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Am Fam Physician. 2001;64(3):373-386

to the editor: It was a pleasure reading the article by Drs. Anandarajah and Hight on spirituality and medicine1 and the accompanying editorial comments.2,3 However, as a longtime student of the relationship between spirituality and health and one familiar with the current debate over the role of spirituality in medicine, I am compelled to comment on the recommendations regarding spiritual assessment. As one who favors an approach to health care that incorporates patients' spiritual concerns, I fear that the authors may have overlooked an important and perhaps more realistic means for initiating a dialogue about spiritual concerns during the clinical interview.

Drs. Anandarajah and Hight1 propose two means for conducting a spiritual assessment: one informal and the other formal. The informal means of assessment that they describe relies on physicians being sensitive to “clues that a patient may be struggling with spiritual issues.”1 Once the clues are perceived, specific questions can then be asked of patients regarding their spiritual needs. Leaving aside the question of whether patient clues are as transparent and easily interpreted as the authors assume, research demonstrates that, while clues can be an important part of the clinical encounter, primary care physicians may be responsive to clues as little as 20 percent of the time.4 While this approach may be suitable for chaplains, it may not be as effective in the family practice setting.

The formal means offered by the authors for assessing spirituality is through the HOPE questions described in detail in the article.1 Although the authors note that the questions have not been validated, they do have strong face validity as a method of obtaining information about a patient's spirituality. However, in offering the HOPE questions for use by family physicians, the authors seem to have overlooked some of the major concerns expressed by family physicians related to the topic of spirituality. Although the use of the HOPE questions could conceivably help physicians overcome their concern over lack of training in spiritual history (59 percent), the authors offer no practical advice to physicians concerned about not knowing how to identify interested patients (56 percent), or the fear of projecting their own beliefs to patients (53 percent).5

Given the types of concerns expressed by family physicians about introducing the topic of spirituality in the clinical setting, a screening question is sometimes recommended and can be helpful. For example, either of the following questions can be asked of patients as a means of initiating a dialogue about spiritual concerns: “Are there aspects of your religion or spirituality you would like me to keep in mind as I care for you?” or “Would you like to discuss the religious or spiritual implications of your health care?”6 Asking this type of question enables physicians to identify patients who have an interest in spirituality and are unlikely to project their own beliefs on patients. Once answered, the response to either of these questions allows the physician to initiate—or not initiate—a dialogue at the discretion of the patient.

to the editor: The issue of American Family Physician highlighting religion and spirituality in clinical practice is a welcome addition to the literature and reflects a growing interest in this field. The commentary by Dr. Walter Larimore1 provides a useful case study of the ethical issues that are raised when physicians address religion and spirituality with their patients. Although Dr. Larimore's tone is largely dismissive of these issues and of “academicians” who lack a clinical viewpoint, I offer one perspective as a family physician who practices in an urban academic health center and in a rural community.

In their global approach to patient care, family physicians and other primary care professionals incorporate social, psychologic, cultural—and now spiritual—information into their clinical assessments. Information about patients' religious and spiritual beliefs can be helpful in many ways. The frequency of religious service attendance, for example, may be a proxy for functional status in disabled elderly patients2 and can represent important clinical information for physicians who care for this population. However, a primary consideration is how this information is framed and integrated in the best interest of the patient. Do physicians construe and subsume patients' religious and spiritual issues as social, cultural or psychologic problems, or are these concerns conceptualized as autonomous religious and spiritual concerns? For example, some physicians may interpret a patient's disclosure of hopelessness as a symptom of depression, while others may view these findings as a religious or spiritual issue within a clinical setting.

Dr. Larimore's theistic perspective regarding spiritual assessment and spiritual care limits the utility of religious and spiritual information to largely existential concerns and highlights the ethical concept of patient autonomy. Within the patient-physician relationship, physicians wield a power that is largely salutary and positive; however, this power may result in a loss of patient autonomy when left unchecked or unguarded.3 Patient autonomy is the cornerstone of published guidelines on patient-physician dialogues that involve religious or spiritual issues.4

In the development of a clinical impression and in the recommendation of a therapeutic intervention, patient autonomy can be threatened when physicians' religious convictions are dissonant with those of their patients, or when these beliefs are at odds with the best interest of the patient. Studies that have measured the association of physician religiousness and physician-assisted suicide are supportive of the assumption that physicians' religious beliefs influence the patient-physician relationship.5 If this is true, how do physicians protect patient autonomy and act in the best interest of their patients when spiritual and religious issues are raised?

