EDUCATION

Spirituality in Surgical PracticeJohn L Tarpley, MD, FACS, FWACS, Margaret J Tarpley, MLS

The role of spirituality in surgical practice has long beenrecognized as important, but it is only now receivingdetailed analysis. In 1910 the British Medical Journalinvited Sir William Osler, the premier physician of hisday, to editorialize about people who depended on faithand prayer rather than medical professionals for treat-ment and healing. Osler concluded this editorial withthe comment, “. . . the whole subject is of intense inter-est to me. I feel that our attitude as a profession shouldnot be hostile . . . A group of active, earnest, capableyoung men are at work on the problem, which is of theirgeneration and for them to solve.”1 Four generationslater the question remains unresolved.

Unfortunately, until the last decade or so the aca-demic medical community has expressed little interest inor support of physicians, and especially surgeons, whoattempt to shed light on spiritual issues as related tomedical outcomes. Arguably the most imaginative andproductive surgeon scientist of the early 20th centurywas Alexis Carrel of France. In 1903 he witnessed andrecounted a scientifically unexplainable (miraculous?)healing of a pilgrim in Lourdes.2 Subsequent to the re-sultant publicity, surgical superiors at the University ofLyon warned that he would likely fail his final examina-tion; this threat possibly contributed to his leavingFrance for the United States, where he later received the1912 Nobel Prize in physiology.3 His account of theLourdes experience and a small volume on prayer4 wereboth published posthumously.

Another surgeon who applied academic scrutiny to

the study of spirituality as understood in psychologicterms was Barney Brooks, chairman of surgery atVanderbilt University Hospital from 1925 to 1951. Inthe early 1940s Brooks secured funds from the Rock-efeller Foundation to assess the psychologic makeup andneeds of surgical patients. Brooks reported the findingsin his 1943 presidential address, “Psychosomatic Medi-cine” at the Southern Surgical Association. His col-leagues responded negatively when he asserted that men-tal preparation and the patient’s mindset were on parwith surgical skill, so the surgeon was responsible inassisting with this mental preparation. Brooks also ad-dressed the psychologic nature of the surgeon as vital tothe patient-physician relationship, deeming some tech-nically skilled but socially deficient people unworthy ofthe surgical profession.5 Although Brooks’s study designwould never be approved by any institutional reviewboard today, his conclusions asserting the importance ofa surgeon’s social interactions with patients were farahead of his time. Matthew Walker, chairman of surgeryat Meharry Medical College from 1944 until 1973, in-sisted that medical students and physicians needed to bein touch with their own mortality if they were to assistpatients and their families in dealing with end-of-lifeissues.6

Addressing the role for spirituality in surgical practiceinvolves the historical perspective, definition clarifica-tion, public opinion, current practices, funding, com-munication skills, and even accreditation requirements.Spiritual issues daily influence academic medical cen-ters. Chaplaincy services, while often underused, exist inmost medical centers. Hospital food services accommo-date Muslim, Jewish, vegetarian, and other dietary re-strictions. Scheduling of clinics, procedures, and evenstaff vacations frequently takes into account religiousholy days. Challenges to hospital regulations concerningclothing, hairstyles, and head coverings arise from cul-tural and faith traditions. Some surgeons have developedspecial techniques in caring for Jehovah’s Witnesses be-cause of their aversion to blood products. Beliefs aboutafter-death physical wholeness lead some patients and

No competing interests declared.

Vanderbilt University School of Medicine is recipient of a John TempletonSpirituality in Medicine Curricular award through the National Institute ofHealthcare Research (now known as International Center for the Integrationof Health & Spirituality). John L Tarpley, MD, is principal investigator.

Received November 16, 2001; Revised December 26, 2001; Accepted De-cember 28, 2001.From the Surgical Service, Veterans Affairs Medical Center (JL Tarpley), andthe Department of Surgery, Vanderbilt University School of Medicine (JLTarpley, MJ Tarpley), Nashville, TN.Correspondence address: John L Tarpley, MD, Surgical Education Office,Department of Surgery, Vanderbilt University School of Medicine, Nashville,TN 37232-2730.

642© 2002 by the American College of Surgeons ISSN 1072-7515/02/$21.00Published by Elsevier Science Inc. PII S1072-7515(02)01174-2

families to refuse procedures such as colostomies, ampu-tations, and even post mortem examinations. Belief sys-tems influence end-of-life treatment decisions and shapeattitudes concerning abortion, fetus gender preferences,euthanasia, and stem cell research and applications. Eco-nomic and justice questions relating to healthcare accesscontain elements of the spiritual. Currently on the nurs-ing intake history for patients admitted to Veterans Af-fairs Medical Centers and other government hospitals isa question concerning spiritual or religious beliefs thatcould influence medical decisions. Although spiritualitypervades the medical environment, determining the ap-propriate role for it to play in the physician-patient re-lationship requires attention to historic precedent andmore recent developments on this subject.

