To the Editor:
In a recent commentary, Puchalski et al1 describe the developing field of “spirituality” and its expansion into health professions education. However, we question whether this promotion really reflects an improvement.
According to Puchalski et al,1 spirituality “encompasses individuals’ search for meaning and purpose; it includes connection to others, self, nature, and the significant or sacred; and it embraces secular and philosophical, as well as religious and cultural, beliefs.” Later in the commentary, the authors present another definition to which Puchalski also has contributed: “spirituality as an individual’s search for ultimate meaning through participation in religion and/or belief in God, family, naturalism, rationalism, humanism and the arts.”2 In the same commentary we are presented with two different definitions, both of which are based on abstract meta-concepts. A crucial question thus presents itself: What is left outside of spirituality? A prerequisite for a meaningful concept is that it is demarcated in relation to other concepts. Puchalski and colleagues’ conceptualization of spirituality lacks this demarcation—it unfortunately qualifies as an example of what Sartori called “conceptual stretching.”3 It becomes a popular catch-all term—it means everything and, therefore, nothing.
Puchalski et al1 report that by 2011, more than 75% of medical schools had “integrated spirituality-related topics into their training programs.” But, since spirituality appears to encompass everything outside of pure biomedicine—it actually seems surprising that this number is not 100%!
At medical education conferences, like AMEE, one can observe that professional identity formation (PIF) is one of the top issues in today’s medical schools. Even if there are local differences, PIF typically encompasses medical psychology (crisis, trauma), social psychology (ethnicity, gender, culture, and group processes), medical ethics, discussions around death and dying, communication skills training, reflection groups for discussing personal experiences, and reflective writing to enhance self-awareness.4 A common conceptualization for this content is “the humanistic side of medicine.” It seems that Puchalski et al would label it all “spiritual.”
In what sense then is the label of spirituality a contribution to the field—why is it not sufficient to talk about the humanistic side of medicine? In our mind, launching a concept in the absence of conceptual coherence, theoretical rationale, and systemic meaning causes more confusion than clarification.
Pär Salander, MSc, PhD
Professor, Department of Social Work, Umeå University, Umeå, Sweden; email@example.com.
Katarina Hamberg, MD, PhD
Professor, Department of Public Health and Clinical Medicine–Family Medicine, Umeå University, Umeå, Sweden.
1. Puchalski CM, Blatt B, Kogan M, Butler A. Spirituality and health: The development of a field. Acad Med. 2014;89:10–16
3. Berger B. Political theory, political science, and the end of civic engagement. Perspect Politics. 2009;7:335–350
4. Lindström UH, Hamberg K, Johansson EE. Medical students’ experiences of shame in professional enculturation. Med Educ. 2011;45:1016–1024