Patients' views about discussing spiritual issues with primary care physicians.

Objectives: The authors sought to explore patients' views about discussing spiritual issues with primary care physicians, including perceived barriers to and facilitators of discussions.

Methods: The study was a qualitative, semistructured interview of 10 chronically or terminally ill patients who were deliberately selected to represent a range of demographic factors (religious background, age, sex). We coded each interview and evaluated interviews for themes through content analysis.

Results: Themes included rationale for addressing spiritual issues; prerequisites for these discussions; roles in spiritual discussions; principles of spiritual assessment; and barriers to and facilitators of spiritual discussions. Patients justified spiritual assessment on the basis of importance of spirituality in life and health. They asserted that patients must feel honored and respected by their physician to risk discussing spiritual issues. They affirmed that physicians are helpful when legitimizing their spiritual concerns. Citing physicians' neglect of spirituality as a barrier, they affirmed that spiritual assessment in the context of other life issues facilitates spiritual discussions.

Conclusions: Patients' willingness to discuss spiritual issues may depend on their sense of physicians' respect for their spiritual views, attitudes about spiritual health, and qualities of openness and approachability.

Key Words: family medicine, patient-centered care, religion and medicine, spirituality and medicine

**********

Spirituality and religion play an important role in overall health. Studies have correlated religious commitment and a variety of health measures, including enhanced coping with illness, recovery from illness, longevity, suicide prevention, prognosis after myocardial infarction, blood pressure control in hypertensives, and mental health measures. (1-4)

Patients affirm the importance of spiritual factors in their health. Many consider spiritual health equal in importance to physical health, (5) desire physicians to consider their spiritual needs, (5) believe that God acts through physicians to cure illness, (6) and want physicians to ask about their religious beliefs in times of serious illness or crisis. (7-10)

Physicians affirm the importance of spiritual health, but are divided about their role in spiritual assessment. In a study of 231 Missouri family physicians, 96% considered spiritual well-being important to health. (11) However, they reported infrequent discussions of spiritual issues with patients, regardless of setting. In a qualitative study of 12 of these physicians, (12) those who seldom addressed patients' spiritual issues were concerned about invasion of patient privacy, and all believed patients and physicians experience significant barriers to spiritual discussions. Physicians who addressed spiritual issues justified this by the primacy of spirituality in life, and viewed themselves as supporters of patients through listening, validating spiritual resources, and being present during crises. Similarly, in a qualitative study of 12 family physicians with expressed interest in spirituality, subjects viewed themselves as encouragers of patients' spiritual resources. (13) A qualitative study of 43 physicians and 47 outpatients identified 5 additional physician-described roles in end-of-life discussions: lifesaver, neutral scientist, guide, counselor, and intimate confidant. (14)

Two recent studies have probed patients' views toward spiritual assessment or intervention by physicians. In a focus group study of 22 patients hospitalized by medical or surgical specialists for life-threatening illnesses, participants identified excellent bedside manner, empathy, and communications skills as necessary prerequisites to spiritual discussions. (15) However, they disagreed about the proper context for spiritual discussions. Some participants advocated having these discussions in the setting of routine medical care or screening. Others believed that discussions about spiritual topics could naturally evolve from "stress" caused by being ill, or that such discussions should be reserved for acute, life-threatening situations. Some participants did not desire to have spiritual discussions with their doctor at all, believing that doctors may impose their beliefs through such discussions or that spiritual inquiry implied a poor prognosis. In the second study, a cross-sectional survey of 456 medical outpatients, regarding physicians' spiritual interventions, respondents' preference for physician-patient prayer increased with acuity of illness (29% in hospital, 50% if near death). (16) In the office setting, however, patients were less likely to prefer physician-patient spiritual interactions as the intensity of the interaction increased, with 33% interested in office discussion of spiritual issues but only 19% interested in physician-patient prayer.

Existing studies establish that spiritual health issues are important to patients and reveal that acuity of illness and anticipated type of interaction may affect patient preference for spiritual interactions. However, the comprehensiveness of these studies is limited by their methodology (focus groups, questionnaire), and their chief focus concerns whether physicians should discuss spiritual issues with patients. We sought a more in-depth look at the patient side of the spiritual interactions themselves, seeking to better understand patient views and preferences about spiritual assessment or intervention by primary care physicians.

