September 2004 Article of the Month
McCord, G., Gilchrist, V. J., Grossman, S. D., King, B. D., McCormick, K. F., Oprandi, A. M., Schrop, S. L., Selius, B. A., Smucker, W. D., Weldy, D. L., Amorn, M., Carter, M. A., Deak, A. J., Hefzy, H. and Srivastava, M. "Discussing spirituality with patients: a rational and ethical approach." Annals of Family Medicine 2, no. 4 (July-August 2004): 356-361.
NOTICE OF ARTICLE ON LINE, WITH DISCUSSION: This month's article was discussed on line, through the Annals of Family Medicine web site, at www.annfammed.org/cgi/eletters/2/4/356, where the full text of the article is also available. Additionally, an editorial in the (print) journal by Kurt C. Strang, MD, PhD, gives an overview of this on-line discussion [--see "Questions, Interpretation, Exhortation," Annals of Family Medicine 2, no. 5 (September 2004): 514-517; available on-line at www.annfammed.org/cgi/content/full/2/5/514]. NOTE [added 10/8/04]: The article was also covered in the October 2004 issue of Science and Theology News (ISSN: 1530-6410) --see "Patients to Doctors: Never Been Asked," by Julia C. Keller.
SUMMARY AND COMMENT: Physicians’ interaction with patients regarding spirituality has been a topic of a good deal of controversy in recent years, with some physicians and clergy seeming most concerned about professional boundary issues. However, research has indicated not only that patients tend to be interested in certain kinds of physician-patient interaction regarding spirituality (see Related Items for Further Reading, below), but the research reported in this month’s featured article indicates that this interest may be based in a desire to be better understood by--and therefore possibly better helped by--physicians, especially in circumstances of serious illness or dying.
McCord and his colleagues approached 1,413 patients at four urban family practice residency sites and one suburban private practice site to complete a 60-item questionnaire [available on-line (only) at www.annfammed.org/cgi/content/full/2/4/356/DC1], to explore "(1) acceptance of spiritual discussion in a wide range of clinical scenarios, (2) reasons why patients want physicians to know about their beliefs, (3) what patients want physicians to do with this information, and (4) a model for predicting which persons would most likely desire spiritual discussion" [pp. 356-7]. A total of 921 patients participated, for a response rate of 65%. The rate of refusal was greatest among patients who were estimated by research assistants to be over 60 years of age.
Twenty percent of participants said that they preferred that their physician "always know about [their] beliefs," 63% said that they preferred their physician "sometimes ask about [their] beliefs depending on the situation," and 17% said that they preferred their physician "never ask about [their] spiritual or religious beliefs" [p. 358 and questionnaire item 37]. Of those who indicated an openness to physician-patient interaction regarding spirituality, "life-threatening conditions, serious medical illness, and loss of loved ones" [p. 358] were the main choices (i.e., 83%-94%) from a list of contexts in which patients said that they would "want to talk with [their] doctor about [their] spiritual or religious beliefs" [preamble to questionnaire items 38-50]. Only 22% and 24% indicated a desire for such interaction during a "visit for a minor medical problem" or as part of a "routine physical or check-up," respectively; though 60% welcomed such interaction "as part of your medical history the first time that you see a new doctor" [pp. 358, 359 (table), and questionnaire items 38-40].
Most interestingly, these same patients who indicated an openness to physician-patient interaction regarding spirituality (--a total of 83% of the participants) also responded to a list of "reasons why someone might want their doctor to know about their spiritual or religious beliefs" [preamble to questionnaire items 51-59], with the following results [see questionnaire items 51-59 and the table on p. 359]:
On the issue of predictive factors for patients who would "desire discussion" [p. 360], the authors identify four: "(1) having beliefs that provide hope during times of illness, (2) having beliefs influencing a health care decision, (3) being 30-64 years of age, and (4) rating oneself as more spiritual" [p. 360]. They propose that "a brief questionnaire based upon these factors may constitute a spiritual assessment" [p. 360].
This reader found the study engaging and indeed a significant contribution to the literature. Yet, one criticism may deserve special note: the wording in the report could in places be more precise. Particularly, while the questionnaire asked patients about circumstances under which they would want their physician to "know about" their beliefs, responses were characterized in terms of patients’ interest in "conversations about spirituality" or "spiritual discussion" with a physician [e.g., p. 358]. Informing a physician about one’s beliefs could be quite distinct from discussing those beliefs, and this distinction is not only important from a research standpoint but also in light of the broad controversy over professional boundaries that is always in the background for this topic. Since the authors have been good enough to provide the actual questionnaire on-line, readers would be well served to refer to it.
For chaplains, the subject of physician-patient interaction regarding spirituality has implications for, among other things, health care teamwork and referrals. Research in this area also holds promise for collaboration between chaplains and physicians (--note: no chaplains appear to have been involved in the present study), and such collaboration may benefit the research enterprise and, along the way, also help address such concerns as professional roles/boundaries for physicians vis-a-vis clergy in working with patients' spiritual beliefs and needs affecting health care.
