steel 2012). What is clear is that the provision of health care today is part of a huge medical industrial complex dependent on profit, growth, and power (Angell 2000; Relman 1980). These serious politico-economic factors influence daily practice in many ways, from basic definitions of disease to treatment protocols, and it is in these measures that we are encouraged to misplace faith as we have defined it. summer 2013 • volume 56, number 3
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Developing a Faith-Based Awareness There are, nonetheless, numerous opportunities for medical students, medical residents, and practicing physicians to nurture the kind of faith in action we envision, both with patients and internally within themselves (CMA 2013; Epstein 2003; Rabow et al. 2010). At the core of each of these opportunities is the appreciation that something vital is going on below the surface of education and practice. What can be seen in the manner and object of these ventures is just the tip of the iceberg. We believe that for physicians at all levels of preparation, the search for meaning in working with patients—looking below the iceberg’s tip—is elemental to the study and practice of medicine; what makes for satisfaction in the profession is this exploration (Ventres 2012b). Seeking, finding, and finding again one’s faith in this search, attending and adding to the four dimensions above with an engaged and inquisitive disposition, are key to nurturing personal growth throughout one’s medical practice. Wherever we go and wherever we end up in medicine, it is through faith that we find ourselves looking deeper, connecting more profoundly, and practicing with heartfelt commitment. This is the faith in which we trust. It can carry us when we are vulnerable and help us cope with dignity and grace even when outcomes look poor. It can offer understanding when understanding is needed and emotional sustenance when it, too, is required. With a healthy dose of skepticism and willingness to question, it can turn ignorance into wisdom. It can bring to us, physicians as well as patients, that very real sense of worth to which we all aspire. May we benefit from reflecting upon this faith in all its dimensions as make our way in today’s modern medical world.
References American Board of Internal Medicine (ABIM) Foundation. 2013. Choosing wisely. http://www.choosingwisely.org/doctor-patient-lists/. Angell, M. 2000. Is academic medicine for sale? N Engl J Med 342(20):1516–18. Bascuñán, R. ML. 2005. Cambios en la relación médico-paciente y nivel de satisfacción de los medicos. [Changes in physician-patient relationship and medical satisfaction]. Rev Méd Chil 133(1):11–16. http://www.scielo.cl/scielo.php?script=sci_arttext& pid=S0034-98872005000100002&lng=en&nrm=iso&ignore=.html. Bernat, J. L. 2012. Restoring medical professionalism. Neurology 79(8):820–27. Bleyer A., and H. G. Welch. 2012. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 367(21):1998–2005. Blumhagen, D. 1979. The doctor’s white coat. Ann Intern Med 91(1):111–16. Bodenheimer, T., and K. Grumbach. 2012. Understanding health policy: A clinical approach, 6th ed. New York: McGraw-Hill. Brody, H., et al. 1993. The mammalian medical center for the 21st century. JAMA 270 (9):1097–100.
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Beyond Religion and Spirituality Burcher, P. 2012. The noncompliant patient: A Kantian and Levinasian response. J Med Philos 37(1):74–89. Campbell, S. M., et al. 2009. Effects of pay for performance on the quality of primary care in England. N Engl J Med 361(4):368–78. Canadian Medical Association (CMA). Centre for Physician Health and Well-being. 2013. ePhysicianHealth.com. http://www.ephysicianhealth.com/. Cassell, E. J. 1978. The healer’s art: A new approach to the doctor-patient relationship. Harmondsworth: Penguin. Cassell, E. J. 1982. The nature of suffering and the goals of medicine. N Engl J Med 306 (11):639–45. Conrad, P. 1985. The meaning of medications: Another look at compliance. Soc Sci Med 20(1):29–37. Curlin, F. A., and D. E. Hall. 2005. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med 20(4):370–74. Dharamsi, S., and I. Scott. 