Materials and Methods

We conducted semistructured interviews (17) with 10 patients of primary care physicians. Interview topics were spirituality in doctor-patient relationships; physician practice of addressing spirituality; and facilitators and barriers to discussing spiritual issues. Interviews averaged 45 minutes, and were conducted by a research assistant trained in qualitative investigation.

To guard against bias in advocating a particular stance toward spiritual assessment, we requested respondents' honest observations during interviews, noted our preconceptions toward spiritual assessment before analyzing data, and consciously sought to avoid bias in favor of spiritual assessment. (18) In addition, we selected a research team whose members represented multiple academic and religious backgrounds. The team consisted of a PhD sociologist with a background in medical student teaching and medical research; a family physician; a family therapist currently pursuing a doctorate in rural sociology; and 2 medical students. Team members' religious backgrounds or current religious practice included Protestant Christianity, Judaism, Catholicism, and Islam.

Because qualitative research aims to uncover new perspectives rather than to draw definitive conclusions from a representative sample, (19) we deliberately selected study subjects by using pre-established criteria. (20) From a patient list provided by participants in our previous physician study, (12) we selected adult subjects 43 to 85 years of age, with a male-to-female ratio of 6:4, and the following self-reported belief-systems: Jewish (n = 1), Christian (n = 6), agnostic (n = 2), and Buddhist (n = 1). Subjects represented 7 practice sites, including rural and metropolitan practices. We chose subjects with a chronic or terminal illness, believing that these conditions would increase the likelihood of subjects having encountered and discussed spiritual crises. Illnesses associated with patients' spiritual questions and issues included bronchiectasis, chronic active hepatitis, renal failure requiring dialysis, diabetes mellitus, coronary artery bypass grafting, congestive heart failure, colon cancer, renal cell carcinoma, prostate cancer, and lymphoma. No subjects were involved in hospice care at the time of this study.

Interviews took place in researchers' offices or patients' homes, depending on participants' preferences. We informed participants of audiotape use during telephone recruitment, and obtained verbal consent before audiotaping. The Institutional Review Board of the University of Missouri-Columbia Hospitals and Clinics approved this study.

Study staff transcribed the interviews verbatim. Investigators verified interview content through comparison with interviewers' notes, then used an iterative process in making a template for coding data. (21) Based on multiple readings of interviews, we revised codes until we reached consensus, then combined the codes into salient issues or themes. (22,23) We solicited respondents' views of our final codes' and themes' validity and of the accuracy of illustrative quotations.

Results

Transcript analysis of respondents' coded interviews revealed six themes, as shown in Table 1 (specific codes under each theme are italicized below): rationale for addressing spiritual issues; prerequisites for discussions of patients' spiritual issues; the role of patients and physicians in spiritual discussions; and principles, barriers, and facilitators associated with spiritual assessment.

Rationale

Respondents proposed justifications for spiritual health assessment, including the primacy of spirituality in life. As one stated, "(Doctors) never bring (spirituality) up.... They should, because that's the most important thing there is." All respondents viewed spirituality as a healing resource, considering spiritual and physical health closely connected. Some viewed physicians' spiritual practices as a means to improved medical care, one expressing that "if (my doctor) prayed, it would help him to understand how to help (me) more." Respondents viewed physicians' knowledge of their spiritual views as a relationship builder. One concluded, "The main thing is to have that basic experience of talking about spirituality ... so that when illness occurred there is that wider basis for conversation." Another noted that knowledge of patients' spirituality aids in medical decision-making:

"Sometimes physicians will have to be the advocate, not for the treatment but for the patient, and maybe because they had a spiritual conversation the family has not had, (the physician) can share provisos with the family."

Finally, addressing patients' spiritual concerns can provide comfort in crisis. As one respondent expressed, "when (facing) ... a critical or terminal illness, (people are) hanging on for something.... If their doctor could talk to them about (spirituality) at that time, it would make a difference ... it would make peace."

