FP Report -- July 1999
Spirituality: Don't make patients check it at the door
SEATTLE -- A good medical history encompasses the whole patient: physical ailments past and present, emotional issues, social influences, family relationships. So why disregard spirituality?
More than 70 percent of Americans say their whole approach to life is based on their religion, yet health care providers rarely take that into consideration.
Workshop presenters at the Society of Teachers of Family Medicine's spring conference made the case for expanding the routine medical history to include questions about spirituality.
Dana King, M.D., associate professor in the family medicine department at East Carolina University in Greenville, N.C., said it wasn't necessary to prove the existence of a higher power in order to prove that spiritual beliefs influence health. "What we're proving is there's something that's important to patients," he said. "It relates to how they interpret the meaning of illness in their lives, it relates to how they cope with illness and stress, and it actually relates to health outcomes because of the importance of that outlook and context in regard to how their neurology and physiology respond."
He cited numerous studies that showed a positive correlation between spiritual or religious commitment and improved mental and physical health outcomes. One study followed patients in a Maryland county for five years and showed that those who were involved in religious activities had lower rates of arteriosclerotic heart disease, lower rates of cancer and lower overall mortality than other people. Seven different studies also have shown decreased blood pressure with greater religious involvement.
King said spirituality usually has a positive effect on health, but that's not always the case. "Patients who believe in a punishing God are associated with having more neuroses," he said. "There's an 80 percent correlation between religious commitment and improved coping with illness, but it's not 100 percent."
Discussing patient's faith? Think FICA
At the Society of Teachers of Family Medicine's spring conference, Christina Puchalski, M.D., offered a mnemonic device to help physicians conduct a thorough spiritual history.
Puchalski, from Washington, D.C., said, "A bunch of us got together at tax time" and came up with FICA (which also stands for the social security law, the Federal Insurance Contributors Act). The mnemonic device offers questions you can use to cover spiritual issues with patients.
- Faith or beliefs. What is your faith or belief? Do you consider yourself spiritual or religious? What things do you believe in that give meaning to your life?
- Importance or influence. Is it important in your life? What influence does it have on how you take care of yourself? How have your beliefs influenced your behavior during this illness? What role do your beliefs play in regaining your health?
- Community. Are you part of a spiritual or religious community? Is this of support to you? If so, how? Is there a person or group of people you really love and who are really important to you?
- Address. How would you like me, your physician, to address these issues in your care?
Despite the convincing evidence, the traditional biopsychosocial model of caring for patients lacks a spiritual element, said King. Nearly all family physicians in a recent study considered spiritual well-being to be an important health component, but most reported infrequent discussions of spiritual issues with patients and infrequent referrals of hospitalized patients to chaplains. Other research has found that up to 70 percent of people think it's a good idea for physicians to talk to patients about spiritual beliefs, but only 10 percent say their physicians have done so with them.
Christina Puchalski, M.D., director of clinical research and education at the Center to Improve Care of the Dying in Washington, D.C., suggested using questions about spirituality during the section of the medical history focused on social issues. "One reason patients love it when we bring up a spiritual history is that you're asking them about who they are, and you're showing an interest in them at a very deep level," she said.
If your patient brings up the topic of religion or makes comments about God, use that opening to discuss spirituality, Puchalski said. She told of an HIV-positive patient who thought her illness was a punishment from God because she had received an abortion. She initially refused treatment until counseling changed her outlook on the disease.
If the topic of spirituality doesn't arise, bring it up, said Puchalski. "I usually open with the question, 'Do you consider yourself religious or spiritual?'" From there, she explores issues that could have health ramifications.
The STFM conference was held April 28 - May 2.
By Sharon Dickinson Dent, Associate Editor
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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