2009. Quantitative and qualitative research: Received and interpretivist views of science. Can Fam Physician 55(8):843–44. Dharamsi, S., et al. 2011. The physician as health advocate: Translating the quest for social responsibility into medical education and practice. Acad Med 86(9):1108–13. Dumit, J. 2012. Drugs for life: How pharmaceutical companies define our health. Durham: Duke Univ. Press. Eisenberg, L. 1977. Disease and illness: Distinctions between professional and popular ideas of sickness. Cult Med Psychiatry 1(1):9–23. Emanuel, E. 1975. A half-life of 5 years. CMAJ 112(5):572. Engel, G. 1977. The need for a new medical model: A challenge for biomedicine. Science 196(4286):129–36. Engel, G. 1980. The clinical application of the biopsychosocial model. Am J Psychiatry 137(5):535–44. Engel, G. L. 1992. How much longer must medicine’s science be bound by a seventeenth century world view? Psychother Psychosom 57(1,2):3–16. Epstein, R. M. 2003. Mindful practice in action (II): Cultivating habits of mind. Fam Syst Health 21(1):11–17. Fierlbeck, K. 2011. Health care in Canada: A citizen’s guide to policy and politics. Toronto: Univ. of Toronto Press. Fort, M., M. A. Mercer, and O. Gish. 2004. Sickness and wealth: The corporate assault on global health. Cambridge, MA: South End Press. Fox, R. C. 1980. The evolution of medical uncertainty. Milbank Mem Fund Q Health Soc 58(1):1–49. Frank, J. D. 1974. Persuasion and healing: A comparative study of psychotherapy. New York: Schocken Books. Friedenberg, R. M. 2003. Patient-doctor relationships. Radiology 226(2):306–8. Ghosh, A. K. 2004. Understanding medical uncertainty: A primer for physicians. J Assoc Physicians India 52:739–42. Gillam, S. J., A. N. Siriwardena, and N. Steel. 2012. Pay-for-performance in the United Kingdom: Impact of the quality and outcomes framework—A systematic review. Ann Fam Med 10(5):461–68. Glasser, R. J. 1976. The body is the hero. Glasgow: William Collins.
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Perspectives in Biology and Medicine, Volume 56, Number 3, Summer 2013, pp. 352-361 (Article) 3XEOLVKHGE\7KH-RKQV+RSNLQV8QLYHUVLW\3UHVV DOI: 10.1353/pbm.2013.0023
For additional information about this article http://muse.jhu.edu/journals/pbm/summary/v056/56.3.ventres.html
Access provided by Carleton University Library (19 Jun 2015 17:54 GMT)
07_ventres 352–61.qxp_02_51.3schwartz 320– 12/3/13 6:20 AM Page 352
Beyond Religion and Spirituality faith in the study and practice of medicine
William Ventres * and Shafik Dharamsi †
ABSTRACT Discussions about faith in medicine traditionally have been linked to religion and spirituality. Faith, however, is also that sense of trust or confidence one has in someone or something. As such, it is a concept integral to medical education and practice. This essay explores several dimensions of faith that play significant roles in medicine. It reviews why developing an awareness of faith is important for medical students and practitioners alike, and concludes by suggesting it is by seeking such faith in the profession that medical students and physicians can nurture their personal and professional growth. AITH HAS BEEN,
F
is, and always will be a part of medicine.
We make this statement knowing full well there exists an intense debate about whether spirituality has any place whatsoever in the work physicians do (Curlin and Hall 2005; Lawrence 2002; Pembroke 2008; Post, Puchalski, and
* Master’s Program in Public Health, School of Medicine, and Institute for Studies in History, Anthropology, and Archeology, University of El Salvador, San Salvador; and Department of Family Medicine, Oregon Health and Science University, Portland. † Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver. Correspondence: William Ventres, Urbanización Buenos Aires III, Block H, Calle Los Maquilishuat, No. 3-A, San Salvador, El Salvador. E-mail: [email protected].
The authors wish to thank Carol Herbert for her thoughtful comments regarding the issues of faith in medicine. Perspectives in Biology and Medicine, volume 56, number 3 (summer 2013):352–61 © 2013 by The Johns Hopkins University Press
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Larson 2000; Robinson, Thiel, and Meyer 2007; Scheurich 2003). We also make it knowing there are those who see in the profession of medicine echoes of religious traditions that fulfill ceremonial rites imbued with deeply ingrained therapeutic meanings (Blumhagen 1979; Frank 1974; Goldberg 2007). These are concerns about faith from perspectives of religion and ritual, but our perspective comes from looking at faith in quite a different light. We use faith to mean the sense of trust and complete confidence one has in someone or something: one might call it little “f ” faith, as opposed to the big “F” Faith of religious tenets, that patients and practitioners bring to their mutual encounters. Seen through this lens, faith touches on almost every facet of medicine. Here we present our view that faith is a concept integral to medical education and practice. We explore several dimensions of faith that play significant roles in medicine and review why developing an awareness of this concept is important for medical students and practitioners alike. We suggest that it is through our conception of faith that physicians can look to create a union between the art and science of medical practice.
