Largely ignored in medical practices of the past are the facts that diseases influence the psyche and that psychological, spiritual and psychosocial factors are of importance both for the preservation of health and for the genesis and development of somatic diseases. The medical community has until recently shown scant interest in the interaction between body and spirit. Today, however, we frequently read and hear about stress©related disorders and "burnout" syndromes and many distinguished researchers predict that the enigmatic interplay of psyche and soma in the human being will be one of the most dominant medical issues in focus during the next millennium. The positive results from scientific studies on the clinical benefits of prayer and belief on health, combined with patients' desire for doctors to acknowledge their spirituality, have led more and more physicians and healthcare professionals to seek education opportunities that, until recently, were unavailable.

Establishing a Spirituality and Healing Institute (SHI) under the auspices of the School of Medicine herein proposed to facilitate the integration of biomedical, complementary, cross©cultural and spiritual aspects of care into the clinical, educational and research programs.

Mission:

The proposed mission of the SHI is to facilitate the integration of biomedical, complementary, cross©cultural and spiritual aspects of care into clinical, educational and research programs of the School of Medicine Department of . Its vision is to become a national and international model of integrative health care by emphasizing self©care and personal responsibility and to explore, develop and evaluate models of health and healing in the new millennium. Principle objectives of the institute are as follows:

To create and nurture a community of healers who are committed to sharing themselves and what they are learning with people in pain, with health professionals who want to transform themselves and their practices and institutions; and with societies that are wounded and dysfunctional.

To create models of healing that will transform patients and healthcare providers in the healing process and make those models as available, as accessible and as influential as possible based on the Pyramid of Healing Model advance in “Who Do You Think You Are”, “The Healing Power of your Sacred Self”, (Bantam, 1998) and Annals of Alternative and Complementary Medicine.

Program Development:

The scope of program development will encompass educational, clinical and research components. All three of these components will evolve from a core (or elective) curriculum educational program focused in the first year of operation on first year medical and nursing students beginning with the Fall 2007 classes. To establish a context and operational structure for supporting the medical and nursing student program, introductory training of medical residents, non©student nursing supervisors, chaplains and hospice staff will be conducted.

The foci of this introductory training will include:

What is health and why do people get sick? A definition of wellness will be advanced and the traditional medical focus, the body, will be contrasted with a multi©dimensionality model encompassing mind and spirit.

Spirituality in care of the dying?
Perhaps no other area of medicine could be more instrumental in eliciting a patient’s spirituality than in the care of the dying. A patient’s spiritual needs are even more important when the patient is not likely to recover from his illness.

Human behavior, spirit and the suppression of spirit via negative
conditioning by:

parents / surrogate parents
cultural
social relationships
principles of behavior modification
integrative models of healing disciplines including the Pyramid of Healing.

Attributes of the effective spirit©based healthcare provider and their implications for:

Cross©cultural medical care medical nursing school entrance and graduation criteria economic impact of spirit©based medicine, i.e. effects on healthcare service utilization, testing hypothesis of increased efficacy and reduced need for healthcare provider intervention.

Courses would be provided by a combination of faculty, adjunct faculty and external advisors to the SHI. During the first year seminars and symposia for faculty and health care professionals in the larger medical and allied health provider community would be offered. An Interdisciplinary Task Force (ITF) of faculty and outside advisors would be formed in the first year to examine trends and critical issues in healthcare education and care delivery develop recommendations for future curricula.

In years two, three and four core (or elective) courses that build on the first year curriculum would be offered to medical and nursing students. These courses would expand on the conceptual models and practical skill sets developed in the first year. Years two and three would emphasize discussion and directed study; the fourth year would focus on specialization. During this period the ITF would assist the SHI in developing a comprehensive plan for weaving integrative / humanistic medicine into the medical and nursing school curricula. During this period, the SHI would design and offer continuing education programs that reach health professionals through the nation. Cross©cultural studies, including the continued scientific evaluation of the world's healing practices, meditation traditions and the importance of religious or spiritual belief in health and healing would be pursued.

