Dr. Christina Puchalski’s medical students were squirming. They had barely gotten used to asking patients questions about sex. Now she wanted them to start asking about spirituality.
“Illicit drugs, sex, and spirituality are the difficult things for us to deal with,” she told the class. “And so is death.”
Puchalski didn’t start out as a physician. She began her career while a research scientist, studying rare genetic diseases at the National Institutes of Health as a doctoral candidate.
But she kept getting pulled away from test tubes toward human beings, especially the very old and the very ill. Several experiences shaped her path—volunteer work that had shown her the cruelty that mentally ill people sometimes endure, contact with severely arthritic patients who found more hope and meaning in life than many able-bodied people, and the death of her fiancé, a psychiatrist, from cancer when she was 33.
When Puchalski entered George Washington University Medical School, she found scant attention paid to patients’ experiences, to the nature of suffering, to how doctors can help. As a student, a resident, and eventually an attending physician and faculty member, she set out to change the teaching and practice of medicine.
Her efforts have resonated beyond GW. Along with colleagues at the med school and at the American Association of Medical Colleges, she is a national leader in helping to enhance doctors’ communication skills and to integrate spirituality—not necessarily religion but a patient’s values and beliefs—into medical care.
She practices what she preaches, spending unusual amounts of time listening to her patients, whether they are young and healthy or in hospice. Now 52, Puchalski is a primary-care physician, a palliative-care specialist, and a geriatrician. She sees patients in the clinic, the hospital, and in homes and hospices.
She also founded and runs GWISH, the George Washington Institute on Spirituality and Health. GWISH trains physicians and other healthcare workers to make spirituality a practical and accessible part of medicine—while making sure it doesn’t stray from the clinically appropriate into proselytizing. Last summer she led a weeklong retreat in Assisi, Italy, where doctors, nurses, chaplains, social workers, and psychologists focused on spirituality in their life and in their work. A second retreat is planned for later this summer.
Her interest in spirituality started early. In her Polish-Catholic household in California, her father taught her to meditate before she could walk. A favorite Protestant teacher at her Catholic high school—who was getting her doctorate in Judaic studies—helped her enroll in teen classes on Hassidic literature at a Jewish institute. In her twenties she learned meditation at a Tibetan monastery. Today she calls herself an “ecumenical Catholic.” But much of her own spiritual life involves her work with patients.
What kind of doctor did you expect to become?
I thought maybe I’d end up at the NIH combining research and seeing patients. I always thought I’d do internal medicine, but I thought maybe hematology/oncology. Or psychiatry. But within two years, I realized primary care was really it. I like looking at the whole human being. And I became interested in hospice.
You set about trying to change medical education while you were still a student. What was missing?
I thought about those arthritis patients at NIH. You walk into a room, you see people who are badly deformed, in wheelchairs, bedridden. You’d think it was pretty hopeless, yet that’s not how they described their lives. They were full of hope, not necessarily for a cure but for all this other stuff in life that had meaning. I knew that at NIH the lectures would focus on the physical; that’s appropriate there. But I assumed that in medical school we’d talk about human suffering, about how people cope. I was surprised how science-based it was. I love science. But suffering didn’t come up very much.
You give your cell-phone number to patients. You spend hours with them. And you let your patients see you cry.
I don’t know how you can do it any other way. Honestly, I think our healthcare system is in more than a crisis if we do not wake up to the fact that all we are doing is putting Band-Aids on things. We say, “Whoops, we’re doing too many tests, it’s too expensive, let’s save money by having doctors see more patients.” But if you can’t take some time talking to your patients, if you say, “I’m sorry I can’t talk to you,” that’s not good care. I get energy from my connections with patients. That’s what gives me meaning in life.
Patients who are seriously ill often want you to tell them how long they have to live, but you can’t know for sure. What do you tell them?
I don’t want to give them too specific a time frame, but I can give them a range of what’s likely for this illness. And I talk to them about what is important in the time they have left. But we need to convey a sense of comfort with our words—blunt and cold is different from honest but compassionate.
Often giving bad news and planning for the end of life happens over multiple visits; it’s not all at once. Sometimes once we finally use the “d” word—death—the patient tells us, “I’ve known that all along.”
How do people facing serious illness—particularly hard-charging Washingtonians—find what’s meaningful to them if they aren’t religious in a traditional sense? How can they bring some serenity to their life?
It can have a lot to do with relationships. If you feel unconnected and not loved by people, that might be a spiritual issue. Some patients can’t step outside themselves, and their pain and dysfunction become the focus. So you have to help them find something outside their illness. And that can take many forms. It can be family, rational thought, science, humanism, the arts, the beauty of the mind.
I had one patient with advanced ovarian cancer. She interrupted her chemo against her doctor’s advice because it was important for her to go hiking with her husband in Washington state. Later when she was in the hospital, she was gaunt, and yet she was radiant. I was running in that morning, feeling rushed, and she said to me, “Did you see the sunrise?” She reminded me that I had not even taken a moment to see the beauty around me.
Now I try to look at the beauty for at least a few minutes each day. And I always remember her when I see the sunrise.