Suggestions for the Use of the Article for Discussion in CPE:
The study by McCord, et al. offers CPE students a very readable text and access to the actual questionnaire (on-line). Discussion could thus go in either the direction of the topic of physician-patient interaction regarding spirituality or the use of questionnaires per se (i.e., a methodological discussion). Regarding the latter, students might focus critically on the lists of items by which participants indicated their desire to talk to their physician about spiritual or religious beliefs and the potentially connected reasons for doing so (items 38-59). Do the lists seem in any way to limit or skew responses, and if so, how? On the general topic of the study, how do the findings fit with chaplains’ own experience? If it is true that patients’ interest in interaction with physicians on this subject is rooted in a desire for "understanding, compassion, and hope"--things that the authors observe are "not necessarily faith dependent" [p. 360]--then what might this say for the motivation of some patients when they interact with chaplains? This article would be well suited for a discussion with one or more guest physicians.
Related Items for Further Reading:
Ehman, J. W., Ott, B. B., Ciampa, R. C., Short, T. H. and Hansen-Flaschen, J. "Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill?" Archives of Internal Medicine 159, no. 15 (August 9/23, 1999): 1803-1806. [In this study of 177 pulmonary outpatients, 45% reported having spiritual/religious beliefs that would influence their medical decisions if they became gravely ill, and 66% wanted their physician to ask whether they had such medically pertinent beliefs and felt that this inquiry would increase their trust in the physician. Only 16% indicted that they would not welcome this inquiry. The study was carried out by a research committee of the Department of Pastoral Care at the Hospital of the University of Pennsylvania.]
[ADDED 2/3/06]: Hamilton, J. L. and Levine, J. P. "Neo-pagan patients' preferences regarding physician discussion of spirituality." Family Medicine 38, no. 2 (February 2006): 83-84. [This study of a convenience sample from Neo-Pagan congregations and visitors to a web site (68% of 673 surveys were completed) found: "Seventy-three percent of respondents stated that they have religious/spiritual beliefs that would influence their medical decisions; 84% agreed that it would be important to have their physician ask about religious beliefs, even if the physician might not agree with those beliefs; and 81% reported that it would strengthen their trust in their doctor if she/he asked about beliefs that would influence medical decisions." The authors state that "the findings of this study may reassure physicians who are hesitant to discuss matters of religion and spirituality because of concerns that their inquiries will be unwelcome." (p. 84)]
Hebert, R. S., Jenckes, M. W., Ford, D. E., O'Connor, D. R. and Cooper, L. A. "Patient perspectives on spirituality and the patient-physician relationship." Journal of General Internal Medicine 16, no. 10 (October 2001): 685-692. [This focus group study of 22 patients who had been recently hospitalized with a life-threatening illness found that religion and spirituality were identified as strong sources of comfort. Patients did not necessarily expect physicians to discuss spirituality, but they wanted physicians to respect religious and spiritual values if patients expressed them. Patients emphasized a desire that physicians have strong interpersonal skills, be empathetic, and show an interest in patients' coping and support mechanisms. The authors illustrate their findings with many quotes from the focus groups.]
MacLean, C. D., Susi, B., Phifer N., Schultz, L., Bynum, D., Franco, M., Klioze, A., Monroe, M., Garrett, J. and Cykert, S. "Patient preference for physician discussion and practice of spirituality: results from a multicenter patient survey." Journal of General Internal Medicine 18, no. 1 (January 2003): 38-43. [This study of 456 patients at primary care clinics at six academic medical centers in three states found, among other things, that (from the abstract:) "one third of the patients wanted to be asked about their religious beliefs during a routine office visit," "two-thirds felt that physicians should be aware of their religious or spiritual beliefs," and "patient agreement with physician spiritual interaction increased strongly with the severity of the illness setting...."]
[ADDED 12/27/05]: Mann, J. R., McKay, S., Daniels, D., Lamar, C. S., Witherspoon, P. W., Stanek, M. K. and Larimore, W. L. "Physician offered prayer and patient satisfaction." International Journal of Psychiatry in Medicine 35, no. 2 (2005): 161-170. [In this randomized controlled trial (n=137) from the University of South Carolina School of Medicine, over 90% of the sample of patients in a family practice setting who were offered physician-led prayer accepted, but there was no measured affect on patient satisfaction.]
Monroe, M. H., Bynum, D., Susi, B., Phifer, N., Schultz, L., Franco, M., MacLean, C. D., Cykert, S. and Garrett, J. "Primary care physician preferences regarding spiritual behavior in medical practice." Archives of Internal Medicine 163, no. 22 (December 8-22, 2003): 2751-2756. [This multicenter study of 476 physicians from sites in North Carolina, Vermont, and Florida, found: "While 84.5% of physicians thought they should be aware of patients’ spirituality, most would not ask about spiritual issues unless a patient were dying. Fewer than one third of physicians would pray with patients if they were dying. This number increased to 77.1% if a patient requested physician prayer." (--from the abstract, p. 2751)]
[Added 10/5/06:] Though not reports of research, the following research-minded articles are good practical guides for clinicians:
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at firstname.lastname@example.org