Faith: A Core Principle of Medicine Much in the practice of medicine is unknown, and medicine itself relies on a not insignificant amount of faith in its own right. There is an old medical school adage that 50% of what physicians know as fact today will in five years time be considered outmoded, only they don’t now know which 50% it is (Emanuel 1975). Physicians commonly come to rely on faith in biomedicine and the hierarchy of evidence that places randomized clinical trials at the pinnacle of what is considered trustworthy knowledge. Yet there are many other factors that influence the presentation, diagnosis, and treatment of disease (Engel 1977). Some of these factors are observable in the cosmos represented by the biopsychosocial model (Engel 1980; Stange 2009); others lie behind a veil of consciousness (what anthropologists, psychologists, or sociologists refer to as cultural, systemic, or structural). All play a part in the individual and collective construction of disease and illness (Cassell 1978; Eisenberg 1977), respectively the “abnormalities of the structure and function of body organs and systems” and the “subjective response of the patient to being unwell” (Helman 1981, p. 548). There is also growing recognition that social determinants (including how the institution of medicine responds to discrimination, social inequity, and poverty) play important roles in the causation and treatment of disease (Fort, Mercer, and Gish 2004; Kim et al. 2000). In addition, basic tenets of practice from even 20 years ago are currently in question, their reliability seemingly based more on market forces than on any scientific proof (Bleyer and Welch 2012; Dumit 2012; Healy 2012; McNaughton-Collins and Barry 2011; Newman 2008). We know these things, but it is faith (the sense of unwavering confidence in something) that helps us continue on our paths as trainees and clinisummer 2013 • volume 56, number 3
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cians—faith in the belief that what we are doing has, at its core, a beneficial value beyond simple monetary remuneration. For patients and their families, faith makes itself known in the implicit confidence they give their physicians, both generalists and subspecialists, to prescribe, order, and operate when needed—and even, on occasion, when not. To be sure, this faith is not absolute. Physicians know that many treatments are inefficacious or troubled with bothersome side effects, and also that the physician-patient relationship doesn’t always work well (ABIM 2013; Burcher 2012). Patients know this too, and they exercise this awareness most commonly by an often-undisclosed lack of adherence to medication regimens or by quietly seeking the care of other clinicians (Conrad 1985). Yet disease and illness make for a vulnerability that necessitates attention. They make for a sense of isolation that requires consolation. And they make for a role—transforming a “healthy” person into a “sick” patient (Segall 1976)—that all but demands the presence of someone to step in and try to help. Into that space enters the physician, who through professional commitment and social approbation is imbued with trust and respect (Wynia et al. 1999). And faith.
