We are taught as medical students to be holistic in our management approach, considering a patient's physical, emotional, social and spiritual needs. However, step into the hectic buzz of a ward... bleeps, patient alarms, drips going off, a patient's relative asking questions, another patient being taken away for physiotherapy, for x-ray, for theatre... and a holistic approach, good in principle, suddenly becomes a lot more difficult to express in reality. I have noticed from the experience that I have had on wards, that often it is spiritual care that is most neglected. Even when filling in 'patients' religion' on A&E forms I have been advised just to put 'not known' rather than asking. Why is this? Time pressures? Lack of training in this area? The assumption that spiritual care should be left to pastors and chaplains to give to those who are 'religious'?

spiritual needs

Such an assumption sits uncomfortably with me for several reasons. One is that it draws the conclusion that only people who have a defined religion have spiritual needs. I have found that there is generally a misunderstanding in society around what is 'spiritual' and what is 'religious'. For us as Christians, our spirituality is an expression of a relationship with the one true, living God, who sent his Holy Spirit to dwell in us when we became believers. (1) However, even the secular definition of Murray et al makes it clear that there is a distinction: 'a quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those that do not believe in any god.' (2)

Even 'secular spirituality' is about relationships - with yourself, other people, nature or God - which are thought to bring us closer to unity, compassion and cooperation. The whole idea lies in opposition to our 'extreme individualism of post- Enlightenment Western culture' (3) which puts pressure on us to see the concept of all as spiritual beings as out-of-date and irrelevant, particularly as church attendance figures continue to plummet. However, many studies would suggest otherwise. Western medicine has been blamed for separating the 'mind, body and spirit (which) are integrally connected'. (4) 76% of non-church attendees when questioned admitted to spiritual and religious experiences and 71% had an important spiritual belief even though it may not have been expressed in a religious way. (5) 75% of people in another survey were aware of a spiritual dimension (interestingly, this is an increase from only 48% reported in 1987). (6)

These statistics imply that a spiritual dimension still deeply affects each one of us. The awkwardness and embarrassment noted in the people who were questioned highlights how frequently spirituality is misunderstood and viewed superficially as little more than a taboo subject that is only relevant for 'religious' people. I believe that it is essential that we do not fall into this trap, but see everyone as a spiritual being with spiritual needs which need to be explored and given the opportunity to be expressed.

patients may have specific spiritual needs

In the medical profession, we will come across people who have specific spiritual needs due to their circumstances. The Bible says that God shapes us in times of hardship: See, I have refined you, though not as silver; I have tested you in the furnace of affliction. (7) Periods where we face difficulties such as ill-health can make us more like Jesus and allow us to rely more on God, or they can be times of doubt, disappointment and movement away from God. Whichever way, illness may well be a time for our patients when the spiritual dimension to their being is brought into focus, challenged and changed. The GMC acknowledge that 'Patients' personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness or treatment.' (8) This is backed by Robert et al who concluded that 93% of cancer patients said that a spiritual hope helped them to cope. 9 The fact that the GMC accept this cannot be ignored but instead highlights that (contrary to popular belief) the NHS is still a place where spirituality can be explored. I have volunteered a couple of times as an assistant hospital chaplain and was amazed at how well received we were and how grateful patients were for us taking the time to be with them, seeing them as individuals and whole people with a wide range of needs.

our responsibilities

Yet, do we as medical students, and in the future as doctors, have a part to play in helping our patients to explore their spiritual needs and express them? If we believe that the duty of a doctor is: 'to cure sometimes, relieve often, and comfort always', (10) then surely part of this process is acknowledging all patients under our care to be whole people with physical, emotional, social and spiritual needs. In our attempts to fulfil Christ's commandment to love our neighbours as we love ourselves, we need to be acknowledging our patients as more than a fractured humerus in A&E or an MI in bed 2, thus showing that we are genuinely concerned for their wellbeing.

This could lead to a positively therapeutic patient-doctor relationship and increase the overall effectiveness of any interventions. (11) It is 'faith, hope and compassion (that enable) people to accept and live with otherwise insoluble problems' (12) and by nurturing these we can 'promote the healthy grieving of loss and the maximising of personal potential.' (13)

The GMC states that: 'For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs.' (14) Therefore, being aware of and addressing spiritual needs is not just acceptable but, in fact, encouraged by the GMC, and can provide comfort and healing even when a physical cure is not possible. An interesting illustration that I found useful has been made by Culliford, who likens the need for good physical nutrition for physical healing to occur to also needing good spiritual nourishment for a fuller notion of healing to occur. (12)

There is a growing amount of evidence to support this claim. Koenig et al analyse 1,200 studies and 400 reviews looking into religion and spirituality, and in many physical and mental health conditions demonstrated that there was a 60-80% relation between being spiritually aware and having better health. (15) This included studies covering conditions as wide ranging as heart disease, immunological dysfunction, pain, substance misuse, psychoses and depression. The areas of health most notably better were in prevention, the ability to cope with illness, recovery from surgery and treatment outcomes. For example, it was shown that patients who had a faith were three times less likely to die after cardiac surgery. (16) Further to this, forgiveness, serving others, having a support network and a time to be quiet and reflect all appear to promote health and wellbeing. (17)

a spiritual history

This gives us an understanding of the importance of taking a spiritual history. Questions asked should give you an indication as to whether the patient has a religion, how they express their spirituality (eg do you have a faith that helps you in a time like this? have you ever prayed about your situation?) and if they have a faith community for support. These may give you the starting point necessary to explore their spiritual needs and how you could best move on to address them. This depends what is requested but may involve contacting someone in the faith community, praying with the patient, offering insight into your faith and working alongside the chaplains.

In conclusion, evidence suggests that the majority of the population are still aware of their spiritual dimension, although the sense of being religious is decreasing. Therefore, these people will be affected by ill-health in a spiritual way as well as physically, emotionally and socially. As Christians, we should be striving to love others with a genuine love and serve God through providing the best medical care possible.

It is vital that we are constantly looking for this care to be patient-centred and holistic in reality as well as in the lecture theatre. This includes spiritual care; giving patients the opportunity to explore and express their spiritual needs, which may help their outcome in many ways - how they respond to treatment, recover from surgery and giving them a means to cope and be comforted even when everything else is looking bleak. I believe, therefore, that providing spiritual care is a responsibility that medical students, doctors and other healthcare staff must address and work towards achieving alongside pastors and chaplains.