Physician's perspective combining spirituality and medicine: one physician's approach.

An increasing number of publications in recent years have examined the importance of physicians taking into consideration a patient's religious or spiritual background in the practice of medicine in an effort to provide more holistic care. Koenig has succinctly described reasons why it is not only reasonable but important for physicians to engage patients on spiritual issues and has proposed some guidelines and caveats for doing so. (1) Curlin and Hall have recently proposed that a new "ethic of friendship, marked by wisdom, candor, and respect" be applied in physician-patient encounters when it comes to the discussion of religion and spirituality. (2) In this commentary I will describe how I integrate spirituality into the daily practice of internal medicine.

I enjoy my medical practice immensely and much of this enjoyment is derived from the relationships I have developed with my patients by asking about their physical, emotional, and spiritual needs. My goal, though not always attained, is to take meticulous care of each patient's medical problems, show an interest in their personal life, and, for those who are interested, encourage them in their spiritual life as well. My prayer en route to the office or hospital each day is that God will give me wisdom, insight, sensitivity, and love for each patient I will meet. During an initial encounter, I include questions about the patient's religious beliefs or spiritual background in the context of the personal/social history and try to get a sense of how important this area is to the person. If a person expresses very little interest in spiritual matters, I try to let them know at some point during the interview that if at any time in the future they would like to discuss spiritual issues I would be open to doing so. The following cases illustrate my approach (permission has been granted from both patients to share these stories).

Patient 1: A 25-year-old patient recently asked to be seen urgently due to acute emotional pain following the murder of her good friend. She had expressed disillusionment with religion at our first encounter, and I had not broached the subject in subsequent visits, though she was aware of my spiritual background in a general sense. This particular day she was distraught and asked my advice regarding how to deal with her intense pain and sorrow. She was not suicidal. I told her that I would seek a trained counselor for her immediately, and she listened while I contacted an appropriate person by phone. She was not interested in any medication to help her through the crisis period. After acknowledging my respect for her previously stated stance on religion, I told her that in times like this I personally pray to God for help and that if she would like I would pray for her. She accepted and I prayed a short verbal prayer asking for comfort and strength and we parted ways. A few days later I checked with the patient who said she had benefited greatly from the counseling session. Later I received a personal note from her thanking me for the prayer in her time of need.

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Patient 2: A retired inventor came for a new patient encounter recently. As I learned about his lengthy past medical history, he interjected a few questions about my family and previous work before joining my current practice. He showed great interest in my experiences in the jungle region of Ecuador as a medical missionary, and I had to redirect the conversation back to his own personal/social history. After asking other sensitive questions, I asked him if he had any particular religious background. He stated very clearly that he was an agnostic, had a scientific outlook on life, and had no particular personal interest in religion. At the end of the physical examination and after addressing each of his medical problems in detail, I felt we had enough rapport to say to him, "I do not want to offend you in any way, so please feel free to say 'no,' but I frequently offer to say a prayer for my patients at the end of the first visit. Would you like me to pray for you today?" He said, "Sure, it can't hurt, and it just might help." I prayed that God would give me wisdom as his physician to make good medical recommendations, that the multiple medical problems he was confronting would be ameliorated by the prescribed medications, that his extended family would be blessed, and that he would have peace in his life. He thanked me for having given him a thorough examination and said he was glad to have a new doctor (his previous primary care physician had moved recently). At subsequent visits he has asked me more questions about my experiences and the basis of my faith, and we always express our mutual respect for one another's views (neither of which have changed significantly).

Studies have shown that the majority of adults in the United States (and even higher percentages in the Southeast) consider religion very important in their lives and over 80% use prayer in times of crisis. (3) These statistics certainly ring true in my practice where, in contrast to the cases above, I find that most of my patients not only acknowledge their faith in God but are pleasantly surprised when I inform them that I too am spiritually minded. The most frequent response I get after praying with a receptive patient is "I have never had a doctor pray with me before. Thank you so much. That meant a lot to me." A bond seems to have been formed between us in these instances that enhances all of our future physician-patient encounters.

As I round with the house staff at the hospital, I sometimes ask them about the patient's spiritual background in the context of their personal/social history, especially as it relates to end-of-life wishes. Most residents are not comfortable with, or do not see the importance of, investigating these issues for reasons that have been described elsewhere. (4) Therefore, I try to model on rounds, to the extent possible, a certain amount of sensitivity to spiritual matters and holistic care. Since I do not have an ongoing relationship with most of the inpatients, I warmly greet them, listen as compassionately as possible to their felt needs, and make sure appropriate investigations and therapy are being instituted by the team. I have found that a simple, sincere statement like "God bless you" as I leave the room somehow makes the patient feel more "cared for." Not infrequently a patient will grab my hand and say "God bless you too, Doctor," or "Please be praying for me, Doctor." In addition, respect needs to be given to our colleagues in pastoral care, who have been trained in ministering to the spiritual needs of patients from varied backgrounds. For hospitalized patients in significant spiritual distress who are open to more in depth help, I ask for a consult from our professional hospital chaplaincy department, or ask for the patient's pastor, priest, or spiritual leader to be notified.

I recognize that not all patients appreciate questions about their spirituality or even small verbal references to God. One elderly lady told me, "Don't you 'God bless' me, I'm sick and tired of all this religious stuff here in the South." In that instance, I apologized and told her I would try to refrain from such comments in the future.

In summary, my hope is to treat all of my patients, regardless of their religious or spiritual background, in a technically excellent manner and with a spirit of love. In my practice, even brief moments of shared spiritual experience have influenced the doctor-patient relationship in ways that have proven gratifying to both parties. Other physicians may find that such an approach enhances their professional satisfaction while providing a new sense of connection and caring for their patients.

Acknowledgment 

The author wishes to thank Dr. Thomas E. Corson and Dr. Kenneth E. Olive for their thoughtful review of the manuscript.

References

1. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J. 97:1194-200, 2004 Dec.

2. Curlin FA, Hall DE. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med. 20:370-4, 2005 Apr.

3. Gallup, GG, Lindsay DM. Surveying the Religious Landscape: Trends in US Beliefs. Harrisburg, PA Morehouse Publishing, 1999.

4. Luckhaupt SE, Yi MS, Mueller CV, Mrus JM, Peterman AH, Puchalski CM, Tsevat J. Beliefs of primary care residents regarding spirituality and religion in clinical encounters with patients: A Study at a Midwestern U.S. Teaching Institution. Acad Med. 80:560-70, 2005 Jun.

Roger D. Smalligan, MD, MPH

From Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Reprint requests to Roger D. Smalligan, MD, MPH, Assistant Professor of Internal Medicine and Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614. Email: [e-mail]