Prerequisites

Respondents identified conditions necessary for spiritual discussions to occur. Patients' sense of whether their doctor cares about them affects their willingness to initiate spiritual discussions. Such an impact of a caring physician is seen in one respondent's words:

"If they come in not showing a heart for you, I don't think you can share with them ... you may give them the outer edges ... but (you) won't ever let them see the heart...."

Patients must feel honored and respected by their physician to be willing to share spiritual concerns. One respondent concluded, "(I can discuss) spiritual issues with my doctor (because) he's receptive, he's appreciative ... of the information you give him." Another patient expressed the converse: "If you're a person, you're an important person. (If my doctor doesn't believe this), I'm not going to waste my time telling them about who I am." Respondents considered rapport and trust essential for fruitful spiritual discussion. They noted that rapport builds over time and through shared experiences, leading to trust. In a caring relationship, an environment of mutual respect, and trust that builds over time, patients feel empowered to discuss spiritual issues. One respondent expressed this well, observing:

"(My relationship with my doctor) has progressed where I ... let everything hang out anymore--I didn't do that in the beginning, but over the years our relationship has (progressed) to that."

Role

Respondents expressed varying views about who should initiate spiritual discussions. Some preferred that physicians initiate these discussions. One reflected, "I wouldn't approach (my doctor to ask spiritual questions), but I would be able to talk to him if he approached me." Patients particularly valued physician initiation in cases of "chronic illness that relates to death and dying" as opposed to less serious presentations such as "headache or suture removal." Conversely, one respondent observed that serious illness empowers patients to initiate discussions despite their preference for doctor initiation. Others believed that either physicians or patients could initiate spiritual discussions. Even when they have a strong preference for spiritual interaction, however, patients' reluctance to question physicians' skill or competence may lead to hesitancy about their role. This is evident in a respondent's question:

"Would it be well to discuss with your physician that you realize ... he's doing all he can to help you, but if he prays to God for assistance, that (would) help him to understand your ailments better than if he didn't? I don't know. Do you think so?"

Despite the hesitancy about their role, respondents recognized that if neither doctor nor patient initiates spiritual discussions, healing and quality of relationship are adversely affected. As one stated, "If no one ever mentions (spiritual issues), how (are) people even going to know where to get help?"

Respondents recognized two boundaries that define and enhance the physician's role in spiritual discussions. One respondent suggested that physicians acknowledge limitations in their power to heal, stating that "it helps me feel better about my doctor to know that they know God has the power.... Whether you live or you die, that's not in their control." Others appreciated that their doctor respects the distinction between being an encourager versus a spiritual advisor. Said one respondent, "(My) physician hasn't led or guided me; she knows where I stand on my faith--so she hasn't tried to change that ... but she has tried to keep me encouraged with it."

With appropriate boundaries in place, and with prerequisites met for spiritual discussions, patients feel empowered to set the agenda of spiritual discussions. One respondent described this patient-centered process:

"I think (physicians) should come straight out and ask (patients) about their spirituality. From there, they could- ... drop the subject or continue on ... based on what the individual wants...."

Skills of discernment and accommodation help patients to negotiate their spiritual health agendas. Respondents noted that they are able to tell who is open to spiritual discussions as early as "when (physicians) enter the room, in most cases." Patients determine the degree to which they are willing to pursue spiritual questions based on this assessment. One respondent stated, "I can count on my physician for support but ... we haven't ever prayed together 'cause I don't feel she's comfortable with that."

Principles

Respondents advocated principles of spiritual assessment. They believed physicians should legitimize spiritual questions and crises by affirming the spiritual dimension, expressing interest in patients' spiritual views, and admitting that they "don't hold all of the answers." Respondents agreed that physicians should not belittle patients for their beliefs. Three patients observed that if their physician were critical of their spiritual beliefs, they would seek out another doctor. Respondents affirmed the value of an attitude of openness, explaining that "the patient looks to them for guidance in how open they can be (about spiritual issues)." All respondents expressed that physicians should avoid proselytizing--being careful to "not be preachy" and not to attempt to convert patients to their faith. They pointed to the powerful potential for positive or negative role modeling, one stating:

"Everybody's a missionary, one way or another.... If you have the opportunity to be a good influence on somebody, you'd better do it.... You be a bad influence by sharp words, actions, or (abruptness) ... It (wouldn't) set good with me."

