A survey of 296 family physicians at a 1996 meeting of the American Academy of Family Physicians (AAFP) revealed that 99 percent believe that religious beliefs can heal, and 75 percent believe that others' prayers can promote healing.1 Another survey of family physicians in Missouri reported that “Most family physicians believed spiritual well-being is an important factor in health. Despite this belief, however, most reported infrequent discussions of spiritual issues with patients and infrequent referrals of hospitalized patients to chaplains.”2 Why? A lack of training seemed to be the common refrain. For example, Ellis2 reported that 59 percent of family physicians feel “uncertainty about how to take a spiritual history” and feel they “lack experience or training,” while 56 percent report uncertainty about how to “identify patients who desire discussion,” and 49 percent report uncertainty about how to “manage spiritual issues.”
For the past several years, I have taught Continuing Medical Education (CME) courses to more than 6,000 health care providers—most were primary care physicians—on incorporating spirituality or religion into their clinical practice. These learners seem interested in the ethical and practical “how-to's” of incorporating basic spiritual skills (“How to take a spiritual history”; “How and when to provide a spiritual consult or referral”; and “How and when to pray with a patient or family”) into their practices. Therefore, the article by Anandarajah and Hight3 in this issue of American Family Physician, suggesting that physicians should use their “practical tool for spiritual assessment,” is timely.
However, there are those who question whether the use of such a tool, by a physician, is either wise or ethical. For example, two recent commentaries4,5 attempted to minimize the ability of and to question the ethics of physicians who desire to assess and address their patients' spiritual needs. Two Ph.D.s and several theologians/chaplains from New York City wrote in the New England Journal of Medicine that “it is not clear that physicians should engage in religious discussions with patients as a way of providing comfort.”4
Another group of academicians suggested that “it is a general mandate of modern developed societies to keep professional roles separate … [as] distinct spheres of activity … [to] ensure competence and boundaries.”5 They assert that “physicians might need to explain to patients why [spiritual] activities usually better fall under the purview of competent pastoral care.”3
These academicians seem to have taken their protestational cues from other limited-care subspecialists who expediently claim that it is in the patient's best interest to always be referred to themselves. Unfortunately, these assertions are usually not accompanied by outcomes-based research. In fact, much research makes the case that basic patient care is most economically, efficiently and expeditiously provided by the primary care physician interested and trained in handling such care.
Just as “obstetrics is just too important to be left to obstetricians,”6 I believe the practice of basic spiritual skills is just too important to be left solely to pastoral professionals. At least three arguments support the teaching of these basic skills to physicians and the practice of such skills by physicians.
First, the overwhelming majority of the medical literature demonstrates a positive association between the depth of religious belief or practice and mental or physical health outcomes. Anandarajah and Hight3 review these data. Many readers may be surprised to learn that more than 260 research studies and 35 review articles reflect positively on the association of faith with physical and mental health outcomes.
One systematic review7 concluded that “the published empirical data suggest that religious commitment plays a significantly beneficial role in (1) preventing mental and physical illness, (2) improving how people cope with mental and physical illness and (3) facilitating recovery from illness.”Another review8 concluded that infrequent religious attendance or “poverty of personal faith” should be regarded as a risk factor for morbidity and mortality that is nearly equivalent to tobacco or alcohol abuse. Obtaining a brief spiritual history is not a clinical skill that should be, nor routinely can be, referred to a religious or spiritual subspecialist.
Second, research results demonstrate that more than 75 percent of patients believe their physicians should address spiritual issues as a part of their medical care. More than 40 percent actively want discussion of spiritual issues to take place.16 Many patients wish for physicians who focus on more than just the pharmacologic and technical aspects of care. Furthermore, most of the evidence that patients want spirituality incorporated into clinical medicine “generally comes from studies in primary-care settings.”4
Nevertheless, patient surveys also indicate that physicians must introduce spiritual subjects with permission, sensitivity and respect. Patients can and should expect their physicians to respect their beliefs and to talk about spiritual concerns in a respectful and caring manner. Professional problems for well-meaning physicians can arise when a personal faith or religious belief is “pushed” on a patient who is opposed to discussing this topic.4,5,17 If patients indicate that they are not interested in questions about their personal religion or faith, the subject should not be pursued.
Third, research reveals that many physicians are in need of and want further education when it comes to incorporating spiritual skills into their clinical practices. Although nearly 80 percent of Americans believe in the power of God or prayer to improve the course of illness, and 63 percent want their physicians to address spiritual issues, less than 10 percent of physicians actually do so.18(pp58–63),19 Nearly 50 percent of inpatients want their physicians to pray with them; yet, these patients report that spiritual matters were rarely discussed by their physicians.20 A Time/CNN poll18(p62) revealed that 64 percent of patients thought that physicians should join their patients in prayer, but 92 percent said they never had a physician make that offer. Furthermore, only 5 percent of physicians report that religious and spiritual issues were addressed in their training.21
Appropriate training for physicians to learn how to respond to these patient needs is long overdue in clinical medicine, notwithstanding the non–evidence-based objections of some pastoral professionals. Furthermore, no outcome data are available suggesting that the application of basic spiritual skills by physicians is harmful to patients desiring these interventions. Nevertheless, like any other new and sensitive area of patient care, physicians must be taught to approach spiritual issues appropriately and sensitively. Doing so is not only apropos, germane and relevant, it may also promote the health of the patient and strengthen the physician-patient relationship.
Without doubt, particular patients or particular spiritual problems arise that may need to be referred to a pastoral professional who has more time, training or experience; however, the skill of obtaining an appropriate consult or referring a particular patient is one that most physicians use routinely.
Thankfully, the tide of ignoring faith as a factor in health is now turning as medical students and practicing physicians are receiving training in basic spiritual understanding and practice skills. Nearly one half (60 of 126) of America's allopathic medical schools1 now provide training in addressing faith and spiritual issues with patients.22,23 A spiritual care curriculum is currently taught in at least 15 psychiatric residency programs in the United States. A similar curriculum for primary care residency programs is nearly complete.22,23
CME courses on these topics are increasingly available for practicing physicians. Unfortunately, these CME courses are often improperly denied the prescribed credit designation from the AAFP or the category 1 credit designation from the American Medical Association that the evidence-based literature would seem to support. These denials probably represent a lack of understanding or awareness of the significant medical evidence supporting these interventions. Increasingly, educators are arguing that this type of training should be provided as a part of evidence-based clinical medicine in primary care. As Matthews and colleagues7 concluded in their systematic review: “The available data suggest that practitioners who make several small changes in how patients' religious commitments are broached in clinical practice may enhance health care outcomes.”
In 1910, in the first editorial published in the British Medical Journal,24 Sir William Osler wrote about “the faith that heals,” stating that “Nothing in life is more wonderful than faith … the one great moving force which we can neither weigh in the balance nor test in the crucible—mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potence.”
The reemergence of age-old spiritual principles and their appropriate use in clinical medicine is new to many practicing physicians but can and should be taught and practiced by physicians in any practice situation. This would be particularly true in primary care, where the physician-patient relationships tend to be ongoing and familiar.
Basic spiritual skills are just too important to patients—their well-being and their health outcomes—to be left to the exclusive domain of pastoral professionals. It's time we physicians take the responsibility and embrace the opportunity to address our patients' spiritual concerns.
Kornhaber has wisely proclaimed, “To exclude God from a consultation is a form of malpractice. Spirituality is wonder, joy and shouldn't be left in the clinical closet.”25