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Posted: May 19, 2006

Spiritual Caregiving

Creating a Culture of Health: A Telling Interview with Ralph Snyderman

How can we bridge the gap between high-tech and high-touch medicine to provide the best possible healthcare?

We asked Dr. Ralph Snyderman, who has combined a career as a world-class scientific researcher, physician, and medical educator with a more recent passionate advocacy of integrative medicine, which combines the best of mainstream and alternative medicine. For 15 years, Snyderman, 65, who looks like Clint Eastwood in a lab coat, served as chancellor for health affairs and dean of the medical school at Duke University in Durham, North Carolina.

Under his watch, Duke established the Center for Integrative Medicine in 2000, and Snyderman was awarded the first Bravewell Leadership Award in 2003 for outstanding achievement in that field. He has received numerous honors for his research on inflammation, and served as senior vice president for research and development at the biotech firm Genentech, Inc.

He has also been a strong advocate for mindfulness and spirituality in health and medicine -- all of which has led him to be called a "twenty-first-century doc." We asked him his views on medicine today -- and tomorrow.

You wrote, in a recent article, "Most of our nation's investment in health is wasted on an irrational, uncoordinated, and inefficient system that spends more than two-thirds of each dollar treating largely irreversible chronic diseases." How are our healthcare expenditures being wasted?

By wasting, I mean spending well over a trillion dollars a year on acute episodes of late-stage chronic diseases, which in many instances are not reversible. That money could be far better deployed to focus on preventing chronic diseases from progressing to the severity where we're currently intervening and "wasting" so much money rather than improving people's health.

How can we do that?

The short answer is, by using our capabilities to better understand and decrease risk -- that is, knowing the likelihood of things happening before they occur and encouraging people to do something about it to help themselves. It's much more cost-effective. The capabilities coming from research, science, and technology are allowing us to anticipate each individual's risk and predict events -- and when events occur, to have a better way to individualize therapy.

Do we have the technological capability to predict these events through testing?

Testing and know-how. It's really a matter of focus. I think physicians -- certainly I, and, unfortunately, most physicians being trained in even the nest medical schools today -- are trained to think of care starting with the onset of disease. But we're beyond that in terms of our capabilities. We ought to train everyone in healthcare to think: "Given the specific needs, opportunities, and risks of the patient in front of me, what can I do to help that person avoid problems before they occur?"

Maybe even more important, we need to shift the emphasis from people expecting the health care system to always give them a pill to x their problem. It would be wonderful if that were possible for every malady, but it isn't. Individuals must take more responsibility, ownership, and maintenance of their health.

Are you talking about changes in lifestyle?

Yes, changing lifestyle, changing mindsets, and changing values. This gets into integrative medicine and issues related to spirituality and health. Once an illness occurs, science and technology can now begin to provide us with tools to predict and determine the best outcome or consequence of intervention. In the near future, these tools will predict risk of events, enabling earlier intervention. This predictive capability shifts a great deal of responsibility to the individual. Most individuals are well for most of their lives, but when disease occurs, it's often too late to do much about it. If you're going to rely on the healthcare system when something happens, the likelihood that your disease will be reversible is much less than if you had intervened earlier through your own behavior.

The irony is that science and technology, while giving us wondrous tools to improve health, will shift far more responsibility to the individual. Individuals will need to take charge of their own health and will have the capability to make a real difference if they are willing to make changes.

You are trained as an immunologist and a rheumatologist, as a scientist and a physician. How did you come to think about these healthcare system changes in the context of values and spirit?

As a card-carrying physician scientist who had funding from the National Institutes of Health for 95% or more of my professional career, and as the dean of the medical school and chancellor for health affairs at Duke, I loved to wow our board of trustees in my presentation every year with research discoveries at Duke. One year, I was compiling the list of discoveries, but for some reason, I asked myself, "How long will it be before this truly affects medical care?" I realized it would be a heck of a long time -- generations. Then I thought, "What percentage of the conditions I see as a physician or as head of Duke Medical Center will these discoveries deal with?" If I looked at the discoveries at Duke and at every medical school that year, I'd say maybe 20% to 30% of the problems would be solved within two or three generations.

I came to the conclusion -- which hundreds of thinkers and philosophers came to long before me -- that as we look for the solution to and understanding of problems, science and technology will answer some questions, but many questions are beyond the realm of scientific investigation.