The modern hospital rests on a spiritual foundation,evolving as a response of the Church to provide “hospi-tality” to pilgrims, travelers, and the poor. In Europeansocieties for several thousand years including the first1,500 years of the Common Era, many people whotreated physical ailments also dealt with psychologic,social, religious, and spiritual matters. Intellectual devel-opments of the Renaissance and Enlightenment resultedin a dichotomous world view: religion versus science;spiritual versus material; church versus state. In non-European cultures such as Native American, African,Middle Eastern, and Asian societies, healing and spiri-tuality remain unified.

Two semantic problems arise when debating a role forspirituality in surgical practice: defining spirituality anddistinguishing spirituality from religion. The word forspirit in Hebrew, Greek, Japanese, and Chinese can alsomean breath, and wind, implying something that ani-mates or gives life. At least 30 definitions of spiritualityexist, none offering total satisfaction. Spirituality may beany of the following: the unifying principle of a person’slife in whatever outward or inward expression it takes;religious beliefs and practices; the soul; belief in a higherbeing or creative force; a sense of community with gen-erations past, present, and future with its emphasis onprogeny. In our definition spirituality includes every-thing about a person that is not physical—personality,intelligence, psychology, and emotions. The word reli-gion connotes beliefs, often accompanied by a body oforal or written teachings. Related to the words ligamentand obligation, religion derives from the Latin word re-ligare, which means to restrain or tie back. Just as ananterior cruciate ligament binds the knee but allows mo-

bility, religion and religious beliefs can offer stabilitywithin rules or restraints. Although the terms are cer-tainly not synonymous, correspondence occurs. Broadlyspeaking, relationships of spirituality and religion rangefrom the congruent as in the case of intrinsic religiosity7

to the separate and distinct.Spirituality and religion both involve faith. In his

1910 editorial, Osler enumerated several types of faith,including faith in an unseen power that inspires wor-ship; faith as the relation binding man to his fellow; faithin oneself; and faith in practitioners of the healing arts,scientific and spiritual. Traditionally, academic consid-eration of spiritual matters occurred in divinity schoolsand departments of religious studies, anthropology, andsociology.

The National Institutes of Health offer funding forstudies on spirituality as one of the numerous esotericcategories of complementary and alternative medicinethat might offer hope for persons suffering with canceror HIV-AIDS. Researchers are investigating how thebrain influences immune function through hormones,particularly those in the hypothalamus-pituitary-adrenal axis, and how immune messengers in turn affectthe brain.8 Spirituality has drawn the attention of thesemedical researchers who investigate the effects of mentalattitudes, including prayer and other spiritual exercises,on chemical and neurologic activities in the brain. Onecurrent study at the Johns Hopkins Hospital looks at theeffects of prayer on disease recurrence, immune, andneuroendocrine function in African-American womenwith breast cancer.9 The John Templeton Foundationfunds the development of curricula on the relationshipof spirituality to medical practice. As of 2001, more thanhalf the 126 American medical schools offer suchcourses. The Association of American Medical Schools(AAMC) has for several years cohosted a spirituality,medicine, and end-of-life conference with the Interna-tional Center for the Integration of Health & Spiritual-ity (formerly known as the National Institute of Health-care Research). The 1999 AAMC national meetingfeatured 25 presentations related to spirituality andmedicine, cultural competency, religion and healthcaredelivery, ethics, palliative care, and end-of-life concerns.

Historically, few surgeons investigated these areas.Currently, aspects of spirituality coming under scientificscrutiny include prayer and its relationship to healing,efficacy of religious participation, communication com-petence of physicians, sensitivity of medical profession-

643Vol. 194, No. 5, May 2002 Tarpley and Tarpley Spirituality in Surgical Practice

als to culture and ethics, and end-of-life issues. Publicopinion polls and hospital surveys indicate that a major-ity of patients want their physicians to discuss spiritualissues with them, yet studies reveal that many physiciansare uncomfortable in conversations that involve spiritualand psychological issues. Andrew Sims, former presidentof the Royal College of Psychiatry, speaks of personalreligious experience as the third great taboo of the 20thcentury after sex and death. For the patient’s own bestinterest, Sims advises evaluation of his or her religiousand spiritual experience in etiology, diagnosis, progno-sis, and treatment.10 If the patient-centered approach11

to medicine is the gold standard, then spiritual aspects ofeach person must be considered.

