For thousands of years, human beings have sought to understand the forces which make them ill and the ways in which an individual’s health can be restored.  Today, the field of medicine, firmly rooted in science and technology, is capable of diagnosing and curing a multitude of illnesses and injuries which in the past would have often condemned a person to death.  However, a number of individuals point to the fact that in a rush towards the scientific, we may be leaving an important facet of medical care behind.

In recent years, a number of medical professionals and industry observers have highlighted the potential importance of spirituality and/or religion in medical practice.  It is first important to note, however, that the terms “spirituality” and “religion” are in many cases not interchangeable.  In an article on spirituality in cancer care, for example, the National Cancer Institute outlines the difference between the two terms:

The terms spirituality and religion are often used in place of each other, but for many people they have different meanings.  Religion may be defined as a specific set of beliefs and practices, usually within an organized group.  Spirituality may be defined as an individual’s sense of peace, purpose, and connection to others, and beliefs about the meaning of life.  Spirituality may be found and expressed through an organized religion or in other ways.  Patients may think of themselves as spiritual or religious or both.[1] 

Many medical professionals and researchers are interested in spirituality as it interacts with the medical profession - an interest that could have far-reaching consequences.  By 2008, in fact, approximately two-thirds of the medical schools in the U.S. offered courses focused on the role of spirituality in medicine.[2]  Of these schools, three quarters required their students to take at least one course on the topic.[3]

Correlation with Health Outcomes

So is spirituality truly relevant in patient care?  Well, religious and spiritual variables have been associated with a variety of health-related outcomes in the literature, including (but not limited to) lower mortality levels in healthy individuals,[4] improved recovery after surgery,[5] lower levels of drug[6] and cigarette use,[7] lower blood pressure,[8] and lower levels of health care utilization.[9]  In a 2000 essay published in the Journal of the American Medical Association, Dr. Harold Koenig of the Duke Medical School Center for Spirituality, Theology and Health reported that out of 350 studies that have examined religious involvement and health, the majority indicated that religious people lead healthier lifestyles and are healthier, while at the same time require fewer health services[10] (though other authors contend that many articles commonly cited as addressing the relation between religious involvement and health are either irrelevant to claims of health advantage associated with religious activity or are not methodologically sound).[11]  In a 2003 review of studies on the topic that the authors judged to be of sufficient methodological soundness, Powell, Shahabi, et al. concluded that healthy church/service attendees had a consistent, robust, and prospective reduction in risk of dying,[12] though the authors failed to find consistent evidence for some other hypotheses, such as the judgments that religion or spirituality slowed the progression of cancer or speeded a patient’s recovery after an acute illness.[13] 

Research also indicates that many doctors feel that religion and spirituality influence patient’s health.  In a 2007 study of 1,144 U.S. physicians age 65 and younger from all specialties, 56 percent of physicians indicated that they believed that religion and spirituality have a significant influence on health.[14]  While few doctors believed that religion and spirituality help to prevent “hard” medical outcomes such as heart attacks or death, over three quarters of those surveyed indicated that faith helps patients cope, and a similar percentage indicated that it gives patients a positive state of mind.[15]  Moreover, over half of those surveyed said spirituality provides emotional and practical support.[16] 

Positive and Negative Coping

Medical professionals should take note of the potentially harmful side of religion and/or spirituality as it relates to health outcomes as well.  Patients can sometimes refuse medical treatment based on their religious beliefs.  Moreover, the type of “coping” individuals employ appears to have an effect on health outcomes and/or individual quality of life in some studies.  Coping is at times segmented into “positive” versus “negative.”  Positive coping methods reflect a sense of connectedness with a religious community and a sense of a benevolent purpose to life, and a sense of secure bond with God and include prayer, compassionate religious judgments of negative conditions, and forgiveness.[17]^,[18]  On the other hand, negative coping methods reflect a more tenuous relationship with God, a more gloomy view of life and include behaviors such as attributing events and/or conditions to some form of punishment.[19] 

Negative coping has been linked to negative outcomes in some studies.  In a study of religious coping and quality of life among 170 patients with advanced cancer, Tarakeshwar, Vanderwerker et al. found that greater use of positive coping methods was related to better overall quality of life, while greater use of negative coping was associated with worse overall quality of life.[20]  In a separate study, Pargament, Koenig et al. followed 268 medically ill, hospitalized patients in a two-year longitudinal study and found that positive coping methods were generally associated with improvements in health, while negative coping methods were predictive of declines in health.[21]

Where Does the Doctor Fit In?