Here again, Dr. Larimore's commentary1 is instructive. Disclosure, or the provision of a core set of one's professional perspective, opinion and recommendation, is essential for sound decision-making.6 The commentary supplies two elements of disclosure—opinion and recommendation—to assist in our decision-making to either implement or decline the call for a greater physician role in the spiritual assessment and care of patients. Dr. Larimore's perspective as a family physician is unambiguous; however, it is unclear if the lack of his disclosure of an affiliation with the Christian Medical and Dental Association was intentional, or an editorial oversight. In any event, it serves to reinforce the practice of physicians' acknowledgment of their own religious or spiritual assumptions, biases and traditions, and the disclosure of these perspectives to patients before undertaking of religious or spiritual issues in the clinical setting.

to the editor: We commend Drs. Anandarajah and Hight for their sensitive and well-balanced approach to spirituality and medical practice.1 We would welcome and recommend additional training for physicians to increase their awareness of and appreciation for the broad diversity of spiritual and religious paths that their patients may follow. Clearly, this awareness and appreciation is critical if physicians are to functionally respond to any spiritual concerns addressed by their patient—particularly if that patient comes from a different spiritual tradition than their physician. At the same time, we have grave concerns about encouraging physicians to assertively approach the area of religion and spirituality in their practices. To move from awareness to “intervention” in this area seems premature at best.

Dr. Larimore's comments2 provide a case in point. The “significant medical evidence supporting these interventions” that Dr. Larimore cites consists mainly of statistics regarding people's opinions about the importance of spirituality. This is neither outcome-related nor evidence-based medicine. Beyond that, statements such as “63 percent want their physicians to address spiritual issues” or “more than 40 percent actively want discussion of spiritual issues to take place” will likely not be particularly convincing to the other 37 to 60 percent.

Dr. Larimore also cites Levin and Vanderpool3 as claiming that “poverty of personal faith” should be regarded as a risk factor … nearly equivalent to tobacco or alcohol abuse.” Again, we are gravely concerned about this approach for two main reasons. First, it muddies the definitions of “risk factor.” Tobacco and alcohol are risk factors because they have more than a simple epidemiologic association with disease; they have clear epidemiologic and physiologic evidence for causality. Such evidence is absent in the case of faith; further, there is no clear evidence that physicians' interventions in this area lead to better health outcomes.4

Second, there is no clear definition of “poverty of personal faith.”1 Can an atheist or agnostic escape this characterization? What about the physician who responded to a survey item by stating, “I feel very “spiritual” but at the moment quite “areligious?”5 What about patients whose faiths are strong but do not conform to their physician's? Before issues of sexuality could be discussed routinely by family physicians, they needed training on a wide variety of sexual practices that may have differed from their own. Similar education will be necessary before spiritual and religious issues can be meaningfully and beneficially addressed. As things now stand, we worry that any Muslim, Buddhist, Wiccan, Hindu, Humanist, or Unitarian Universalist in this country might be at risk of being diagnosed as “under- or mal-faithed.”

It used to be said that a physician knew when a patient was an alcoholic if the patient drank more than the physician. We hope it will not be said in the future that a physician prescribes faith-based interventions to those patients whose faith seems somehow weaker than the physician's.

to the editor: The commentary by Dr. Walter Larimore1 advocates family physician involvement in the spiritual concerns of patients, but he perpetuates three significant confusions that plague current discussions.

The first confusion concerns the professional boundaries of medical practice. Where are those boundaries for family practice? Dr. Larimore quotes Klein2 that “obstetrics is just too important to be left to obstetricians” as support for the fact that obstetrics is firmly established within family practice. The importance of religion and spirituality, however, does not in itself justify physician attention because they are categorically different from medical subspecialty practices. These patient concerns share similarities with other human experiences that impact health and illness, but generally lie outside medical practice (e.g., marital status, employment/unemployment and concerns about housing). Family practice may be a broad specialty but it does have boundaries. In what way is attention to religious and spiritual concerns within those boundaries? Dr. Larimore's suggestion that physicians need more training does not address this issue.