Post Graduate Education

Education programs in spirit©based medicine will be organized and delivered as:

Individual and groupings of courses for professionals and allied health professionals seeking to learn about spirituality in medicine but not seeking subspecialty degree or certification groupings of courses for professionals and allied health professionals seeking subspecialty degree or certification in spirituality of medicine public lectures and discussion forums for such groups as the Institute for Civic Partnerships / Healthy Communities and Cities.

A leading topic for post graduate (continuing medical education, CME) seminar conferences would be Enhancing the Process of Healing Physician Heal Thyself. This topic is appropriate given the recent surge of interest in mind©body©spirit issues in medicine. While advances in medical research and technology have led to improved health and healthcare outcomes, cures for patients with many chronic illnesses have been illusive. It is increasingly evident that lifestyle and psychosocial and spiritual factors play and important role in the etiology of stress and chronic illness. These factors are also significant in the management of these illnesses, and in determining the quality of life that patients with such illnesses will be able to anticipate and achieve. The primary touchstone for making a positive impact on these biopsychosocial factors in medicine is the provider©patient relationship. CME programs will examine the broadening of medical practice to encompass an integrated psychospiritual approach to patient care.

Participants will acquire the perspective and skills to facilitate their own self©care and healing, thus increasing their effectiveness in advancing these perspectives and skills in their patients. Attendees would include:

Physicians
Psychologists
Nurses
Clergy
Social workers
Allied health professionals
Healthcare administrators

Other themes for symposia and additions to curricula include:

What is spirituality?
What do the world’s wisdom traditions mean in health?
What is health?
Spirituality and End of Life Care
Medical Research on Prayer
Wisdom Circles
Mindfulness and Stress Reduction
Care of Spirit
Consciousness, Science and Society
Integrating the Best of Conventional and Complementary Approaches
Stress Management With Complementary Touch Therapies
Spirituality and Healing
Spiritual Dimensions in the Healing Relationship

Religion and Spirituality:

How are they the same or different?
Mind©Body©Spirit Approaches in Addictions Treatment

The Ultimate Issue of Who We Are:
Essential Identity
Research Programs

Formal research programs would be planned during the first year of
operation.

Foci of research would include:
Delineation and comparative evaluation of traditional and spirit©based medical modalities of diagnosis and treatment:

depression
stress
cancer
heart disease

reproductive issues (with increased pollution, these issues are becoming more prevalent and affecting not only individuals but offspring as well) surgical recovery death and dying

comparative evaluation of emerging behavior modification modalities

Professional Board Formation

If not mandated by public or professional communities earlier, the (SHI) would, in years five and six, advocate for and participate in the establishment of an international board to credential licensed professionals in spirit©based medicine and to certify standards for continuing education programs in spiritual©based medical, nursing and allied healthcare practice.

Core Faculty for Program Development and Administration

Program Director © Carlos Warter, MD, PhD

Program Objectives (See Attachment A for Operating and Capital Budgets)

Pre©Start Up Program Planning Objectives

Organize Institute offices

Establish Interdisciplinary Task Force (ITF) for collaborative planning with University of HAWAII, School of Medicine faculty / administrative staff and outside advisors to:

Examine trends and critical issues in health care education and care delivery
Develop curricula and faculty / lecturer staffing plan
Assess climate and opportunities for establishing community outreach programs for patients and medical providers
Identify additional grant / funding sources
Conduct introductory training of medical residents, non©student
nursing supervisors, chaplains and hospice staff

Year 1 :: Program Instruction

Complete course work for 1 year medical and nursing student educational programs (3 integrated [medical and nursing] courses)

Evaluate program; revise course as necessary

Organize continuing education programs to be launched in Year 2

Year 2 :: Program Instruction

Conduct annual training of medical residents, non©student nursing supervisors, chaplains and hospice staff

Complete course work for 1 and 2 year medical and nursing student educational programs (6 integrated [medical and nursing] courses)

Evaluate program; revise student and faculty courses as necessary

Complete continuing education programs scheduled for Year 2

Organize continuing education programs to be launched in Year 3

Year 3 :: Program Instruction

Conduct annual training of medical residents, non©student nursing supervisors, chaplains and hospice staff

Complete course work for 1 and 3 year medical and nursing student educational programs (includes 9 integrated [medical and nursing] courses)

