The Role of Spirituality in PhysicianPatient Interactions
November 1, 2010
The Role of Spirituality in Physician–Patient Interactions
The Reverend Dr. Howell Sasser, PhD
Dr. Sasser is Priest Associate, St. Peter's Episcopal Church, Peekskill, NY, and Associate Professor of Epidemiology, New York Medical College, Valhalla, NY; he reports no financial relationship to this field of study.
Recent decades have seen a dramatic expansion in the visibility of ethnic and cultural diversity in the United States. Much of this is not new, only newly prominent. Numerous ethnic, linguistic, religious, and cultural groups have been present in the United States since its beginnings, and even the popular image of a Caucasian Protestant majority includes many variations. A paradoxical consequence of this growing awareness of diversity may be a reluctance to address it directly that is motivated by a wish not to seem ignorant or give offense. Yet failure to do so can itself lead to misunderstandings and bad outcomes, especially in fields like medicine.
While there are numerous relevant aspects to the topic, this article will concentrate on the role of spirituality and religious faith in physician-patient interactions. Even that limitation leaves too large a subject to cover exhaustively, so the goal will be to offer general suggestions that might serve as guides for an exchange of relevant information rather than as precise instructions. For this purpose, it will also be assumed that the encounter in which the subject of spirituality arises is part ofor at least at the beginning ofan ongoing therapeutic relationship. Medical relationships that begin in times of crisis have their own dynamics and deserve separate treatment.
A clinician who wishes to be sensitive to the beliefs and practices of his/her patients would be well advised to begin by considering his or her own. Our reactions to the attitudes and opinions of others are necessarily influenced by those we carry ourselves, whether conscious or unconscious. Even if after careful consideration, the outcome is, "I don't subscribe to any religious or spiritual practices or beliefs," or, "I don't know what I believe," that insight will help to put anything a patient says into perspective. It is important also to bear in mind that there can be no right or wrong answers in such matters. Belief in a higher being is not intellectually equivalent to believing in the efficacy of antibiotics. The purpose in asking about a patient's spirituality is to incorporate that information into a plan to provide the best medical care possible to the whole person. Differences in belief between physician and patient need not prevent that from happening, but a physician who is unaware of his or her own influences and attitudes may miss or misinterpret important information.
With this understanding in place, the next step is to ask simple, open-ended questions of the patient. Physicians and patients have become conditioned to the asking and answering of all kinds of sensitive questionsabout substance use, sexual habits, family dynamicsso questions about spirituality need not seem any more awkward. A question in an intake exam such as, "Do you have any spiritual or religious beliefs or practices that I should know about?" allows for a polite refusal ("No, not really.") or a more complex response. Such questions can easily be made "condition-specific." A visit that focuses on affective issues or a condition in which the response to stress is relevant (for example, hypertension) presents an opening for a question like, "Do you use any practices like meditation to help manage the way you feel?" With older people and those from racial/ethnic groups in which churches or other religious organizations remain strong social institutions, a question about social support may be helpful"Do you have people at your church who can help you with jobs around the house or with getting to appointments?" This can provide some information about a patient's level of religious involvement, and might also elicit further information about the role of religion as a coping strategy in his/her life.
A seemingly obvious, but important, point is to allow time for answers. Medical encounters are often very brief by necessity, with a large amount of information to give and receive. Efficiency may be predicated on an assumption that answers to questions can be succinct. However, when a patient is asked about his or her approach to spirituality, the answer may be lengthy either because of its complexity or because it requires going into unexplored territory. To ask about it and then have to cut short the answer is perhaps worse than not to ask at all. A patient's description of his/her beliefs and practices also may be aided by a few prompts. If something is not clear or could have multiple interpretations, do not hesitate to say, "I'm not sure I understand that." Summarizing what the patient has said, often aided by the expression, "What I hear you saying is...," can also help avoid misunderstandings.
Don't expect to get the full story all at once. A significant portion (perhaps a majority) of actively religious people in modern America are reticent about discussing their faith in one-on-one encounters with others whom they suspect may not share them. In the case of medicine, this may be because physicians are widely viewed as being drawn fromor educated intoa social and educational class that is dismissive of religion ("followers of Scientism"). This view, coupled with the message, communicated in many ways, that physicians' time is very limited, may constrain or sanitize what is said. The same strategies for overcoming such concerns about other issues are useful herebeing at eye level, avoiding negative body language, using visual and vocal cues to indicate interest.
Be prepared to answer questions as well as ask them. Part of making a patient feel comfortable discussing his or her faith is being willing to go wherever the conversation leads. It may be to the personal ("And what do you believe?") or the more theoretical ("What did I do to deserve to be this sick?"). The latter sort of question is often rhetorical, but a response in the form of a question like, "What does your religious tradition teach about that?" can elicit valuable information and almost always will be well received.
Be sure to make a few notes. Information obtained at a routine or low-acuity visit may usefully be brought up again later. When a time of more serious illness arises, a question like, "Do you have someone praying for you?" may both remind the patient of the earlier conversation and put him/her at ease in talking about it now. It is a common observation of the clergy that religious faith serves as a "fallback" resource for many more people than attend services regularly. Such a question, asked in a time of stress, is unlikely to be viewed as offensive. At the same time, it is important for the physician to consider in advance what reply to make if the answer is "no." In this, as in other situations, sincerity and assurance that the physician is in a "therapeutic alliance" with the patient are more important than empty words.
These suggestions are intended as points of departure. Variations in geography, local culture, practice patterns, and concordance or discordance in physician-patient age or race/ethnicity, among many other factors, will influence whether and how to bring religion or spirituality into the clinical picture. At a personal level, a physician's comfort with the subject will also drive such choices, though ironically, this may be the part of the equation over which the individual physician has the most control. Careful consideration of one's own past and present circumstances, combined with an open and nonjudgmental style with patients, can yield much that will be of diagnostic and therapeutic value.
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