Dimensions of Faith in Medical Education and Practice What are some basic dimensions of faith as they apply to the study and practice of medicine, and what is essential to know about these dimensions? Based on our lived experiences and reflective narratives born of our varied cultural, educational, and—indeed—religious backgrounds, we answer these questions by settling on four principles of faith that apply to medical training and practice: offering service, valuing relationship, fostering resiliency, and holding the unknowable. Offering Service
Medicine is a service profession that, as such, relies on confidence and trust. Physicians and other medical practitioners exist to attend to people in physical and emotional need. This has generally meant to work to save and extend life, to promote and maintain health, and to relieve suffering, all when feasibly possible (Cassell 1982). While there are discussions as to the viability of these traditional goals in our technologically and market-based society (Hastings Center 1996), it remains that the practice of medicine, at its core, has much to do with addressing to the concerns of others, both in sickness and in health. A major role of physicians is to ameliorate the effects of disease and assuage the concomitant challenges of illness through the course of people’s lives. Faith is made manifest in where, how, and ultimately why physicians practice their profession. Recognizing that medicine around the world is tied to particular models of funding and delivery—in Canada and the United States, for exam354
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ple, both the market and the state play significant, interconnected parts in the provision of medical care (Bodenheimer and Grumbach 2012; Fierlbeck 2011)— we suggest that physicians have definite choices in these matters. How is it that they extend their daily work into the realm of social responsibility? Is it in areas of need, attending to those who suffer disproportionate levels of disease burden due to social determinants (Hart 1971)? Is it with compassion and care, offering empathy at the same time expertise and skill (Spiro et al. 1993; Wallace 1997)? Is it with a sense of profession, knowing that with respect received also comes responsibility: to learn with practice, to contribute with conscience, to give as one is able to a greater good beyond the economic and social remuneration that comes with the work (Bernat 2012; Dharamsi et al. 2011)? Fostering Resiliency
Part of faith is the belief, often without much contributing evidence, that one can manage in spite of all the challenges disease presents. Medical practitioners skilled in the uses of persuasion can lessen the isolation these challenges provoke by building therapeutic relationships with their patients, encouraging a sense of shared hope (Frank 1974). In the face of demoralization, fear, and the nagging limitations that are commonly part and parcel of the illness experience, faith is the confidence that we—patient and physician together—can overcome and survive. From faith is born the almost universal knowledge, across divisions of geography, culture, and language, that we can and will find a path through suffering (remembering that physicians, too, invariably face infirmity, disability, and death). Even when the prospect of death looms, faith can transform adversity into transcendence and help when biomedical innovation and new technologies reach their limits of effectiveness. In medical practice, by helping create this sense of hope, physicians can offer a bridge for patients from worse to better, from dependence to functioning, from resignation to coping, and, on occasion, to actualization. At various moments in time, that shared hopefulness suggests protection, nurturance, guidance, and an expectation of realistic recovery (Penson et al. 2007; Renz et al. 2009). There may come a time—perhaps while listening to a patient’s story, hearing a review of systems, examining an abdomen, or prescribing a medication—when physicians might even suggest that the power to become and live healthier comes from within, that the patient is the true healer (Glasser 1976). Thus pointing the way to resiliency, toward a capacity beyond what one believes is possible, is a potent force in physicians’ therapeutic armamentarium. Valuing Relationship
Patient- and relationship-centered care have long been key theoretical components of medical practices (Stewart et al. 1995; Tresolini and Pew-Fetzer Task Force 1994). There is growing evidence that physicians can significantly influence patient outcomes for the better when they figuratively meet patients where summer 2013 • volume 56, number 3
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they are and work to develop relational connections (Roter 2006; Stewart 1995; Stewart et al. 2000). These connections mean much more than the easily quantifiable metrics of satisfaction and access. While these two metrics are increasingly part of performance measurements, they function only as proxies for the actual interpersonal work of physicians and do not accurately portray the depth of physician involvement with their patients. This is where faith enters the picture. Faith suggests that when physicians are open to patients, something more therapeutic happens than when they simply attend to biomedical concerns (Sulmasy 1999; Ventres 2012a). We are not suggesting that physicians should ignore biomedicine. Yet when they allow their research and practice environments to devolve into techno-centric hubs of throughput and outcomes (in which either randomized controlled studies or return on investment become the sole models for success), something is lost in the process. What is lost is engagement: on a basic level simply contributing to human interaction, on a higher one touching the human spirit. Engagement is a social capital that nurtures patients’ capacities to mend when healing is feasible and to manage when it is not (Friedenberg 2003). From a community perspective, engagement gives recognition to the work of medicine in the world beyond laboratory, clinic, and hospital. From the point of view of patients, it promotes adherence to shared treatment plans and fosters acknowledgment on a path toward resolution. From that of physicians, maintaining an engaged stance vis-à-vis patients may mean the difference between contentment and burnout (Bascuñán 2005). Holding the Unknown
In its fourth dimension, faith is the capacity to carry all that is unknown in medicine with equanimity and sensibility. In the face of prognoses that are unclear, procedures whose outcomes are in question, and what lies beyond, faith gives physicians the age-old ability to be present and attendant when uncertainty and anxiety reign. For patients, these are times when questions arise: why me? will I be okay? what is my fate? They want to know: will my physicians be there as I go through this process? will they keep faith with me and serve my best interests, given the ordeals I may face? For physicians, responding to these uncertainties is a matter of harnessing faith in times of trouble, of suggesting they are present to hold their patients’ concerns. Yet there is another face to the coin of faith: how do physicians hold their own worries? Guidelines and algorithms only go so far to reassure physicians that what they are doing is good practice. Tests and more tests sometimes provide relief, as do consultations with subspecialists (for primary care clinicians) and limits to practice (for subspecialists); however, these frequently offer only temporary comfort. Many times there is no one ideal answer to a presenting problem. Not only is the practice of medicine full of nuance, it is also full of the unknown (Fox 1980; Ghosh 2004). Faith is the practiced belief that by know356
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ing their patients, knowing their practices, and knowing themselves, physicians can not only get through demanding situations, but do so responsively and with compassion, giving and receiving with trust and respect along the way (Stephens 1975; Ventres and Gobbo 2005).
