Editorials - January 1, 2001 - American Family Physician

Editorials

Spiritual Assessment in Medical Practice

HAROLD G. KOENIG, M.D.
Center for the Study of Religion/Spirituality and Health
Duke University Medical Center
Durham, North Carolina

See article on page 81,
related editorial on page 33
and Medicine and Society on page 36.

In some areas of the United States, up to 90 percent of patients rely on religion for comfort or strength during times of serious illness. Religious coping behaviors include prayer, inspirational reading, participating in worship services and seeking support from clergy or congregation members. In studies that have objectively examined these behaviors and their relationship to health status, a connection has often been found.¹ A recent review² of more than 1,200 studies of religion and health reported that at least two thirds of the studies evaluated had shown significant associations between religious activity and better mental health, better physical health or lower use of health services.

Physicians should be aware of the role that religion plays in how patients cope with illness. Anxiety, depression and loss of hope may complicate the course of many diseases, interfering with compliance, self-care activities and motivation toward recovery. Scientists are only now beginning to discover the powerful effects that the mind and social relationships can have on physiologic processes, especially cardiovascular, neuroendocrine and immune function.^3,4 Religious beliefs and practices are one method that patients use to modulate emotional distress during illness.

How does a physician address religious issues in the context of a medical visit or during acute hospitalization? The physician does so by taking a spiritual history that identifies religious or spiritual needs and then coordinates the resources needed to meet those needs.⁵ While recognizing the value of spirituality, many physicians feel uncomfortable addressing the topic of religion, and many patients may not expect a physician to ask (although such questions might be welcomed). Taking a spiritual history in a sensitive and appropriate manner is controversial, although most experts agree that proper timing and a patient-centered approach are essential elements for success. It is unnecessary to take a spiritual history for a patient who comes in for a wart removal. A religious or spiritual history is best obtained during a comprehensive medical evaluation, introduced naturally as part of the social history.

Unlike most other aspects of the medical history, simply taking a spiritual history is often the intervention. Frequently, all that is necessary is to listen to the patient's responses, providing presence and support, rather than demonstrating expertise in religious matters. While providing spiritual advice or direction is best left to the chaplain or to the patient's clergy, the spiritual history should not be deferred to others. If the physician asks these questions, it signals to the patient that the physician cares about the patient's sources of hope and meaning during illness. When religion is what gives meaning, purpose and hope, patients are often comforted by sharing beliefs with their physician. Likewise, if there are religious doubts or anxieties present, sharing these feelings with a caring, accepting physician may help with resolution.

Taking a religious or spiritual history may have far-reaching effects on the patient's ability to cope with illness as well as on the physician-patient relationship, affecting compliance and possibly future effectiveness of medical interventions. Even in this managed-care era of shorter and shorter patient visits, taking two to five minutes to inquire about and listen to patients talk about this area of their lives may actually save time in the long run. "Cure sometimes; relieve often; comfort always," is really what it is all about, and taking a spiritual history may be one way to do it more effectively.

In this issue of American Family Physician, Anandarajah and Hight⁶ provide physicians with an instrument, the HOPE questionnaire, which will help in taking a spiritual history. The HOPE questionnaire is useful because it is relatively brief, it is patient-centered and introduces the topic gradually, and it is respectful of the beliefs of most religious or spiritual traditions.

As a young family physician nearly 15 years ago, I became interested in this subject after repeatedly asking patients the question that, unknown to me, was to become the H part of Anandarajah and Hight's HOPE scale: What has given you hope, meaning, comfort and strength during this medical illness? Because so many patients gave a religious response when I asked that question and so many seemed to deeply appreciate my asking, I ultimately directed my research career into this area. Physicians, too, may benefit from taking a spiritual history.

In recent times, I have heard more and more patients express dissatisfaction with medical care and more and more physicians indicate that their job has become less fulfilling. I believe that physicians and patients may be responding to how mechanistic the practice of medicine has become. Bringing spirituality back into medicine may be what we all need.