Finally, respondents believed that to best assist with spiritual issues, physicians should be willing to consult others. These could be pastoral care professionals or clinic staff known to be skillful in addressing spiritual topics.

Facilitators and barriers

Our respondents identified facilitators and barriers that affect spiritual assessment. They regarded office settings that emphasize patient vulnerability or powerlessness as barriers to spiritual discussions, but believed patient-friendly office settings facilitate these discussions. All respondents viewed physicians' sacrifice of spiritual health to time constraints as a barrier. They considered lack of continuity a barrier and viewed healthy doctor-patient relationships as facilitators of spiritual discussions.

Patients' perceptions of their doctor's background may impact spiritual discussions. Our respondents stressed that they are unlikely to broach spiritual topics if they perceive their physicians as "strictly biomedical," also acknowledging that doctors' "high social class" may hinder these discussions. Conversely, patients expressed that having life priorities similar to their physician facilitates spiritual discussions.

Personal qualities and behavior may affect spiritual interactions. Our respondents noted that physicians generate barriers to spiritual discussions through unprofessional demeanor or actions and words that indicate a low regard for patients as people. Conversely, physicians who have an out-going, caring, receptive personality facilitate spiritual interactions, as do those who relate as people rather than strictly as "doctors," who encourage and foster a deep doctor-patient relationship, and who have knowledge of and affirm the importance of the spiritual.

Attitudes and actions also affect spiritual discussions. Respondents noted that their uncertainty about how to approach the doctor with spiritual questions, discomfort with spiritual topics, and unwillingness to initiate discussions create barriers to spiritual interactions. They believed that physicians' avoidance of spirituality makes patients less likely to bring up spiritual issues, but that physician actions facilitate spiritual discussions. These actions include relationship-building through outstanding bedside manner and being available, encouraging, and present for patients.

Our respondents were not aware of formal spiritual assessment tools. However, they suggested that physicians initiate spiritual discussions by candidly asking screening questions of new or hospitalized patients. Such discussions were viewed as most effective if linked to general questions about a person's priorities, goals, and family life.

Quotations illustrating specific codes for barriers to and facilitators of spiritual discussion are included in Tables 2 and 3.

Discussion

Our study of spiritual assessment from patients' perspectives is a companion work to a previous qualitative study of family physicians. (12) The previous study's themes uncover physicians' views toward spiritual assessment, including principles, barriers, and facilitators impacting this process. Our current study adds to this and other studies in several important ways.

As in the physician study, (12) our respondents asserted that the healing potential and primacy of spirituality justify discussions of patients' spiritual health. We uncovered new justifications for spiritual assessment--the comfort and decision-making assistance that knowing a patient's spiritual views can provide in crises.

Our respondents affirmed that physician qualities of concern and respect enable fruitful spiritual discussions and foster trusting relationships--relationships in which patients feel empowered to bring up spiritual issues. This process is reflected in previous studies of seriously ill hospitalized patients and terminally ill subjects, whose spiritual growth and spiritual interactions with others were fostered by care provider empathy, (9,15) strength of the patient-physician relationship, (15) and physician styles that empower patients. (9,10)

Our study increases our knowledge about the physician's role in spiritual assessment. In common with previous studies, (12,15,16) we confirmed that discussing spiritual issues carries a potential for offense and abuse of position, factors that may bring reluctance to initiate spiritual discussions. As in previous studies, (9,11,12) respondents viewed physicians as encouragers of patients' spiritual resources. We reported important patient roles in spiritual interactions: discerning physicians' interest in spirituality, accommodating discussions to physicians' perceived orientation, and setting agendas for discussions that occur.

We found support for specific principles of spiritual assessment. Our respondents' assertion that physicians should legitimize spiritual questions parallels the gentle, reverent physician approach proposed in other studies. (12-14) In common with studies stressing the value of presence and encouragement rather than advice-giving, (12-14) we found that patients appreciate physician openness and disdain proselytizing. Our respondents expressed two principles that show a well-considered view of spiritual assessment: They acknowledged the power of physician role-modeling and suggested that physicians utilize pastoral professionals in spiritual crises requiring expertise.

