What typically happens when you visit a doctor for a check-up? Your temperature and blood pressure are monitored. Weight, height and age are all duly noted. The assumption is that such clinical details add up to a picture of sickness or health. For all this surface probing, however, very few "physicals" include the psyche, much less the soul. Who are we? What gives our existence meaning? Why do we want to go on living? These are vitally important questions, yet for many years now, most doctors have done their best to pretend they have no relation to health.

"Spiritual questions are like the elephant sitting in the corner of the room," said Christina Puchalski, a physician and professor of internal medicine at George Washington University. "They are there, even when they are not addressed." "Doctors need to respect a patient's belief or lack of belief, but they worry that any inquiry of this nature will open a can of worms," agreed Harold Koenig, a physician and professor of psychiatry at Duke University.

This standoff may be about to change, however. Drs. Puchalski and Koenig are leading proponents of a new focus in medicine: namely, recognizing that patients' spirituality can be quite relevant to their physical condition. Puchalski is the founder and director of the George Washington Institute for Spirituality and Health, and Koenig is director of the Center for the Study of Religion/Spirituality and Health at Duke University Medical Center. Both organizations are recipients of funds from the John Templeton Foundation.

Dr. Koenig co-authored the definitive text, Handbook of Religion and Health (Oxford University Press, 2001), and recently published Spirituality in Patient Care (Templeton Press, 2002), a primer for healthcare professionals. Koenig says that he could not have imagined the existence of such texts in the early 1980s when he was a family doctor in Columbia, Missouri.

"I had many older patients, and I quickly began to notice how differently certain of them coped with cancers, strokes, death and dying. When I asked, many told me that their religious beliefs were very important to them. Reading scriptures, praying, and knowing they were being prayed for were crucial," Koenig recalled. "This was in such contrast to what I'd learned in medical school, I decided I needed to study it systematically." Thus embarking on research that would define his career, Koenig began to observe the impact of religiosity on everything from blood pressure and Alzheimer's, to HIV. His research attracted national publicity in 1995, when the media trumpeted results of one of Koenig's experiments, which suggested that people who attended church often had healthier immune systems.

In all the ballyhoo, Koenig acknowledges a key point was overlooked-that a correlation between spirituality and health was hardly new. On the contrary, it's the separation of the two that is a relatively recent phenomenon. "You have to understand this in the context of history," Koenig advises.

In the Handbook of Religion and Health, Koenig and his co-authors Michael E. McCullough, Ph.D., and David B. Larson, M.D., include a fascinating time-line of key events in the millennia-long relationship between religion, science and medicine. Here, one can learn that in ancient Egypt, China or India, the supernatural and natural were blended in efforts to cure disease. Well into the Renaissance, a doctor was generally also a priest, and most centers of medical training were either monasteries or church-supported universities. The medical arts were so transformed by scientific discovery in the late 19th century, that Sigmund Freud could posit in 1927 that religion had an "irrational and neurotic influence on the psyche."

The gradual separation of spirituality and health is a topic that Puchalski has studied extensively, too. She points out that in America, most hospitals were originally built by religious denominations such as the Baptists, Lutherans, Catholics and Jews. "More importantly, in the 1800's and 1900's, doctors had personal relationships with their patients," she noted. "They went to the same temple or church. They were in the patient's home. Issues of spirituality would come up naturally all the time."

In Puchalski's view, more divisive than Freudian psychology were the huge strides forward in both curing and treating disease that occurred in the 1960's. Because of these advances, specialties grew in importance. Rather than going to the general practitioner, patients would consult urologists, cardiologists or oncologists-each highly trained to treat only one part of the whole patient.

"As we shifted from the family doctor to the specialist, we figured out ways to let people live longer, but left them to face more challenges alone," said Puchalski, who cited the decision whether or not to take chemotherapy as a classic existential dilemma posed by modern science. "Such 'quality of life' questions weren't asked in the old days. Then, you just died."

What's needed to help people with medical decision-making, she feels, is a change from a disease-based model, to a patient-centered model. "We want to talk about Tom who has colon cancer, not 'the colon cancer in Room 444,'" she said. "It's a question of trust, and of forming a better relationship between doctor and patient. As it is, our health care system is not providing that, so we are advocating for a change in this area."

Currently, Puchalski is spearheading two efforts. First, she is developing curricula for medical schools to help instruct students, those in residency programs and faculty members on the best ways to interview patients on their spiritual histories. In 1995, only a handful of medical schools had spirituality and health courses; today, more than 70 of America's 125 medical schools offer them.

"Here at the Association of American Medical Colleges, we devised the Medical Schools Objective Project to foster consensus on what attributes students should have when they graduate from medical school. We determined these to be altruism, skills, knowledge and a sense of duty," said Brownell Anderson, Senior Associate Vice President for medical education. "Christina saw these results, and within a couple months, we'd put together our first conference on 'Spirituality, Culture and End of Life.' It was clear from attendance at this conference that we'd identified if not a need of the medical community, then at least a great interest."

Secondly, Puchalski is pioneering a new model of outpatient care called a "Spiritual Care Clinic." She explained, "we'll have physicians, nurses and chaplains working together and sharing resources so that all the patient's issues can be dealt with at once."

Koenig is fully supportive of his colleague's initiatives. However, he also believes there is much more for medicine to discover about the relationship between faith and health, and he's anxious to pursue further scientific study. "There's a huge amount of circumstantial evidence that religion is related to health, but we need to do randomized, clinical trials"-studies similar to those conducted on new drugs or surgical procedures.

Though Koenig is fascinated by what discoveries lie ahead at this 21st century juncture of science and theology, he also offers a word of caution. "We're not saying that doctors should prescribe religion to their patients. Absolutely not," he said. "They should know, though, if religion has any role to play in an illness. It might be positive; sometimes it's negative. Whichever, doctors need to know a patient's spiritual history."

Dr. Koenig is editor-in-chief of Research News and Opportunities in Science and Theology, a monthly publication that frequently covers research and clinical studies on religion and health.
www.researchnewsonline.org

The Center for the Study of Religion/Spirituality and Health at Duke provides detailed information about Dr. Koenig's research.
www.dukespiritualityandhealth.org

The George Washington Institute for Spirituality and Health (GWISH) offers extended coverage of Dr. Puchalski's programs.
www.gwish.org

Stephen Henderson, a writer based in New York City, contributes frequently to the New York Times, The Baltimore Sun, Town & Country, and Religion News Service, as well as other publications.