Harold G. Koenig, M.D., is an associate professor of psychiatry and medicine and director of the Center for the Study of Religion/Spirituality and Health at Duke University Medical Center, Durham, N.C.

Address correspondence to Harold G. Koenig, M.D., 415 Clarion Dr., Durham, NC 27705.

REFERENCES

Koenig HG. The healing power of faith: science explores medicine's last great frontier. New York: Simon & Schuster, 1999.

Koenig HG, McCullough ME, Larson DB. Handbook of religion and health: a century of research reviewed. New York: Oxford University Press, 2000.

McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998;338:171-9.

Rabin BS. Stress, immune function, and health: the connection. New York: Wiley-Liss, 1999.

Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med 1999;130:744-9.

Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81-8,89.

Spirituality and Medical Practice: A Look at the Evidence

RICHARD P. SLOAN, PH.D.
Columbia-Presbyterian Medical Center
New York, New York

EMILIA BAGIELLA, PH.D.
Columbia University
New York, New York

See article on page 81,
related editorial on page 30
and Medicine and Society on page 36.

In the general public and within medicine, interest in the possibility that religious and spiritual activity may confer health benefits is increasing, as the article by Anandarajah and Hight¹ in this issue of American Family Physician clearly demonstrates. The empiric support required to convert this interest into recommendations for medical practice is weak and inconclusive at best, with most studies having numerous methodologic shortcomings.² Even if there were methodologically solid findings demonstrating associations between religious and spiritual activities and health outcomes, problems would still exist.

First of all, such associations would occur at the epidemiologic level, not at the level of clinical interventions. To convert epidemiologic findings to clinical practice, randomized trials of interventions must be conducted. Without such trials, no scientific basis exists for making recommendations to engage in religious activities in clinical settings. We have no idea, for example, whether recommending that patients attend religious services will lead to increased attendance and, if so, whether attendance under these conditions will lead to better health outcomes. The difference between going to church on one's own and doing so on the advice of a physician may be substantial. There is a qualitative difference between engaging in religious activity and, for example, following a low-fat diet. And even if we had convincing evidence that these interventions worked, they still raise substantial ethical concerns.

First, many factors that influence health are nonetheless regarded as beyond the domain of medical practice. For example, marital status is strongly associated with health effects, but we would recoil at a physician recommending marriage because of its association with health. This is because we regard such decisions about marriage as personal and private, even if they have associations with health.

Second, the physician-patient relationship is asymmetric: physicians expect patients to comply with their recommendations, and patients generally accede to this authority. Recommending religion to patients in this context may be coercive.

Third, by linking religious activity with better health outcomes, the physician also implies the converse: that poor health outcomes are associated with insufficient devotion. Even in the 21st century, patients still confront the age-old folk wisdom that illness is a punishment for moral failure. By linking religion to health outcomes, physicians may actually cause harm.

Finally, by probing the religious interests of patients and distinguishing those for whom religion and spirituality are important from those for whom they are not, physicians run the risk of discriminating by encouraging only the former group to engage in religious activity. If, as proponents of making religious activity an adjunctive medical treatment indicate, the evidence of the health benefits of religious activity is overwhelming, then by this assessment two classes of patients are created: those who will receive this important advice and those from whom it will be withheld.

Thus, the absence of compelling empiric evidence and the substantial ethical concerns raised suggest that, at the very least, it is premature to recommend making religious and spiritual activities adjunctive medical treatments.

Dr. Sloan is director of the behavioral medicine program at Columbia-Presbyterian Medical Center, New York, N.Y.

Dr. Bagiella is assistant professor of clinical biostatistics at the Joseph Mailman School of Public Health, Columbia University, New York, N.Y.

Address correspondence to Richard P. Sloan, Ph.D., Director, Behavioral Medicine Program, Columbia-Presbyterian Medical Center, 622 W. 168th St., Box 427, New York, NY 10032.

REFERENCES

Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81-8,89.

Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-7. *

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