Cover Story -- November 2004
By Ken Ortolon
An elderly couple stopped in to see the Rev. Jim Alcorn, director of pastoral care and education at St. Luke's Hospital in Houston. The husband had been hospitalized with heart problems at St. Luke's for nearly a month. Despite two surgeries, his prognosis was poor and he had accepted the reality that his doctors were sending him home to Florida to die. Even so, the couple was uplifted by their experience at St. Luke's.
"They said this had been the most spiritual month of their lives because not only were the caregivers tender and caring and efficient and professional, but because they were spiritual," said Reverend Alcorn. "They felt they had been spiritually sustained while they were here by the nurses, by the folks who took care of them. They thought in some way we had told them that not only were their lives worthwhile, but they were affirmed in their own personal faith walk."
Spirituality may seem out of place in a field grounded in hard science. Indeed, many physicians and other health care professionals are reluctant to talk to patients about spiritual issues. But spirituality, religion, and medicine long have been intertwined. And recent years have seen renewed interest in the role spirituality and religion play in influencing positive health outcomes.
Not only is there more research in this area, but also medical schools across the country have begun teaching prospective physicians how to acknowledge and incorporate faith into their patients' care.
Grounded in Tradition
"This seems new for many of us. Bringing religion and spirituality to health care seems revolutionary," said Harold Koenig, MD, director of the Center for the Study of Religion/Spirituality and Health at Duke University Medical Center. "But it wasn't always that way."
Dr. Koenig says the whole concept of caring for the sick arose from religious teachings. Churches built the first hospitals in the Western world beginning in the 4th century, and most early physicians and nurses were from religious orders, says Dr. Koenig, who recently spoke at a conference on spirituality and health care sponsored by Texas Tech University Health Sciences Center.
But emphasis on spirituality and religion began to disappear from health care after World War II as allopathic medicine gained dominance.
"Since the mid-20th century, religion has been seen as irrelevant, neurotic, bothersome, and conflicting with care," Dr. Koenig said. "For most physicians today, even in this area, that is how religion is viewed."
Dr. Koenig says only about 5 percent of physicians today routinely discuss spiritual issues with their patients.
But that is beginning to change as an increasing volume of scientific research establishes a definite link between spirituality and positive health outcomes.
"To the surprise of a great number of persons, particularly to researchers, religious affiliation and actual practice -- from prayer to attending religious services -- have been shown to have a salutary effect on everything, from how long you stay in the hospital or whether you get there in the first place, to how long one recovers from major surgery, to the sense of disability one feels or doesn't feel," said Harold Vanderpool , PhD. Dr. Vanderpool , professor of history and philosophy of medicine in the Institute for the Medical Humanities at The University of Texas Medical Branch (UTMB) at Galveston, says some 1,200 studies in the past decade show religion has a positive influence on those factors.
Dr. Koenig says studying spirituality is "almost becoming trendy." Between 1980 and 1982, about 100 scientific articles were published on religion and medicine. Between 2000 and 2002, more than 1,100 such articles were published.
"The increase in research is because of the previous findings," Dr. Koenig said. "A critical mass of research shows a connection, and there's logic behind the connection."
A number of studies on spirituality's role in mental health show that religious or spiritual people in general are more likely to have a sense of well-being, hope, and optimism, are less likely to be depressed or abuse alcohol or drugs, and are less likely to commit suicide.
Other studies have found connections between spirituality and positive physical health outcomes. According to a study in Alameda County, California, between 1974 and 1987, cancer deaths among weekly churchgoers were substantially lower than the overall cancer mortality rate. Other studies found a demonstrable decline in mortality from heart disease among those who regularly attend religious services.
And, regular churchgoers tend to have longer lifespans than those who aren't -- seven years longer for Anglos and 14 years longer for African-Americans, Dr. Koenig says.
Learning to Cope
One of the ways spirituality impacts health is by helping people cope with illness. Religious or spiritual patients are more likely to be optimistic, to have a sense of meaning and purpose in their lives, and to remain hopeful, Dr. Koenig says. They also are more likely to have adequate social support from family, friends, or their religious congregation.
"Religion is a coping behavior," Dr. Koenig said. "We know that emotions affect the physical body. So if you're ignoring the coping part, you're going to be ignoring part of the person's physical body and ability to recover."
Dr. Vanderpool adds that spirituality can impact the body's physical response to the stresses that come with illness. "Prayer and meditation -- not just Christian prayer, but prayer in any religious tradition -- lower stress, lower particularly biochemical responses and enzymal responses that lead to stress and distress."
Reverend Alcorn says he believes hospitalization for a serious illness is a "time of confession" for many patients. "They want to be right with their god simply because all of a sudden they're dealing with their mortality," he said. "I think that the idea that God is with them in their illness and their recovery is significant to most all people, regardless of how they worship or what name they call their god."