Evaluate program; revise student and faculty courses as necessaryComplete continuing education programs scheduled for Year 3

Organize continuing education programs to be launched in Year 4

Year 4 :: Program Instruction

Conduct annual training of medical residents, non©student nursing supervisors, chaplains and hospice staff

Complete course work for 1 and 4 year medical and nursing student educational programs (includes 12 integrated [medical and nursing] courses)

Evaluate program; revise courses as necessary

Complete continuing education programs scheduled for Year 4

Organize continuing education programs to be launched in Year 5

Year 5 :: Program Instruction

Conduct annual training of medical residents, non©student nursing supervisors, chaplains and hospice staff

Complete course work for on©going classes of medical and nursing students

Evaluate program; revise courses as necessary

Complete continuing education programs scheduled for Year 5

Organize continuing education programs to be launched in Year 6

Major Themes in Research and Media Supporting
Development of Educational Programs in Spirituality In Medicine
Americans See Spiritual Advocacy as Physician’s Role ©
A recent CNN/Time poll three©quarters (74%) of Americans feel a physician should either introduce a discussion about a patient's spiritual needs; refer patient to a rabbi, priest, minister or other spiritual advisor; or suggest prayer to a patient as part of the
patient's treatment.

Physicians Want Formal Medical Training in Clinical Applications of Spirituality©Relaxation and meditation techniques should be a standard part of formal medical training. However, only 20% said they actually received this training during medical school. In fact, their patients have picked up on their lack of training in this area.

Over Half (54%) Of Americans Believe Physicians Should Receive Special Training, Either During Or Following Medical School, To Learn How To Incorporate A Patient's Spiritual Needs Into Medical Treatment ©© Already 30 of the nation's top medical schools and several psychiatric residency programs train physicians to address their patients' spiritual needs as well as provide medical care. In these programs, chaplains join physicians and students on hospital rounds, and the students learn to tap each caregiver's expertise © from palliative care and meditation to hospice © forming a health care team that treats both body and spirit. Caregivers from all sectors of medicine are interested in this type of training. Nurses, social workers, counselors, family physicians and psychiatrists, all interested in learning about the physiological, neurological and psychological effects that spirituality has on healing chronic and acute illness, depression and stress.

Spirituality Is A Key Issue In Care For The Dying ©© Perhaps no other area of medicine could be more instrumental in eliciting a patient's spirituality than in the care of the dying. A patient's spiritual needs is even more important when the patient is not likely to recover from his illness. Ninety percent of Americans (90%) believe that, in end©of©life situations, when a patient's illness can no longer be helped or cured by medical treatment, a physician should either open up discussion about the patient's spiritual needs; volunteer to refer the patient to a rabbi, priest, minister or other spiritual advisor; suggest prayer to the patient as part of the patient's treatment; or volunteer to refer the patient to a hospice. However, only 24% said that when they or their family were faced with such a situation, the physician takes spiritual needs into consideration.

Securing Medical Coverage, Insufficient Medical Education And The Lack Of Health Care Coverage Really Go Hand©In©Hand ©© Improvement in one area will positively impact the other, as physicians learn exactly how to complement traditional medical and surgical therapies with these mind/body techniques, it's only a matter of time before health plans follow suit with medical coverage. According to a recent survey, 55% of Americans say they would choose a health plan that included spiritual and religious healing practices over another health plan that did not. Yet, nine in ten (89%) HMO professionals said that the rules and policies of their health plan or institution do not take into account scientific data and research findings regarding the relationship between spirituality and well©being. In order to consider providing more health care coverage for spiritual and meditative practices, the HMO executives said they would need direct evidence of clinical effectiveness (76%), cost savings (65%) and patient satisfaction (62%). This will require active research and publications in the field.

Prayer, Meditation And Other Spiritual And Religious Practices Continue To Undergo Careful Randomized And Controlled Evaluations To Identify Verification And Reproducibility ©© Health plans will have to reconsider their policies as an increasing number of scientifically sound research studies become available. A patient's spirituality is an important component of the healing process. Specifically, 86% of Americans, 99% of family physicians and 94% of HMO professionals believe personal prayer, meditation or other spiritual and religious practices can accelerate or generally aid in the medical treatment of people who are ill.

