Science and religion have always had a complicated relationship, so it's not surprising that, as interest in holistic care grows, physicians are trying to come to grips with whether they should play a role in patients' spiritual care.
"We've always talked about the limitations of the biomedical model that would reduce people to our physiology," says Carol Taylor, PhD, director of the Center for Clinical Bioethics at Georgetown University. "When we talk about holistic health, we talk about biological, psychological, and social needs and now we're talking about spiritual needs as well. They're all interrelated."
More than half of physicians believe that religion and spirituality affect patient health in some way, according to research conducted by the University of Chicago. In a survey of 2000 physicians, 56% believed that religion and spirituality have much or very much influence on health, but only 6% believed they often changed "hard" medical outcomes.[1] Rather, respondents suggested that religion and spirituality help patients cope, give them a positive state of mind, or provide emotional and practical support via the religious community.
While doctors might believe religion and spirituality influence health, acknowledging a connection raises some fundamental and tricky questions. The American College of Physicians' ethics manual encourages physicians to explore a patient's religion and spirituality as part of an overall physical. But how are they to do that? What does it mean, and what are they to do with the information?
Stethoscope and Spiritual Care?
Spirituality, broadly defined, is what gives a person's life meaning. Religion may or may not factor into the picture. In asking about spirituality, clinicians are seeking to identify a patient's source of hope, strength, and values, not their dogma or doctrine.
Research indicates that roughly 80% of medical schools now offer spiritual care courses or integrate spirituality into their curricula, according to Christina Puchalski, MD, an internist at George Washington University and director of the George Washington Institute for Spirituality and Health. But what's included and how it's taught differs tremendously from one institution to the next. In an effort to bring consistency to the spiritual history and assessment process, various proponents have development of myriad tools represented by apropos acronyms such as FAITH, SPIRIT, and HOPE as well as the slightly less catchy FICA and FACT.
Assessing a patient's spiritual health is important, because spiritual issues can not only impact a patient's health, but they can impact a patient's medical compliance and treatment choices as well, says Puchalski.
"What if they don't want to take medicines because they believe God will heal them? What if they're very nature-centric and don't want to put medications in their body? What if they don't believe in blood transfusions?" she asks. "Physicians need to know these concerns if they're going to treat a patient."
However, not everybody believes spiritual care belongs in the examination room. Indeed, those who oppose the idea present a litany of arguments: Spirituality is a private matter. Over-zealous physicians might abuse their position and proselytize to their patients. Pragmatically, many note that in the real world of 15-minute office visits, taking the time to ask questions about spirituality would come at the expense of addressing clinical issues.
Most worrisome says Richard Sloan, professor of behavioral medicine at Columbia University Medical Center and author of Blind Faith: The Unholy Alliance of Religion and Medicine, taking a spiritual history sets a doctor up to be a spiritual guide, "which they are completely untrained and unequipped to do."
"Nobody should deny that spirituality is important to a great many people, but I don't think it's grist for the physician's mill," he says. Doctors need to know about all facets of their patients' lives, he says, but shouldn't ask more than "Is spirituality important to you?" A simple "yes" or "no" answer suffices, he says.
As for the possibility that patients' spirituality might impact their care, Sloan notes that spiritual, financial, transportation, and other potential barriers to care are more likely to surface if a doctor asks, "Is there anything that would keep you from taking this medication?"
How do patients feel about the subject? Not surprisingly, it depends. World War II Army Chaplain William T. Cummings famously declared, "there are no atheists in fox holes." Patients seem to have the same sentiment when it comes to talking to physicians about their spirituality.
In a survey published in 2003 in the Journal of General Internal Medicine, researchers asked 456 outpatients in North Carolina, Florida, and Vermont whether they wanted their doctor to ask them about their spirituality. Only one third of respondents interviewed in a clinic setting liked the idea, but the number climbed to 40% in a hospital setting and 70% in hospice.[2]
"Should we do this in every primary care practice and patient interaction?" asks Drew Rosielle, MD, director of the University of Minnesota's Hospice and Palliative Medicine Fellowship. "Realistically, of course not."
But when a doctor has a little more time, such as during an annual physical, or when a patient is faced with a major diagnosis, working a question or two about spirituality into the conversation can help a physician better understand and support a patient, he says. Rosielle routinely asks a couple of questions about spirituality as part of his initial palliative care consultation with patients so he can refer them to the chaplain on his care team if necessary.
"For patients who are not interested, it's a non-issue," he says. "You just move on. I've never had a patient get offended about being asked."
But for patients with spiritual concerns, the conversation helps him connect them with the support they need. "When you get sick -- especially when you're facing a terminal illness or a life-changing situation, it affects your entire being emotionally, spiritually, existentially," he says. "Patients are hungry for any support they can get."
Puchalski sites an example from her own experience. Several years ago her father, a devout Catholic, underwent surgery for colon cancer. Prior to the procedure, the nurse asked him whether he was spiritual and what that meant to him. A retired opera singer, he responded that he couldn't live without music. Intrigued, she asked him to sing and he responded with a heart-felt aria. Afterward he felt more relaxed and uplifted. The nurse noted his love of singing on his chart. After the operation, other clinicians read her notation and encouraged her father to sing as a way of exercising his lungs.
For her father, Puchalski says, bringing music into the hospital was a profoundly positive experience, "but how would the doctors and nurses have known that if the nurse hadn't asked the question?" she asks.
Assessing Spiritual Outlook
Still, fitting spiritual assessments into practice is a hodgepodge. "From what we've seen in our research almost nobody is using those acronyms," says Farr Curlin, MD, co-director of the Program on Medicine and Religion at the University of Chicago. "It's the rare physician who uses these pneumonic tools. Rather they try to pay attention to signs from the patient and then they try to query them to bring those issues out and connect the patient with spiritual resources in the community or their organization's pastoral care department."
Taylor, says clinicians are caught in a theory-practice gap.
"The problem is we say, 'spiritual care matters,' but we haven't gotten to the point where clinicians can identify spiritual need," she says.
References
- Curlin FA, Sellergren SA, Lantos JD, Chin MH. Physicians' observations and interpretations of the influence of religion and spirituality on health. Arch Intern Med. 2007;167:649-654.
- MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med. 2003;18:38-43.
http://www.medscape.com/viewarticle/750959?src=mp&spon=25
regards, taniafdi ^_^
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