The statistics seem to bear that out. A recent Gallup poll found that 95 percent of Americans believe in God, and eight out of 10 older Americans belong to a religious organization. Three-fourths of older Americans said religion is very important to them; more than half said they attend religious services weekly or more often.
"To me it just seems to be an incredible figure that over half of older adults attend church every week or more," Dr. Koenig said.
A study published in the April 2004 issue of the Journal of the American Geriatrics Society also found that 88 percent of patients over age 60 consider themselves both religious and spiritual. Only 3 percent said they were neither.
Other studies say patients rank religion as one of the most important factors in helping them cope with their illnesses and that religious beliefs impact patients' medical decision-making.
A University of Pennsylvania study shows two-thirds of patients say religious beliefs would impact their medical decisions. When asked what they would do if they discovered a lump in their breast, 44 percent of women randomly surveyed in North Carolina said they would trust more in God to cure their cancer than in medical treatment. Thirteen percent said only a religious miracle could cure their cancer.
"If religion influences medical decision-making with that kind of magic, how can a health care professional not know about the religious leap of faith?" Dr. Koenig asked. "How can they ignore that area of health care and practice good medicine?"
Making the Spiritual Connection
The answer, according to Dr. Koenig and others, is they shouldn't. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to conduct spiritual assessments of patients being admitted for care.
Those assessments, at a minimum, are supposed to determine the patient's denomination and beliefs, and identify what spiritual practices are important to that patient. That information is to be used in determining the impact of spirituality, if any, on care or services being provided.
Among questions that might be asked as part of a spiritual assessment are:
- Who or what provides the patient with strength and hope?
- Does the patient use prayer in his or her life?
- How does the patient express his or her spirituality?
- How would the patient describe his or her philosophy of life?
- What type of spiritual/religious support does the patient desire?
- What is the name of the patient's clergy, minister, chaplain, pastor, or rabbi?
- Is there a role for church/synagogue in the patient's life?
- How does faith help the patient cope with illness?
Since JCAHO added this requirement, the agency has struggled to increase the use of meaningful spiritual assessments, and many hospitals have "gotten dinged for not doing it," Dr. Koenig says.
"Many health care professionals are uncomfortable with it, they're queasy about doing this," he said. The reason, he says, is that most physicians and health care professionals lack information, time, and training to deal with spiritual issues.
"Most physicians don't know about the amount of research in this area that shows the connection," Dr. Koenig said. "They don't understand the rationality behind taking a spiritual history and communicating with patients about that."
That's largely because medical schools have virtually ignored spirituality over the past several decades. In 1993, only five of the nearly 130 medical schools in the United States addressed spirituality and religion as part of their curriculum. Today, that number is close to 100.
"There's been a real resurgence in the number of medical schools that have courses or course segments on these factors," said Dr. Vanderpool . Both UTMB and Texas Tech require some instruction in spirituality.
Taking a Spiritual History
Patti Patterson, MD, vice president in the Office of Rural and Community Health at Texas Tech, says students there are exposed to issues about religion and spirituality as part of a first-year course on fundamentals of medical practice. During clinical rotations, spiritual assessment and history-taking are incorporated on a case-by-case basis with individual patients, she says. Some faculty members are more interested in this area or more comfortable in teaching these skills than others, she adds.
John Belzer , PhD, associate director of the Oklahoma Geriatric Education Center and assistant professor of geriatric medicine at the University of Oklahoma Health Sciences Center, says students there are required to conduct at least two spiritual histories as part of a mandatory four-week rotation in geriatrics.
"They're certainly not going to be experts, but at least they're getting the experience of having to go in, visit with patients, and take that spiritual history," he said.
While a number of spiritual assessment tools have been developed for use in hospitals or physician offices, one that seems to be favored for its speed and simplicity is called FICA, which stands for Faith and Belief, Importance, Community, and Address in Care.
FICA, developed by researchers at George Washington University, can be completed in a matter of minutes, Dr. Belzer says. "It's quick and easy to administer, it allows you to interact with your patients, and it gives them permission to discuss issues that are not normally covered in a physical or psychosocial history."
Using the FICA model, a physician would start by asking a patient what his or her faith or beliefs are and if that faith is an important part of his or her life. If the answer is no, the history is concluded. If the answer is yes, the physician proceeds to questions regarding how faith influences how the patient takes care of him or herself, whether the patient is part of a spiritual or religious community, and how the patient would like the physician to address his or her spiritual needs.
UTMB teaches the FICA model, which Dr. Vanderpool says allows the physician to gauge the patient's interest in spiritual issues without being intrusive. "My point here is you only go as far as the patient wants to go and you only get information that would be important for factoring in decisions about the person's health care," he said.