Our study identified factors affecting spiritual assessment, including the previously reported barriers of time, setting, discontinuous care, physician's avoidance of spiritual topics, discomfort with initiating spiritual discussions, and uncertainty about approaching these discussions. (11,12,15,16) Newly identified barriers included perception of doctors as "biomedical," class barriers between patients and physicians, and undignified, flippant, or dispassionate physician manner. Facilitators included early assessment of patients' spirituality in a general context, echoing previous studies' support of spiritual discussions in the context of broader issues (12) or life themes. (14) In common with a previous study, (15) we found that a high-quality physician-patient relationship facilitated spiritual discussions. We found new facilitators, including shared life priorities and perceived physician receptivity to patients' spiritual questions.

Limitations

Because qualitative research aims to uncover new perspectives rather than making generalizable assessments, our findings may not apply to all patients or all physician-patient relationships. Although respondents did not represent all major world religions, ethnic groups, and cultures, they did offer a diversity of spiritual and religious perspectives. We will use results of our qualitative studies of physicians and patients to frame a survey instrument for a more inclusive, national study of spiritual assessment.

Conclusion

Regardless of religious background, patients' willingness to discuss spiritual health issues may depend on their sense of such key physician qualities as openness, nonjudgmental nature, respect for others' spiritual views, and attitudes about spiritual health. Their views of how physicians should address spiritual issues may favor a direct, principle-based, patient-centered approach in the context of "getting to know the patient" rather than more structured approaches such as using spiritual assessment tools. How these observations play out in varying cultural contexts and during patient illnesses and crises is an important topic for additional study.

We either make ourselves miserable, or we make ourselves strong. The
amount of work is the same.
--Carlos Castaneda

Table 1. Themes and related codes from 10 chronically or terminally ill
patients

Rationale for addressing spiritual issues
  Primacy of spirituality
  Healing resource
  Relationship builder
  Advocacy in medical decision-making
  Comfort in crisis
Prerequisites for discussions of spiritual issues
  Caring physician
  Honor and respect
  Rapport/trust
  Empowerment
Role of physicians, patients in spiritual discussions
  Initiation
  Boundaries--limitations in power to heal
  Boundaries--encourager vs advisor
  Agenda--setting
  Discernment/accommodation
Principles of spiritual assessment
  Legitimize spiritual questions and crises
  No belittling of beliefs
  Convey attitude of openness
  Role modeling
  Avoid proselytizing
  Consult others, if needed
Barriers to discussions of spiritual issues
  Vulnerability
  Time constraints
  Lack of continuity
  Doctors as strictly biomedical
  Differing social class
  Physician demeanor
  Low regard for patients
  Patient discomfort with spiritual discussions
  Patient unwillingness to initiate discussions
  Patient uncertainty approaching spiritual issues
  Physician avoidance of the spiritual
Facilitators of spiritual discussions
  Setting
  Relationship
  Shared life priorities
  Physician personality
  Physician relates as person
  Physician knowledge--spiritual health
  Physician affirms importance--spiritual health
  Physician actions
  Methods of screening