You help your students understand that spirituality can mean many things—traditional religion, New Age, bike riding, intellectual pursuit, time with family, a weekend in the Shenandoahs.
In the clinical context—I’m not talking about theology but the clinical context—it’s important to know how people find meaning in life in the midst of illness, in the midst of crisis. What sustains them, what helps them cope.
My personal concept of spirituality is broad-based, religious and nonreligious. It’s about how one sees one’s relationship with the transcendent, which for me happens to be God. But I’ve encountered people who see it in different ways besides theistic.
Do you do a spiritual assessment of all your patients?
I do it with everybody, the first time I meet someone, and I follow up at annual exams. I don’t necessarily ask it at every visit—for instance, if someone comes in with strep throat. It sort of builds, or it might change; like with everything else, you learn when it’s applicable. Certainly with end-of-life patients it comes up more often. You might have a very healthy person with a crisis in life, and it comes up then.
Your students say it’s easier to ask people about their sex life than about their spirituality.
For some it is. But others think it’s easier to talk about spirituality. We teach the patient-centered model—that’s the buzzword these days. You have to know how to talk about wishes and beliefs, you have to know how to integrate the patient’s family and what that means to them. There’s a lot of mystery. Sometimes people we are sure are going to die—they don’t. People who we think are going to go on forever die sooner. The human organism is very complex.
Are most medical schools now teaching end-of-life skills and spirituality, or are they doing an hour long lecture on opiates and pain management that lets them check off the “palliative care” box?
My sense is that other medical schools may have done pain management—which is major progress. Here spirituality came on board first; we did the pain part later.
Students do expect this at GW, and some come here because they are interested in spirituality and health, or hospice and palliative care. It’s part of the required curriculum, and we have a palliative-care elective for fourth-year students. I’m not the only one teaching these topics.
Our students learn about breaking bad news, about advanced-care planning, what it means to partner with somebody, and to say goodbye to the person in hospice. We’ve looked at how students can come to terms with working with people who are dying. We’ve had real patients come in and talk about terminal illness, and sometimes we’ve had family members. My goal is to have every doctor know how to do it, not just those going into palliative care. Even in pediatrics, even in dermatology. Every doctor should have those skills.
Hospice has been around for more than 25 years, but dying people and their families still don’t always understand it. Now we have this new field of palliative care. Can you explain it?
Palliative-care doctors and nurses get special training in a holistic model of care for people who are dealing with a serious or chronic illness. Death is a likely possibility but not necessarily imminent. And unlike hospice, patients can get concurrent care—they can continue treatment but also have palliative care for physical symptoms as well as emotional, social, and spiritual issues. That includes advanced-care decision-making.
What I love about palliative care is that it takes in the best of all the worlds. These specialists are open to complementary medicine, they are open to spirituality, they are open to the use of arts and humanities as equal to morphine and all of the symptom management we do. We address pain and physical symptoms. But we focus on other dimensions. It’s a model for good care across all life, for medicine in general.
Some doctors don’t want to deal with the dying. But you say it is a privilege.
It’s a privilege, period, to care for anybody whether they are dying or not. We as healthcare professionals are invited into people’s lives in ways that other professions aren’t. It’s very intimate sharing, and people are vulnerable. I don’t know if you have been ill in your life, but I have; it’s scary. For me it was minor, but when it’s dark in that hospital room and you are pushing that button and no one is coming, it’s very lonely. Imagine if you are old or very sick or have dementia. When you are weak, when people are the most naked—and I don’t mean that physically—they are exposed, they are dealing with issues that we all will face. Patients are at that point when they look at their lives in deep and profound ways. Being a partner in that is a very humbling experience.
Not everybody wants to work with people who are dying. Those are tough conversations. But to walk with people in the midst of that is profound and rewarding, and that’s what I try to impart to my students.
You say you’re changed by all of your patients. What have they helped you learn about life?
The bottom line is it’s about love. I know that sounds like a cliché, but it’s a cliché that comes from people who are living it. It’s about loving other people and being present for them and helping them live meaningful and dignified lives—and treating everybody with dignity regardless of their abilities or disabilities.
The kind of things some of us worry about—status things—that’s not important. When people are dying, those are not the things they hold on to. What’s important are their relationships, be it with God or with others, their family. A sense that maybe they have made a difference in the world. For the most part looking back on their life they can say it’s been okay. And they are at peace with that.
You knew Art Buchwald. What was his message about meaning at the end of life?
He asked me, “So what are you into?” I told him spirituality. And of course he had a joke about spirituality. His sense of humor was his way of coping with life and of connecting to people. His final book was all about having a chance to interact with people, and his family, and having his rabbi come by, and eating good food and laughing instead of being on dialysis. It gave him so much meaning. He was enjoying dying. He said it was a blast.
I was in Paris last week, and in the Louvre I thought of that article he wrote, about taking a six-minute visit to the Louvre, the famous three things you were supposed to see. It was bittersweet for me to go through and see the different statues that he had written about. I could see him laughing.
But he was right. The Louvre is overwhelming. If you went in and wanted to see absolutely everything, you’d never be able to, and you’d feel that you’d failed. Instead I did those things that Art Buchwald said were important. And it was a meaningful trip.