Medical databases reveal abundant articles on religionand medicine, prayer, spirituality, ethics, and ethnic andcultural issues. An increased academic surgery interest inthe effects of prayer and religious activities began in1988 when Byrd reported positive effects of prayer oncoronary artery bypass patients in San Francisco.12 In the1990s Harris attempted to replicate the study and re-ported mild positive correlations.13 Keith Thomsonsummarized a number of these prayer study articles withthe observation: If you’re a believer you don’t need proofand if you’re a skeptic you won’t accept proof. One canalways find something wrong with the materials andmethod of the experimental design with too many vari-ables.14 Studies of older adults in North Carolina15,16 andof adults in Israeli kibbutzim17 suggest statistically sig-nificant health benefits (including survival) from reli-gious participation. The 2001 Handbook of Religion andHealth reviews 1,500 articles with the majority demon-strating the positive correlation of religious activities andhealth.18 Critics may accept association of religious, spir-itual, or communal practices and health benefits but notconcede causation. The Cochrane criteria for class I datahave been used to evaluate studies on the efficacy ofdistance healing (prayer). After deleting substandardstudies the investigators admitted there appeared to besome unidentified factor in the well-designed papersworth further study.19 In a recent, well-designed studyCha and associates20 reported their masked, randomizedtrial of women undergoing in vitro fertilization—embryo transfer wherein the prayed-for group had al-most twice the implantation success rate. A major defectof any prayer study remains the lack of a totallyunprayed-for group. Even in the light of possible bene-fits, academic centers continue to debate and agonize

over the propriety of conducting clinical trials on spiri-tual intercession.21 CS Lewis posed the question, “Whatsort of endeavor would prove the efficacy of prayer?” andconcluded that “a compulsive empirical proof such as wehave in the sciences can never be attained.”22 Chibnalland coworkers23 have provided a cogent statistical andphilosophical critique of the various experiments on dis-tant intercessory prayer. Echoing the thought of CSLewis, they concluded “that research on the effects ofreligion and spirituality on health should avoid attempt-ing to validate God through scientific methods.” Re-gardless of the interpretation of medical benefits fromprayer, religious activity, or social support, medicalinstitutions and teachers admit the need for improv-ing physician communications and interpersonalskills.

Medical accreditation agencies and specialty reviewboards now focus attention on spiritual, ethical, andmoral issues. The Joint Commission on Accreditation ofHealthcare Organizations requires that the spiritualneeds of patients be addressed.24 The AccreditationCouncil for Graduate Medical Education (ACGME)outlines six broad areas of general competencies thatresidencies must address; at least two areas hold spiritualimplications: interpersonal and communications skillsand professionalism.25 The ACGME also requires insti-tutions to provide residents a regular review of ethicalissues that affect graduate medical education and medi-cal practice.26 The American College of Surgeons Preambleto the Statement of Principles declares its commitment tothe ethical practice of medicine, which “establishes andensures an environment in which all individuals aretreated with respect and tolerance; discrimination or ha-rassment on the basis of personal attributes, such as gen-der, race, or religion, are proscribed.”27 The AmericanBoard of Surgery certifying exam includes assessing thesurgeon’s understanding of and “sensitivity to moral andethical issues.”28 The very words ethical and moral re-quire subjective judgment and have spiritual and legalimplications.

“There was a time when the analytical and technicalskills of the surgeon were sufficient to carry the day ofthe doctor-patient relationship . . .This is no longer thecase,” according to Milch and Dunn.29 With ACGMEguidelines mandating competency in interpersonal andcommunications skills, residency programs search foreffective methods of honing these skills. Mutual respect,active listening, and true dialogue are necessary if mean-

644 Tarpley and Tarpley Spirituality in Surgical Practice J Am Coll Surg

ingful communication is to take place between physi-cians and patients. General surgeons and orthopaedicsurgeons permitted video cameras in their offices for astudy on surgeon-patient communication. Analyses ofthe tapes revealed that surgeons tended to provide infor-mation, talk more than the patients, and not allow thepatient sufficient time to ask questions, express con-cerns, or share personal information.30 Accompanyingthis report in Surgery were editorial comments by Sarrand Warshaw on surgeons’ assumptions that all patientquestions are answered and understanding occurs.31

Braddock and coworkers32 assert that surgeons focus onPAR: procedure, alternatives, risks.

