November 2019 Article of the Month
George, L. S., Balboni, T. A., Maciejewski, P. K., Epstein, A. S. and Prigerson, H. G. "'My doctor says the cancer is worse, but I believe in miracles' --when religious belief in miracles diminishes the impact of news of cancer progression on change in prognostic understanding." Cancer (2019): online ahead of print, 10/28/19; 8pp.
SUMMARY and COMMENT: This month's study "is the first to provide direct evidence that religious belief in miracles may limit the impact of prognostic information [about cancer progression], even when that information involves concrete medical data coming from scan results" [MS p. 5]. It is aimed at medical providers but touches upon circumstances relevant to chaplaincy, especially in terms of how this belief may play into patients' coping and potential health care decision-making. Previous literature around this subject has been largely anecdotal.
"Specifically, using patient-report assessments, we examine whether receiving cancer progression news is associated with a previsit to postvisit change in prognostic understanding with respect to patients' baseline level of religious belief in miracles" [MS pp. 1-2]. Data came from a larger study, with the analytic sample for present purposes consisting of 158 patients.
At study entry, patient demographics and disease characteristics were recorded. Before and after clinic visits at which cancer restaging scan results were discussed, trained interviewers assessed patients via structured interviews. At the previsit assessment, religious belief in miracles was measured; at the postvisit assessment, receipt of cancer progression news was measured; and at the pre- and postvisit assessments, prognostic understanding was measured. The median time between pre- and postvisit assessments was 35 days (interquartile range, 16-70 days). [MS p. 2]The Religious Beliefs in End-of-Life Medical Care (RBEC) scale was used, with belief in miracles assessed with the item: "I believe that God could perform a miracle in curing me of cancer" [MS p. 2; and see Items of Related Interest, §I, below]. Other measures included the Multidimensional Measure of Religiousness and Spirituality Brief Scale, and a four-item measure of patients' prognostic understanding drawn from previous research by some of the current authors and lined out in a table [--see p. 3]. Patients were also "asked what their provider said about their cancer during the discussion of scan results" [MS p. 2], with options being that their cancer condition was worse, stable, better, or other.
Among the results, belief in miracles for the overall sample was: 22.2%, not at all; 9.5%, a little; 15.2%, somewhat; 7.0%, quite a bit; and 46.2%, a great deal [--see Table 3, MS p. 4]. So, "religious belief in miracles was highly prevalent, with approximately 78% endorsing at least some belief and with 46% endorsing the strongest level..." [MS p. 5]. For the majority of patients, who reported moderate to strong belief in miracles, "news of cancer progression was associated with no change in prognostic understanding" [MS p. 5], while patients who reported a weak belief in miracles showed a more accurate prognostic understanding.
The researchers lit upon this predictive association as a function of a significant interaction effect [--see Items of Related Interest, §II, below] between two variables in the data: 1) the patient reporting that provider said their cancer was "worse" and 2) the patient reporting a religious belief in miracles, even though each of the variables by themselves did not show a significant effect. Further analyses "showed that a modifying role was unique to religious belief in miracles and not shown by general religiousness or other religious beliefs..." [MS p. 6].
Thus, there may be something specific about believing in a miracle beyond general religiousness and spirituality and other religious beliefs that limits the impact of receiving news of cancer progression. By definition, religious belief in miracles refers to the expectation that because of some divine intervention, events may unfold in ways that defy the natural or expected order of things to be more in one's favor. This belief may, therefore, be uniquely associated with more favorable expectations of one's prognosis than general religiousness because the latter may manifest in a variety of ways, including unfavorable disease expectations (eg, "if dying from this illness is part of God's plan for me, I am okay with that"). [MS p. 6]Atop their main results, the authors also note: "Interestingly, younger participants showed stronger religious belief in miracles, and this was a surprising finding because religiousness and spirituality tend to increase with age" [MS p. 6]. They go on to comment: "This counterintuitive association raises questions regarding potential psychosocial processes among younger patients driving such stronger belief in miracles (eg, younger patients may be more likely to hear from others that God will cure them)" [MS p. 6].