A significant number of patients have indicated in prior studies that they want physicians or other health professionals to have knowledge of their spiritual and/or religious beliefs, although different studies have yielded substantially different results.  As McCord, Gilchrist, et al. noted in their 2004 Annals of Family Medicine article, outpatient studies have found that anywhere between 13 and 73 percent of patients want physicians to have knowledge of their spiritual or religious beliefs.[22]  In their survey of consenting patients in four family practice residency sites and one private group practice in Ohio, McCord, Gilchrist et al. found that 83 percent of respondents indicated that they wanted physicians to ask about spiritual beliefs in at least some instances.[23]  Moreover, the percentage of those patients welcoming spiritual inquiry seemed to increase with the severity of the illness.  Seventy-seven percent of respondents indicated that they would welcome spiritual discussion in the event of some life-threatening illness, but only 43 percent indicated that spiritual discussion would be welcome during a medical history consult or an initial visit to the doctor, and only 7 percent indicated that they would welcome a discussion during a routine physical/check up.[24] 

Additional studies support the idea that a patient’s desire to discuss spirituality is related to the severity of patient injury/illness.  In a survey of patients in six primary care clinics in three states (North Carolina, Florida, and Vermont), MacLean, Susi, et al. found that the number of patients who would welcome a spiritual inquiry increased as the severity of illness increased.  Thirty-three percent would welcome a spiritual inquiry in an office visit, while 40 percent would do so in a hospitalization setting, and 70 percent would do so in a terminal situation.[25]  Likewise, in a study noted by McCord, Gilchrist, et al., Maugans and Wadland found that physicians report religious inquiries only 4 percent of the time evaluating minor illnesses, 45 percent of the time evaluating major illnesses, and 69 percent of the time counseling terminal patients.[26]  

Proceed with Caution

If a health professional does decide to attempt to address a patient’s spiritual beliefs, care should, of course, be taken to do so in a professional, courteous, and respectful manner.  Recommendations abound for methods to deal with a patient’s spiritual issues.  Thomas McCormick, a faculty member in the University of Washington School of Medicine’s Department of Medical History and Ethics, observes health professionals can take a “spiritual history” which can often be introduced by simply stating something like the following:

As physicians, (or, as physicians-in-training,) we have discovered that many of our patients have strong spiritual or religious beliefs that have a bearing on their perceptions of illness and their preferred modes of treatment.  If you are comfortable discussing this with me, I would like to hear from you about any beliefs or practices that you would want me to know as your care giver.[27]

In this manner, if the patient answers in the affirmative, the physician can then follow up with additional questions on the topic.[28]  However, if a patient responds with “no” or “none,” this is a clear signal to the physician to move on.[29] 

In addition, various mnemonics exist to assist in framing an approach to spiritual history taking.  Todd Maugans offers the SPIRIT mnemonic, which he defines in an Archives of Family Medicine article as a consideration of the patient’s Spiritual Belief System, Personal Spirituality, Integration and Involvement in a Spiritual Community, Ritualized Practices and Restrictions, Implications for Medical Care, and Terminal Events Planning.[30]  Another mnemonic proposed by Anandarajah and Hight in the journal American Family Physician (2001) is the HOPE mnemonic, in which “‘H’ stands for sources of hope, meaning, comfort, strength, peace, love and connection; ‘O’ for organized religion; ‘P’ for personal spirituality and practices; and ‘E’ for effects on medical care and end of life issues.”[31]

Striking the Balance

Different physicians will approach a patient’s spiritual needs and questions in different manners.  However this is done, physicians should remember that they have other resources for helping patients with their religious and spiritual needs.  Board-certified chaplains have extensive training to help them meet patients’ spiritual needs.[32]  Clergy can also be a resource.  Physicians should take care to avoid certain actions when dealing with religious and spiritual matters with patients.  Physicians should take care not to “recommend” or “prescribe” religious beliefs to patients of a different religion or those who do not consider themselves religious/spiritual.[33]  Discussion of spirituality/religion, like other health practices, should be patient-centered.[34] 

Nonetheless, there is a delicate balance in patient care.  In many cases, in-depth religious counseling is better accomplished by trained clergy.[35] Relating to a patient’s spirituality, on the other hand, can be as simple as paying closer attention to your bedside manner.

Whatever a physician’s feelings concerning spirituality and religion, the physician should always keep in mind the simple fact that it is a physician’s duty to care for and comfort the sick and injured.  If a patient in a time of need asks for a spiritual/religious observance or about a spiritual issue and the physician sees that fulfilling this will bring the patient comfort, then physicians may consider supporting these beliefs/requests,[36] to the extent it is morally, ethically, and professionally acceptable to do so. 

Ultimately, physicians must find a way to reiterate that their goal is to provide the best medical treatment possible and get the patient on board with this mission.  After all, quality care, combined with respect, compassion, and an occasional dose of optimism is the best way to serve all patients.