Just as institutions provide sensitivity training on sex,gender, and racial issues, education for encounters in-volving spiritual and religious issues should be a part ofresidency training. Helping surgeons understand thespiritual concerns of patients and encouraging healthprofessionals to form partnerships with chaplains, thepatients’ own spiritual mentors, social workers, and psy-chologists become the responsibility of the medical ed-ucational system. When physicians address spiritual top-ics with patients, the power inequality of the doctor-patient relationship must be considered. A boundaryviolation can occur unless a faith-system-neutral spiri-tual dialogue ensues. Proselytizing (attempting to con-vert to or impose a faith system) by the physician istotally inappropriate and unacceptable except in thoseinstitutions with clearly stated religious or spiritual mis-sions. The patient’s own spiritual beliefs are paramountas the doctor seeks to address concerns and to learn howthese spiritual concerns will affect the patient’s under-standing of the disease process, his or her fears, andperhaps even his or her decisions regarding treatment.Informed consent may be anything but. The currenttrend toward outpatient practice may be injurious forresident and medical student education. Medical stu-dents and residents may not have been present duringthe office visit when the attending physician explainedthe procedure and obtained the operation permit.Night-before-procedure admissions allowed time forresidents and students to interact with the patient anddiscuss procedures and outcomes in a less hurried atmo-sphere and perhaps form a personal relationship, a lux-ury disallowed by early-morning admissions. Accordingto William Silen of Boston, “In some programs, resi-dents actually do a history and physical in no more than

10% of the patients with whom they are involved in theoperating room.”33

Physician time has frequently been limited by heavyworkloads. Unfortunately, a business notion of time asmoney, with an emphasis on efficiency, has invadedmedical practice. In a surgical practice, time spent inoffices or at the bedside must be subtracted from themore “valuable” operating room time. Listening skillscan be enhanced just as technical skills can be im-proved.34 Focusing attention on body language and ver-bal responses, making eye contact, and asking questionsrequiring more than affirmation or negation is a start.One study35 suggested that data elicitation was improvedwith the asking of open-ended psychosocial questionsand increasing the time patients themselves talked. Dis-cerning the patient’s level of understanding and his orher anxieties assists the physician in decision making.Practical suggestions for improving in-hospitalphysician-patient interactions with a minimum ofadded time include: reviewing the patient’s chart (as-suming it is paper!) in his or her room rather than out inthe hall; sitting down at the bedside rather than standingin the doorway or at the foot of the bed; touching thepatient by shaking hands or taking a pulse; talking to thepatient and not just the nurse or other health profession-als; making eye contact with the patient; and verballyacknowledging family members present. In the clinic,reviewing records in the presence of the patient ratherthan the hall or the workroom increases the interactiontime. Inquiring about the hometown or family situa-tion suggests concern beyond the primary complaint.Chaplains or social workers should be consultedwhenever the physician senses spiritual or psycholog-ical stress related to uncertainty of outcomes, generalanxiety, anger, or end-of-life concerns.

End-of-life decisions often involve questions of a spir-itual or ethical nature. Most patients answered “Yes” tothe following questions: “Do you want your physician toinquire about your spiritual or religious beliefs if youbecome gravely ill?” and “Do you have spiritual or reli-gious beliefs that would influence your medical decisionif you became gravely ill?”36 This latter question is on thenursing intake history for patients admitted to VeteransAffairs Medical Centers and other government hospi-tals. The American College of Surgeons Statement onPrinciples Guiding Care at the End of Life states: “Recog-nize, assess, and address psychological, social, and spiri-tual problems.”37 The end-of-life consensus panel from

645Vol. 194, No. 5, May 2002 Tarpley and Tarpley Spirituality in Surgical Practice

The American College of Physicians, American Societyof Internal Medicine produced material on palliativecare and developed three sets of open-ended questions.38

In summary, historical and present-day evidence andpractices support greater attention to the spiritual as-pects of surgical practice. Spirituality in the medical en-vironment and the relation of spirituality to healing arenot recent innovations. Spirituality can be separatedfrom organized religion. Health benefits of spiritual andreligious practices have been identified (though not ex-plained) in a number of studies and creditable funding isnow available for further investigation. Medical boardsand accreditation agencies require that spiritual needs ofpatients be addressed. Patients want physicians to dis-cuss spiritual issues. Spiritual dialogue can enhancephysician-patient communication and relationship.Nearly a century after Osler’s charge to study prayer andspiritual issues in health and healing, scientific scrutinyof the mechanisms involved has begun.

Author ContributionsStudy conception and design: Tarpley J, Tarpley MAcquisition of data: Tarpley J, Tarpley MDrafting of manuscript: Tarpley J, Tarpley MCritical revision: Tarpley J, Tarpley M

Acknowledgment: The spirituality in medicine initiative atVanderbilt includes Bonnie Miller, MD, FACS, Mary LouO’Gorman, MDiv, Gerald Gotterer MD, PhD, and ListonO Mills, PhD, Vanderbilt Divinity School. Michael Sarr,MD, FACS, provided invaluable insights. We appreciatethe support and encouragement of James A O’Neill, Jr,MD, FACS.

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647Vol. 194, No. 5, May 2002 Tarpley and Tarpley Spirituality in Surgical Practice