This study highlights "the value of integrating patients' spirituality into their medical care" [MS p. 5] and attending to the process by which patients' translate new information about their disease progression into a changed understanding of their situation affecting their sense of the future and decisions before them. The authors conclude with guidance for oncologists:
During discussions of prognostic relevance, mere provision of medical information is likely not enough; assessing and addressing personal beliefs that limit the impact of provided information may provide added utility. When appropriate, openly discussing relevant beliefs in miracles and other patient beliefs may improve the impact of prognostic information provided, such that patients have a more accurate understanding to guide their treatment decisions. Oncologist training and competency in addressing patient beliefs during prognostic discussions may be important. [MS p. 7]The article put this reader in mind of the potential role of chaplains as resources for the development of particular educational programming for providers, for assessment of patients' beliefs in miracles as part of a larger spiritual assessment, and for referral in those cases where miracles have come up in provider-patient conversations. The authors do comment on the need for research into "patients' receptivity to having discussions with their medical providers regarding their belief in miracles" [MS p. 7], so while belief in miracles could be clinically significant, there may be others -- like chaplains -- who could be in an optimal position to engage patients on the subject.
Variability of findings is noted for geographic and certain demographic differences, but it is not analyzed according to specific religious traditions. That would seem to suggest a factor for future research. And, then there's the idea of "nonreligiously based" [MS p. 7] beliefs in miracles. Moreover, it is possible that even in light of the current results, there could also be some types of belief in miracles that enhance rather than limit patients' accuracy in understanding information about disease progression, like a belief that a miracle would come through medical processes. This article provides a quantitative baseline by which much additional research might proceed.
The bibliography of 23 references is adequate for the immediate purpose (with the most recent citations coming from 2016), and the Author Contributions note [MS p. 7] nicely lays out the individual roles of the authors. The research was supported by the National Cancer Institute and the National Institutes of Health.
Suggestions for Use of the Article for Student Discussion:
The article should be quite readable for all levels of CPE students, with technical/statistical aspects covered in clear terms in the Discussion section. It would be a useful entree to a broad discussion of miracles, with the first question to the group being how they have encountered patients' beliefs in miracles. Do the results about the percentages of participants who hold such beliefs [--see especially Table 3, MS p. 4] surprise anyone? What of the finding that younger participants showed stronger beliefs in miracles [--see MS p. 6]? The authors comment briefly about how belief in miracles may be special among religious beliefs in terms of an effect upon hearing news of disease progression, but students might discuss a variety of theological understandings of miracles and consider some potential subtleties of influence upon patients' coping with bad news. Do the students themselves believe in miracles, and how have they found their own beliefs influencing their work with patients who believe differently? Have they ever been involved in helping clinicians understand the religious perspective of patients' decision-making? Have they ever been involved in helping patients understand clinicians' perspective on disease? The article does not mention chaplains, but how might a chaplain participate in a patient-provider conference about disease progression? Does the group have any speculation about unmeasured variables that the study does not take into account but that may affect patients' understanding of information about disease progression? How have students witnessed patients coping with bad news in general, and how have they seen religious beliefs play into decision-making? Is there an opportunity to have an oncologist join in the discussion?
Related Items of Interest:
I. For more on the Religious Beliefs in End-of-Life Medical Care (RBEC) scale, see:
II. The idea of an "interaction effect" [--see especially pp. 3, 5, and 6 of our featured article] is quite well explained in the following entry by Rafa M. Kasim for that term in Lavrakas, P. J., ed., Encyclopedia of Survey Research Methods, Vol. 1 (Thousand Oaks, CA: Sage Publications, Inc., 2008): 339-342:
An interaction effect is the simultaneous effect of two or more independent variables on at least one dependent variable in which their joint effect is significantly greater (or significantly less) than the sum of the parts. The presence of interaction effects in any kind of survey research is important because it tells researchers how two or more independent variables work together to impact the dependent variable. Including an interaction term effect in an analytic model provides the researcher with a better representation and understanding of the relationship between the dependent and independent variables. [p. 339]
III. One of the contributions of the present research is that it captures some data about the incidence of belief in miracles. The Pew Research Center on Religion and Public Life published their U.S. Religious Landscape Survey on Religious Beliefs and Practices in 2008, and this included an analysis of Miracles and the Supernatural (in chapter 1 of the full report). And, for a more recent and wide-ranging report of American's religious beliefs, see Pew's 2018 survey, When Americans Say They Believe in God, What Do They Mean?.
IV. Note the following articles that our authors cite regarding physicians interacting with patients who express a belief in miracles. These are not reports of research, though the article by Rhonda S. Cooper, et al. raises research questions about their proposed approach.
Plus, see the following more recent article:
V. The following recent study out of the Department of Psychology at North Dakota State University used an undergraduate population to establish "the first experimental test of the relation between meaning and belief in miracles" [p. 781]. It may be interesting and thought-provoking in light of the context of our featured article.
VI. Authors of our featured article have been significant contributors to the religion & health literature. One of their own studies that they cite is the following, which was our June 2011 Article-of-the-Month.
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