A second related confusion arises when Dr. Larimore and other authors do not recognize the difference between gathering a spiritual history and providing clinical services. Dr. Larimore states, “obtaining a brief spiritual history is not a clinical skill that should be, or routinely can be, referred to a religious or spiritual subspecialist.”1 Most religious professionals would agree and support physicians' practice of gathering spiritual histories from patients—a practice that current discussions seek to improve.

Confusion emerges, however, when authors go on to suggest that family physicians also should provide spiritual services; for example, praying with patients or trying to help them with their spiritual concerns. Once again, questions about professional boundaries emerge and the important differences between screening, assessment and the provision of clinical services are ignored. If family physicians provide religious and spiritual services, would Dr. Larimore agree that they should also routinely provide services directly related to such concerns as marital status, unemployment and poor housing—all of which influence health and illness? It seems appropriate in specific circumstances that some physicians provide such services, including spiritual care. Research results are necessary, however, and will likely demonstrate that such situations are the exception rather than the rule. This issue certainly deserves clearer discussion.

Third, Dr. Larimore confuses issues by arguing his position from poll and survey results. The general public, patients, their family members and family physicians themselves have many opinions about what ought to be included in medical practice. Such survey results by themselves, however, cannot determine the content of medical practice. Here, Dr. Larimore's own emphasis on the need for outcome-based research is essential. While research results will likely demonstrate that a spiritual history can inform treatment decision, it is notable that Dr. Larimore himself provides no results from the 6,000 health care professionals who have attended his workshops. Such results are necessary before his assertions can be sustained. Research results are also required before advocates can promote family physicians as spiritual care providers and Dr. Larimore's quotation from an earlier publication on which I was a co-author remains appropriate, “It is not clear that physicians should engage in religions discussions with patients as a way of providing comfort.”3

in reply: The four thoughtful “Letters to the Editor” in response to our article1 and accompanying commentaries2,3 on spirituality and medicine highlight the ethical issues and controversies surrounding the incorporation of spirituality into medical practice.

Drs. Daaleman, Hamilton/Swain and VandeCreek discuss ethical issues including the respect for patient autonomy and diversity, the appropriateness of spiritual “interventions” recommended by physicians and the careful delineation of professional boundaries. I agree that physicians wield a certain amount of power and authority, and the possibility of coercion is very real. It is our responsibility to make sure that our power is used to promote healing and not used to inflict harm—even unintentionally.

America is a diverse country based on freedom of thought, including religious belief. I have found that, when asking patients about beliefs, the key is the attitude of the person doing the asking. The depth of a given response seems directly related to the degree of genuine interest. While it certainly helps to have a working knowledge of the diversity of spiritual beliefs present in the patient population, I have found that you can never know enough. Everyone has a unique life journey. A useful approach, for me, has been a humble acknowledgment of my ignorance and a genuine request for people to tell me what is important to them and how I can help. We can empower patients to tell us and choose what “interventions” might help them. With this approach, I have been enriched by the wisdom and experience of my Christian, Jewish, Hindu, Buddhist, Islamic and atheist patients and friends.

In terms of professional boundaries, a delicate balance exists in family medicine. Family physicians must be able to discuss all factors affecting health and well being. However, we must also be aware of our limits and help patients find the appropriate resources to help with their problems. Most of us are not trained spiritual counselors and should be extremely cautious about taking on responsibility for this complex service. Clinical pastoral education (CPE)-trained interfaith chaplains must undergo extensive training, self-reflection and supervision to ensure that they can provide spiritual care without imposing their own beliefs, biases and issues. Likewise, physicians should probably grapple with their own beliefs and biases before discussing spiritual issues with patients.

Dr. DeHaven suggests that, since physicians respond to clues during a medical interview only 20 percent of the time, listening for clues to spiritual concerns in patients' narratives is not a practical assessment approach for family physicians. However, the study he quotes4 also reports shorter visits when at least one clue was acknowledged by the physician. This, coupled with the fact that recent books5,6 underscore the importance of narratives in the physician-patient relationship, suggests that informal spiritual assessment can be a valuable tool for busy family physicians. As for specific questions, there are many possible approaches. Great care must be taken regarding the use of language and avoiding assumptions. I encourage physicians to try different approaches to see what works for them.