Challenges to Faith in Education and Practice We hold faith—including its dimensions of offering service, valuing relationship, fostering resiliency, and holding the unknowable—to be a self-evident part of the practice of medicine. That it has not been frequently discussed in this way is due, in part, to a predominately reductionist view of medical practice, which postulates among other things that only through empiricism can a better practice of medicine be created (Brody et al. 1993; Engel 1992; Ho 2011). We believe that many subjective and interpretive forces cannot be seen under this microscopic paradigm (Dharamsi and Scott 2009). The prevailing perspective in medicine focuses predominately on a world of increasingly particularized knowledge that can be quantified, reported, and used for evaluation of performance. To a great extent, this gaze guides our actions as both trainees and practitioners. Medical students and residents become prey to the so-called hidden curriculum, which suggests that it is better to attend to areas of endeavor in which knowledge can be theoretically mastered than it is to explore the existential vagaries inherent in patient care, as exemplified by the above dimensions of faith in medicine (Hafferty and Franks 1994; Michalec 2012). The overt quality of its not-so-subtle message—issues of faith are too hard, too confusing, too ambiguous, and too frightening—moves many a trainee away from types of practices in which patient contact is valued toward more highly remunerative subspecialties of limited scope that focus on technocentric procedures for diagnosis and treatment. In practice, there are constant pressures that make it challenging for physicians to pay attention to faith and have confidence in their capacities to work amid the dimensions we have mapped. As one example, whereas once expert opinion and personal experience were the only media by which physicians could be reassured of doing a good job, now an array of performance criteria determine whether or not we measure up to our peers. Yet it is not at all clear that these criteria lead to better health outcomes; neither is it obvious that they are of sustainable value (Campbell et al. 2009; Gillam, Siriwardena, and Steel 2012). What is clear is that the provision of health care today is part of a huge medical industrial complex dependent on profit, growth, and power (Angell 2000; Relman 1980). These serious politico-economic factors influence daily practice in many ways, from basic definitions of disease to treatment protocols, and it is in these measures that we are encouraged to misplace faith as we have defined it. summer 2013 • volume 56, number 3
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Developing a Faith-Based Awareness There are, nonetheless, numerous opportunities for medical students, medical residents, and practicing physicians to nurture the kind of faith in action we envision, both with patients and internally within themselves (CMA 2013; Epstein 2003; Rabow et al. 2010). At the core of each of these opportunities is the appreciation that something vital is going on below the surface of education and practice. What can be seen in the manner and object of these ventures is just the tip of the iceberg. We believe that for physicians at all levels of preparation, the search for meaning in working with patients—looking below the iceberg’s tip—is elemental to the study and practice of medicine; what makes for satisfaction in the profession is this exploration (Ventres 2012b). Seeking, finding, and finding again one’s faith in this search, attending and adding to the four dimensions above with an engaged and inquisitive disposition, are key to nurturing personal growth throughout one’s medical practice. Wherever we go and wherever we end up in medicine, it is through faith that we find ourselves looking deeper, connecting more profoundly, and practicing with heartfelt commitment. This is the faith in which we trust. It can carry us when we are vulnerable and help us cope with dignity and grace even when outcomes look poor. It can offer understanding when understanding is needed and emotional sustenance when it, too, is required. With a healthy dose of skepticism and willingness to question, it can turn ignorance into wisdom. It can bring to us, physicians as well as patients, that very real sense of worth to which we all aspire. May we benefit from reflecting upon this faith in all its dimensions as make our way in today’s modern medical world.
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