The Role of Spirituality in Patients' Ability to Prevent, Cope with or Recover from Illness ©© As the miracle of modern medicine continues to demonstrate, there is no boundary to human ingenuity. Growing understanding of the biological basis for disease and healing
combined with modern medications and procedures, have produced dramatic improvements in patient survival and quality of life in the United States. But a growing number of scientific studies in the last decade have found that the patient's spirit and even his religious conviction is both protective from illness and a compelling part of the recovery process. In addition, survey data suggest that most Americans, their physicians and their health plans see spirit/body/ spirit connection as important to health care (Time/CNN poll, Time Magazine, 1995; John Templeton Foundation Family Physician survey, 1996, and HMO executive survey, 1997. All surveys by Yankelovich Partners). While the scientific literature on spirituality, religion and healing is growing and is highlighted below through both epidemiological studies and clinical trials, ongoing work should produce more results over the next few years.

Spirituality can Prevent Illness © Those who attend religious services, at least once per week, have been shown to have stronger immune system function (Koenig et al 1997a), compared with less frequent attendees. Older adults who attend religious services at least once a week and pray or study the Bible at least once a day are 40% less likely to have hypertension than those who attend serves and pray less often (Koenig; 1998).

Substantially lower rates of smoking among persons more religiously involved is likely to translate into lower rates of lung cancer, coronary artery disease and chronic obstructive pulmonary disease. (Koenig; 1998) Spiritual Patients Better Cope with and Recover from Illness ©© 40% of hospitalized patients say their religious faith is the most important factor that enables them to cope (Koenig; 1998). This has also been documented for patients with gynecologic cancer (Roberts, et al; 1997), other types of malignancies (Kaczorowski; 1989), end stage renal disease (O'Brien; 1982), open©heart surgery (Oxman, et al; 1995), cardiac transplantation (Harris, et al; 1995), Alzheimer's disease (Whitlatch et al1992) and health problems related to aging (Conway; 1985). Patients are three times more likely to survive open©heart surgery if they depend on their religious faith (Oxman, et al; 1995). Those who attend religious services, at least once per week, maintain their physical activity significantly longer (Idler & Kasl; 1997), compared with less frequent attendees. At the time of discharge, hip©fracture patients who are religious walk longer distances and have less depression than non©religious patients do (Pressman, et al; 1990). Religious values and practices (defined a number of different ways) have been shown to result in faster recoveries from depression (Koenig, et al; 1997; Props, et al; 1992) and anxiety (Azhar, et al; 1994). * If prayed for, patients have fewer complications when admitted to an intensive care setting (Byrd 1988).

Cost©Benefit of Faster Recoveries ©© Heart surgery patients who are religious have 20%shorter post©operative hospital stays than non©religious patients (McSherry, et al; 1987). Hospital stays are nearly two and one©half times longer for older patients without a religious affiliation, compared to older patients with any religious affiliation (Koenig & Larson; 1997). The same study shows that older adults are less likely to be hospitalized if they regularly attend religious services. Black schizophrenic patients are less likely to be re©hospitalized if families encourage them to continue religious worship while in the hospital (Chu & Klein; 1985). Patients assigned daily chaplain visits have shorter hospital stays, use less RN time, and use fewer pain medications (Florell; 1973). Heart surgery patients assigned chaplain intervention showed an average 2 days shorter length of stay, or about $4200 cost©savings per patient (Bliss et al 1995).

Spiritual Patients Live Longer, Healthier Lives ©© A prospective, matched©control study of persons living in religious kibbutzim versus secular kibbutzim in Israel, demonstrated pervasive morbidity and mortality advantages to those who led religious lives, even in comparison with those in a tightly©knit community without religious focus (Kark, et al; 1996). Over a 28©year study period, the risk of dying was almost 25% less (35% less in women) for frequent religious service attendees, after controlling for health practices, social ties, and well being (Strawbridge ,et al; 1997). Elderly persons who attended religious services were 36%less likely to die. Even after controlling for a number of variables, like chronic disease, disability, smoking and alcohol use and weight, elderly persons who attended religious patients were 24% less likely to die during the 5©year follow up. (Oman; 1998)

CARLOS WARTER MD