Finally, a comment on the “spirit” of spirituality and medicine. Spirituality, in a broader context, is about the mystery of our existence, the meaning of our lives and the love and connection we feel toward self, others, nature and the transcendent. Spirituality in medicine is more about the genuine compassion, presence and the helping hand we offer our patients than the specific questions we choose to ask. As we continue our discussion about how to proceed in the best interest of our patients, I hope we go forward with humility, respect and balance.

in reply: Most who publish on the intersection of religion and medicine agree that physicians should become comfortable addressing the basic spiritual/religious needs of their patients: taking a religious history, supporting healthy religious beliefs, ensuring access to religious resources, providing spiritual referral or consultation and viewing the pastoral professional as an integral part of the health care team.1,2

There is less agreement about spiritual interventions such as praying with patients or providing religious counsel. Those supporting these interventions agree that they should be patient and not physician-centered.1,2 Physicians must honor patients' autonomy, follow patients' lead and needs, and utilize permission, respect, wisdom and sensitivity.134

Current data indicate that physicians' religious beliefs will influence whether and to what extent they addresses these issues.1 Yet, almost 70 percent of primary care doctors agree that physicians should address at least some religious issues with patients and between 46 percent and 78 percent of patients indicate that they would like their physician to pray with them.1 One third of primary care physicians and two thirds of religiously devout physicians report doing so.1 As pointed out by the letters, outcome-based, clinical research on the effects of spiritual interventions is almost nonexistent. Nevertheless, there are sufficient, evidence-based reasons for physicians to provide such services, albeit cautiously.

For the vast majority of patients, the apparent benefits of intrinsic religious belief and practice outweigh the risks.134 Surveys indicate that a sizable majority of patients want their physician to address religious/spiritual issues in the context of a medical visit.1,3 Fears of religious abuse and claims of possible negative effect of religion on health are highly speculative and have no basis in population-based systematic reviews.1

In fact, results from the vast majority of the cross-sectional and prospective cohort studies1 indicate that religious beliefs and practices are consistently associated with better mental and physical health outcomes. Some critics assert that the magnitude of these effects is weak and inconsistent,5 while others claim these effects do not reflect risk. These are minority opinions among the 1,600 publications in this area.1 Yet, these apparent health benefits are not established beyond doubt. Better research is needed.

In the year 2000, at least 65 of 126 U.S. medical schools and a growing number of residencies offered courses on religion, spirituality and medicine.1 Studies have begun to describe the results of such courses.1 Despite the appropriate concerns of the letter writers, I am unaware of any published reports or systematic studies about physicians having caused harm by addressing patients' religious/spiritual needs. One would expect such reports should harm be widespread.

The evidence to date tells us it is not clear that physicians should not engage in religious discussion with patients. Until such evidence is available, I would encourage interested family physicians (most of whom do involve themselves in the marital, unemployment and housing concerns of their patients) to learn to assess their patients' spiritual health and to provide indicated and desired spiritual intervention.

For family physicians, the continuous care of the entire patient, mind, body and spirit, in the context of the family and community is both foundational and essential to true primary care and caring. Physicians should not, without compelling data to the contrary, deprive their patients of “… the spiritual support and comfort upon which their hope, health and well-being may hinge.”1

editor's note: My intent in featuring the article1 and commentaries2,3 on spirituality was to examine the impact of spiritual or religious factors on the medical care of patients. I would certainly agree that it wouldn't be appropriate for American Family Physician to advocate for any one religion or set of spiritual beliefs; however, there does seem to be an increasing amount of literature demonstrating the value of addressing spiritual concerns with patients. That is not to say that a physician must do so, but it does lend credibility to the desire of some patients to have these concerns addressed. For reasons such as these, many medical schools have added required courses to their curricula dealing with the interface of medicine and spirituality. In my role as editor, I try to respect the sensitivities of our readers when dealing with potentially controversial topics. Our “Letters to the Editor” department exists, in part, to provide the opportunity for differing viewpoints on subjects such as this.

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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