Table 2. Barriers to spiritual discussions: Codes and illustrative
quotations

Barriers                  Illustrative quotations

Vulnerability             (A barrier to spiritual discussions is) being
                            unclothed or (having) a nightgown on ... It
                            would be better to go sit in their office at
                            a desk.
Time constraints          I'm anxious to get out of the exam room,
                            too ... He's got his work and I've got my
                            interests ... but if we had leisure time,...
                            it'd be really great if I could talk to him
                            (about spiritual issues).
Lack of continuity        You might be more apt to discuss (spiritual
                            questions) with your regular doctor than
                            someone who just comes in.
Doctors as "strictly      People are just reticent to talk with doctors
  biomedical"               on anything that doesn't relate to their
                            (medical) illness.
Differing social class    I think it's not just religion, but I think
                            there's a class barrier here that is
                            operative. (Physicians) are perceived as
                            being high class.
Physician demeanor        (A barrier to spiritual discussions with my
                            physician is) his demeanor.... He's a hard
                            man to talk to.... He laughs very loud ...
                            the kind of laughter I've seen ... in people
                            who are in denial.
Low regard for patients   If they don't act like they care, if they act
                            like they're in a big hurry, and they don't
                            have time for me, or they have more
                            important things to do, I'm not going to
                            open up to them and share a part of me.
Patient discomfort with   There are some patients I know that it would
  spiritual discussions     plain blow their minds when (doctors would)
                            suggest spiritual issues of any kind.... The
                            main reason (is) ... their inexperience of
                            the world. Everything where they have no
                            experience in, the average person is afraid
                            of.
Patient unwillingness to  People themselves being the barrier, not being
  initiate spiritual        open to talk ... not willing to take the
  discussions               time and effort ... convincing themselves
                            that (the doctor) is too busy. Just not
                            wanting to take the initiative.
Uncertainty about how     I think there's lots of people that would like
  to approach spiritual     spiritual discussions, but don't know how to
  issues                    approach ... the doctor.
Physician avoidance of    I think we've touched on just about everything
  the spiritual             else, but ... my doctor's not gonna say,
                            "You have to have faith,' or something like
                            that.... They don't get very deep into the
                            spiritual.

Table 3. Facilitators of spiritual assessment: Codes and illustrative
quotations

Setting                 It's easy to talk (at the Health Department)
                          because there are no boundaries there.
                          (Usually) in the medical field, they have
                          boundaries.
Relationship            I have a good relationship with my doctor, and I
                          feel like if I needed to talk with him (about
                          spiritual issues), I could.
Shared life priorities  I could talk to (my doctor) about spiritual
                          issues ... because I know he is positioned for
                          social responsibility. Being I'm an
                          antinuclear person, I need to know that our
                          priorities are ... in the same place.
Physician personality   Down to earth, calm, compassionate, assuring,
                          caring, tender, outgoing, friendly, willing to
                          listen, receptive/open, appreciative of the
                          information you give.
Physician relates as    She treats everybody the same ... she treats her
  person                  patients as friends. She truly tries to get to
                          know you.
Physician               I like to see an individual who has the
  knowledge-spiritual     training, the background, the education and
  health                  (who) has incorporated his spirituality with
                          it ... It could be such a definite influence
                          on their patients.
Physician affirms       I think doctors could help (patients) by being
  importance of           positive about the spiritual-don't throw up
  spiritual health        that wall, you know. If God wanted to heal
                          everybody,... it's not the issue. The issue is
                          can and does God heal.
Physician actions       She's there for me, and I can call her day or
                          night and I know that ... whenever they told
                          me I had cancer again, she called me every
                          day.
                        Touch, direct eye contact, actually sitting down
                          for a few seconds, taking time to say "How are
                          you, today?," and actually listening.
                        (My doctor has helped me with spiritual issues
                          by) encouraging me. He's always got a smile on
                          his face.... I really appreciate him.
Methods of              A physician, in about two minutes, can find
  screening               out ... "Do you have a religious community ...
                          or are you in spiritual practice?"
                        The doctor ... should figure out what kind of
                          patient this is: where they live, how they
                          live, what they work at, their spiritual
                          views ... all these have a bearing on who they
                          are, what's concerning them.

Acknowledgments

The authors thank Ann Detwiler-Breidenbach, MA, Dena K. Hubbard, MD, and Arej Sawani, MD, who assisted in data collection and preliminary data analysis; Richard E. Ellis, MD, MPH, Steven Zweig, MD, MSPH, and Daniel C. Vinson, MD, MSPH, who reviewed the manuscript and offered editorial suggestions; and Kathy Conway, who assisted in editing and manuscript preparation.

Accepted February 5, 2004.

Presented in part at the Society of Teachers of Family Medicine Annual Conference, May 2001, Denver, CO.

References

1. McBride JL, Arthur G, Brooks R, et al. The relationship between a patient's spirituality and health experiences. Fam Med 1998;30:122-126.

2. Matthews DA, McCullough ME, Larson DB, et al. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-124.

3. Gartner J, Larson DB, Allen GD. Religious commitment and mental health: a review of the empirical literature. J Psychol Theol 1991;19:6-25.