While determining a patient's spiritual beliefs is important in providing what Dr. Koenig calls "whole-person care," physicians should not cross certain unethical lines. He says physicians should never prescribe religion to a nonreligious person, force a spiritual history if a patient is not religious, coerce patients in any way to believe or practice a faith, spiritually counsel patients, argue with patients over religious matters, or do anything that is not patient-centered.
Praying with patients may be appropriate, if the patient requests it, Dr. Koenig says. However, the physician could be flirting with a lawsuit if the patient or patient's family believes the physician is forcing prayer on the patient, he says.
Dr. Vanderpool says it is important to avoid "any hint of proselytizing." He adds that he also is uncomfortable with physicians actually recommending meditation, prayer, or attending religious services. "It's not the physician's business to be recommending but rather to see if there are things about the patient that are important, that should be factored into the patient's health concerns."
Dr. Patterson says the point is not to encourage physicians to provide spiritual counseling themselves, but to be comfortable asking questions about a patient's spiritual needs and then referring that patient to a chaplain. "Those are the people trained in helping patients work through these issues," Dr. Patterson said.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
Death by Religion
By Richard Viken , MD
A provocative cartoon depicts an insurance representative speaking at the bedside of a hospitalized patient, appropriately monitored and IV'd . The caption reads, "The doctors say it's a miracle you survived. Unfortunately your policy doesn't cover miracles." Apparently, an untimely choice of word exchange between physician and third-party payer! Yet how often do we admit, at least to ourselves if not publicly, that a patient's recovery was indeed attributable to a higher power?
Our profession of medicine has grown and flourished from spiritual roots. Aesculapius was the son of Apollo, one of the major gods of Olympus. The Old and New Testaments, listed first among Sir William Osler's 10-volume Bed-Side Library for Medical Students , contain abundant examples of healing in the names of Yahweh and Jesus. Moses Maimonides [1135-1204], a Jewish philosopher and physician practicing Arabic medicine, devoted much of his effort to reconciling scientific reasoning and religious faith. His Morning Prayer of the Physician contains this often quoted passage: "O, God, Thou has appointed me to watch over the health of Thy creatures; here am I ready for my vocation." And to bring us up to more modern times, Santiago Ramon Y Cajal [1852-1934], Spanish neuropathologist and Nobel laureate, wrote, "When I consider the healthy color and peace of mind of pious people, I think that religion possesses not only high moral value but also excellent nutritive worth."
Personally, I attribute 99 percent of my healing ability to God! The remaining 1 percent represents the talent He has invested in me and which He expects me to apply wisely. I pray regularly with my patients and their families. I refer them to appropriate pastoral resources. I attend their funerals.
Yet I, and you also, I imagine, have been regularly reminded through multiple channels that we must not violate the legendary boundary between "church and stent ." This attitude seems to have originated with the scientific revolution, which excluded religion and spirituality from its experimental paradigm. As the science of medicine continues to expand, fueled by public demand for technologically sophisticated care, the art of medicine becomes increasingly suspect.
Physicians have been criticized in the medical literature for having no expertise in spiritual matters, leading to the suggestion that we might actually do harm to patients by linking health status and spirituality. 1 I imagine this scenario:
Doctor : Hello, Mr. Pootywinkle . I see by the arrow sticking out of your head that you have a problem.
Patient : Yes, doctor.
Doctor : As you know, this was predicted in the Bible and later in the 1952 Sears farm implement catalogue.
Patient : Well, I also have some cantaloupe-sized boils. Do you think they might be related to my headache?
Doctor : No. The three medical causes of headache are a hammer, a spring, and a lightning bolt. It's obvious that you are inhabited by an alien spirit. Let me spin your head around on your neck a few times … Oops! ( Klunk ... klunk ... klunk .)
Thankfully, a renewed interest in integrating medicine with spirituality is emerging. Whereas a MEDLINE search for the keyword "spirituality" produced 52 articles from 1960 to 1990, a more recent search produced 554 citations from January 2000 to April 2003. 2 As of this writing, about 100 medical and osteopathic schools include spirituality as a curricular element. Residency training awards have been granted through the George Washington Institute for Spirituality and Health for 20 primary care and 24 psychiatry programs.
What do our patients want us to do with spiritual information? A recent study answers that patients think that information concerning their spiritual beliefs will positively affect their physicians' abilities to encourage realistic hope, give medical advice, and change medical treatment. 3 Hopefully, God will not be left out of the equation.
Dr. Viken is chair of the Department of Family Medicine at The University of Texas Health Center at Tyler. He is a member of the Texas Medicine Editorial Board.
- Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet . 1999;353:664-667.
- Lieder S. Allowing spirituality into the healing process. J Fam Pract . 2004;53:616-624.
- McCord G, Gilchrist VJ, Grossman SD, et al. Ann Fam Med . 2004;2:356-361.
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