Another thing struck me, which was truly an epiphany: Every year at Duke, up until last year, I would deliver the Hippocratic oath to graduating medical students, and for about the last six years, I was asked to deliver the oath of Maimonides, the great Jewish philosopher and physician. And lo and behold, the philosophy of Maimonides -- who lived in the 12th and 13th centuries -- was that the realm of knowledge could be divided into two great spheres -- one approachable by rational thought, the other by spirituality. The two may be synergistic, but to some degree they have boundaries around them, and if you truly want to be a thinking physician, you need to understand and embrace both.

If Duke was going to be an institution that I could be proud of, we could not limit our approach to science and technology. We needed humility, openness, caring, spirituality — at least in the sense that we think there is a greater purpose for all the things we do, and that we want to strive to make things better than they are today. We needed to broaden our horizon beyond what I then considered conventional medicine, which was becoming more and more specialized, segmenting individuals into their component parts, and, at times, losing sight of the individual and their needs.

Given your leadership position in medicine at that time, how was your epiphany translated into the changes you made or the actions you took?

I say to you truly, in all humility and sincerity, that it was important that the head of one of the world's leading medical centers -- which in many minds was the bastion of science-and-technology specialty medicine -- realized that we cannot be limited by science and technology and need to embrace a broader range of thinking. With that bully pulpit, I could nurture what was already a burgeoning feeling on the part of a number of our faculty about alternative and complementary approaches. Although that feeling was bubbling up, it was important for me to empower the faculty to come out of the woodwork. I felt very much like a student, and still do.

Another major learning experience for me occurred during a large integrative medicine conference at Duke that I helped sponsor for which Jon Kabat-Zinn, the pioneer in mindfulness-based stress reduction, was a keynote speaker. On hearing Jon, I felt like a person in the desert dying of thirst who found an oasis. He opened my eyes to mindfulness. I met other like-minded people whose thinking was far more advanced than mine, and I was able to help develop a Center for Integrative Medicine at Duke. I was very proud to introduce integrative medicine to the Council of Deans of the Association of American Medical Colleges.

I was also fortunate to be involved in the development of the Consortium of Academic Medical Centers, which at last count included more than 23 academic centers and nine schools where integrative medicine is becoming a larger part of the curriculum.

If you could go to a mountaintop and look down and see the future of medicine, what would you want to see?

Given that we are the richest country in the world and we still have more than 40 million Americans uninsured and many businesses that can't afford health insurance for their workers, access to a good, appropriate level of healthcare in this country should be everyone's right. We should do it in the most humane, cost-effective way. We need to use our tremendous capabilities to develop a culture where people recognize their own responsibility in maintaining good health.

It is not going to be easy, but I am impressed that we have gone from being a nation of smokers 20 years ago to a nation where smoking is broadly frowned upon. For the good of everybody, we need to develop a culture of wellness, a culture of health. This should include embracing mindfulness -- paying more attention to yourself, your own body, who you are, where you are, being in the moment -- resulting in less stress, less anger, and an embrace of spirituality and wellness.

Wellness is future-directed and therefore spiritual. It's not living in the moment for the sake of the moment alone. It's living in the moment while understanding that the moment is part of a much greater dialectic, which is where one is going with their life.

Is that what has happened to you personally? Do you feel more spiritually attuned? Has this work had an impact on you personally?

So many other things are at times so seductive that it's not easy for me to stay "in the moment" and totally reflect on all the things I should reflect on. But I do the best I can. I am very mindful of my own health and wellness, and I'm very careful of what I eat. I exercise every day. I try hard to be mindful every day. In stressful situations, I try to get into my breath and dissociate my inner self from the factors causing my anxiety. This is an area that I need to learn more about and work on. This focus has changed my life dramatically, although I'm far from where I want to be -- and far from where I'd like other people to be.


Sheldon Lewis is editor of the journal Advances in Mind-Body Medicine and co-author of the books The Human Side of Cancer and Stress-Proofing Your Child.

This article originally appeared in Spirituality & Health magazine, For subscriptions call 1-800-876-8202 or see Editor Stephen Kiesling and his staff contribute weekly columns, features and articles published every Friday as "Spiritual Caregiving" at Contact staff directly via email at

© 2006 Pederson Publishing, Inc. All Rights Reserved.
Commercial use, redistribution or other forms of reuse of this information is strictly prohibited without the prior written permission of Pederson Publishing.

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