4. Larson DB, Milana MA. Are religion and spirituality clinically relevant in health care? Mind/Body Med 1995;1:147-157.

5. King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994;39:349-352.

6. Mansfield CJ, Mitchell J, King D. The doctor as God's mechanic? Beliefs in the southeastern United States. Soc Sci Med 2002;54:399-409.

7. Koenig HG, Smiley M, Gonzales JAP. Religion Health and Aging: A Review and Theoretical Integration. Contributions to the Study of Aging. No. 10. New York, NY, Greenwood Press, 1988, pp 129-140.

8. Ehman JW, Ott BB, Short TH, et al. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803-1806.

9. Hart A, Kehlwes RJ, Deyo R, et al. Hospice patients' attitudes regarding spiritual discussions with their doctors. Am J Hospice Palliative Care 2003;20:135-139.

10. Koenig HG, Bearon LB, Dayringer R. Physician perspectives on the role of religion in the physician-older patient relationship. J Fam Pract 1989;28:441-448.

11. Ellis MR, Vinson DV, Ewigman BE. Addressing spiritual concerns of patients: family physicians' attitudes and practices. J Fam Pract 1999;48:105-109.

12. Ellis MR, Cambell JD, Detwiler-Breidenbach A, et al. What do family physicians think about spirituality in clinical practice? J Fam Pract 2002;51:249-254.

13. Craigie FC, Hobbs RF. Spiritual perspectives and practices of family physicians with an expressed interest in spirituality. Fam Med 1999;31:578-585.

14. Pfeifer AP, Sidorov JE, Smith AC, et al. The discussion of end-of-life medical care by primary care patients and physicians: a multicenter study using structured qualitative interviews. J Gen Intern Med 1994;9:82-88.

15. Hebert RS, Jenckes MW, Ford DE, et al. Patient perspectives on spirituality and the patient-physician relationship. J Gen Intern Med 2001;16:685-692.

16. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality: results from a multicenter patient survey. J Gen Intern Med 2003;18:38-43.

17. Crabtree BF, Miller WI. A qualitative approach to primary care research: the long interview. Fam Med 1991;23:145-151.

18. Crabtree BF, Miller WL (eds): Doing Qualitative Research. 2nd ed. Thousand Oaks, CA, Sage Publications, 1999.

19. Kuzel AJ. Sampling in qualitative inquiry, in Crabtree BF, Miller WL (eds): Doing Qualitative Research. Thousand Oaks, CA, Sage Publications, 1992, pp 31-44.

20. Gilchrist VJ. Key informant interviews, in Crabtree BF, Miller WL (eds): Doing Qualitative Research. Thousand Oaks, CA, Sage Publications, 1992, pp 70-89.

21. Crabtree BF, Miller WL. A template approach to text analysis: developing and using codebooks, in Crabtree BF, Miller WL (eds): Doing Qualitative Research. Newbury Park, CA, Sage Publications, 1998.

22. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA, Sage Publications, 1994.

23. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA, Sage Publications, 1992, pp 93-109.

RELATED ARTICLE: Key Points

* Respondents justified spiritual assessment on the basis of the primary importance of spirituality in life, and the positive impact of a spiritual focus on patients' health.

* Patients may need to feel honored and respected by their physician to risk bringing up spiritual issues in clinical settings.

* Patient perception that a physician is uninterested in or hostile to spiritual matters may constitute a major barrier to discussing spiritual health issues.

* Asking spiritual health questions over time, in the context of other important questions about a patient's life, may facilitate discussions of patients' spiritual questions and views.

Mark R. Ellis, MD, MSPH, and James D. Campbell, PHD

From Cox Family Practice Residency Program, Springfield, MO, and the University of Missouri-Columbia, Center for Family Medicine Science and Department of Family and Community Medicine, Columbia, MO.

This study was supported by a departmental faculty development grant. University of Missouri-Columbia; and by medical student research funds provided by the Missouri Academy of Family Physicians.

This study was approved by the Institutional Review Board, University of Missouri-Columbia, Columbia, MO.

Reprint requests to Dr. Mark R. Ellis, 1423 North Jefferson Ave. #A-100, Springfield, MO 65802. Email: [e-mail]