Taking Your Spiritual Pulse
Oct. 2, 2000 -- Have any allergies? Past surgeries? Do you use caffeine, alcohol, cigarettes? Rhonda Oziel has been asked the same questions by doctors so many times she thought she could recite the checklist by heart. Then one day a doctor deviated from the drill.
The occasion was a checkup with her new internist, Christina Puchalski, MD. Near the end of the visit, the doctor asked Oziel if she considered herself spiritual or religious. What sorts of beliefs sustained her in difficult times?
"I was receptive to the questions, and it made me feel very good to have that discussion," says Oziel, a 50-year-old Washington, D.C., librarian. "It made me feel my doctor looks at me as a human and not just a medical specimen."
We'd all prefer that our doctors see us as more than just another backache or sore throat. But do we really want strangers with stethoscopes inquiring about our spiritual beliefs? Increasingly, researchers say we do. And, in response, medical schools are now beginning to teach doctors-in-training to take a spiritual history along with the patient's medical history.
Many Nonbelievers Agree
Researchers at the University of Pennsylvania surveyed 177 outpatients at the university hospital and found surprisingly high support for such "spiritual intakes." Some 94% of those who had religious or spiritual beliefs felt physicians should ask about those beliefs, according to the study published Aug. 9, 1999, in the Archives of Internal Medicine. And more than half of those who professed no significant beliefs still thought doctors should at least inquire. In comparison, just 16% of patients said they would not welcome such questions from their doctors.
Yet despite these strong sentiments, only 15% of the patients surveyed said a doctor had ever asked about their religious or spiritual convictions.
The Medical Benefits of Faith
There are sound medical reasons to take these beliefs seriously. An analysis of 42 studies involving 125,286 patients, published in the June 2000 issue of Health Psychology, found that those with some sort of religious involvement live longer -- though no one knows whether longevity is due to their faith or their community ties.
Moreover, two-thirds of the patients in the University of Pennsylvania study said that being asked questions about their beliefs would increase their trust in a doctor, which has also been linked to better medical outcomes in some studies.
"We're not doing our jobs if we ignore these questions," says Daniel Sulmasy, MD, director of the Bioethics Institute at New York Medical College, a Catholic university. "After all, it's not just bodies that become sick. Any illness raises issues of spiritual or religious meaning and values."
The point of a spiritual history is not to quiz patients on their formal religious affiliation, says Puchalski, who is medical director at the National Institute of Healthcare Research, a group promoting the integration of spirituality and health care. "We're really just trying to understand what's important to a patient and how those beliefs and values might affect how the patient copes with illness."
The "Spiritual Intake"
Puchalski has developed a series of four questions that attempts to get at a patient's belief system, which could include nature, philosophy, family, and community -- along with formal religion. Such so-called "spiritual intakes" have been taught at 64 medical schools in the United States, including Johns Hopkins and Harvard.
"Physicians are not being trained to be spiritual directors," she says. "The idea is simply to open the door to discussion." If a more in-depth exploration seems warranted (for instance, if a patient believes that an illness is a deserved punishment from God), a doctor might then refer the patient to a clergy member or counselor -- in the same way physicians refer patients who bring up issues of domestic abuse or family troubles. Puchalski calls her system FICA; here's what the letters stand for:
F: Faith or beliefs. Do you consider yourself spiritual or religious? What things do you believe in that give meaning to your life? (If the patient doesn't want to discuss such questions, this is the time for the doctor to end the spiritual history interview.)
I: Importance and influence. How might your beliefs influence your behavior during this illness? What role might your beliefs play in helping you regain your health?
C: Community. Are you part of a spiritual or religious community? Is there a person or group of people who can help support you in your illness?
A: Address. What can I, your doctor, do to address and support spiritual issues in your health care?
In this time-pressed era of managed-care medicine, do doctors really have time to get into patients' spiritual beliefs? Puchalski and others say they're merely urging physicians to broach the subject -- not conduct an in-depth interview. Her interview format can take as little as two minutes, she says.
Ask But Don't Push
Despite patients' hunger for such discussions, Pulchalski and Sulmasy at New York University recognize that some doctors could potentially take advantage of their position of influence to evangelize about their own beliefs. "That would be absolutely wrong, a serious affront to patients," Sulmasy says.
To avoid misuse of the technique, patients should be allowed a quick exit from the discussion if spirituality is not an issue for them or they feel it is none of the doctor's business, they say.
When the conversation is conducted with care and respect, however, Sulmasy says it can help doctors engender trust and open discussions about end-of-life decisions in the event the patient becomes seriously ill.
In Rhonda Oziel's case, she was glad her doctor had broached the subject of belief at their first meeting. "I don't pray very often," Oziel told her doctor, "but I know there's a spirit looking out for the world." Their talk was enough to open the doors of communication. Several months later, when Oziel's husband died, she felt comfortable turning to her doctor to discuss her loss and what might happen after death. The conversation, though brief, provided just the sort of comfort she craved.
Ann Japenga, a contributing editor at Health magazine, writes frequently about psychology for WebMD. She lives in Palm Desert, Calif.
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