Religion, spirituality and medicine: the beginning of a new era.

This issue of The Southern Medical Journal inaugurates the Journal's Spirituality/Medicine Interface Project. The project is crucial because it represents the first time that a mainstream professional medical journal has attempted to systematically examine both the positive and negative effects of religiosity/spirituality on health and health care delivery. The topic of religion, spirituality and medicine makes many physicians nervous, and with good reason. Already over-whelmed with clinical responsibilities, clinicians are reluctant to consider taking on additional responsibilities in terms of spiritual assessment or intervention. Many do not understand why they should take precious time to address these issues, do not know how or when to address them, are uncertain of what to do with this information, or are uncomfortable about delving into such a personal aspect of patients' lives. (1) The appropriateness of physician involvement has also been debated. (2,3)

Yet, there is a growing research base suggesting that spiritual beliefs and practices do seem to influence health one way or another, even if only the capacity of the patient to cope with their illness, and it is also becoming evident that these beliefs influence compliance, affect use of health services, and impact medical decisions in many different clinical situations. (4) It is also clear that medical professionals are not addressing the spiritual needs of patients. In fact, only about one-third of physicians feel that doctors should ask about spiritual beliefs, (5) and fewer than 10% actually take a spiritual history, even among dying patients. (6) According to surveys of patients after hospital discharge, satisfaction with emotional and spiritual care has received some of the lowest rankings of all outcomes measured. (7) This finding has prompted the Joint Commission for the Accreditation of Hospital Organizations to require that a spiritual history be taken and documented on all patients admitted to acute care hospitals, long-term care settings, and those receiving home health services. (8) Many physicians realize that delegating this task entirely to nurses and chaplains, however, is not sufficient or appropriate, particularly when this may influence the success or failure of medical treatment plans. (9)

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From the research side, since the year 2000 there has been literally an explosion of articles published in an array of medical, nursing, psychological, social science, and epidemiology journals on religion/spirituality and health. Most physicians, however, are not aware of this literature. The Spirituality/Medicine Interface Project is a bold and pioneering effort to take on religious/spiritual topics of great importance to many patients, yet which are often avoided by physicians because they are controversial and doctors often lack exposure to them during medical training. Such areas include treatment refusal on religious grounds, taking a spiritual history, role of the chaplain, and religion's effects on sex education, abortion, end-of-life decisions, and other ethical and moral issues. Physicians need to be made aware of how different religious belief systems interact with illness and medical care, especially those that may be unfamiliar to them such as Hinduism, Buddhism, Judaism, or Islam. This knowledge is essential in a pluralistic health care system where patients and providers have a wide range of religious world-views. While a serious attempt has been made to inform clinicians about the diverse religious and spiritual beliefs of patients in the field of psychiatry, (10) such an effort has yet to be attempted in mainstream medicine--until now.

The goal of the Spirituality/Medicine Interface Project is to help physicians better understand the religious and spiritual beliefs and practices of their patients, how these impact health and medical outcomes, and how they can utilize this information to maximize patients' health and well-being. This effort will help to educate physicians about the role that religion/spirituality plays in the health and disease of patients, and will provide them with knowledge and tools on how to integrate this knowledge into clinical practice.

References

1. Koenig HG. An 83-year-old woman with chronic illness and strong religious beliefs. JAMA 2002;288:487-493.

2. Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med 2000;342:1913-1916.

3. Cohen CB, Wheeler SE, Scott DA, Anglican Working Group in B. Walking a fine line. Physician inquiries into patients' religious and spiritual beliefs. Hastings Cent Rep 2001;31:29-39.

4. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, Oxford University Press, 2000.

5. Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med 2003;163:2751-2756.

6. King DE, Wells BJ. End-of-life issues and spiritual histories. Southern Med J 2003;96:391-393.

7. Clark PA, Drain M, Malone MP. Addressing patients' emotional and spiritual needs. Joint Commission Journal on Quality and Safety 2003;29:659-670.

8. Joint Commission: Setting the Standard for Quality in Health Care. Spiritual Assessment, April 1, 2005. Available at: http://www.jcaho.org/accredited+organizations/behavioral+health+care/standards/faqs/provision+of+care/assessment/spiritual+assessment+.htm. Accessed.

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

10. Josephson AM, Peteet JR. Handbook of Spirituality and Worldview in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2004.

Harold G. Koenig, MD

From the Duke University Medical Center, Durham, NC.

Reprint requests to Harold G. Koenig, M.D, Professor of Psychiatry and Behavioral Sciences, Associate Professor of Medicine, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]