Thursday, August 09, 2007

Training Spirit-Friendly Doctors


For the past few months, I've been attending meetings at the University of Nevada Medical School of a group of people who have a small grant from the George Washington Institute for Spirituality and Health (GWISH). (I'm now listed on the grant as a research assistant, which involved completing three hours of online Institutional Review Board training. This was quite the adventure, since I have no biomedical training and was taking the biomedical module!)

The GWISH group is going into the third year of a three-year grant, with a charter to work on integrating awareness of spiritual issues into the medical curriculum. For instance, our med school, like many others, uses standardized patients (SPs), laypeople coached to provide specific medical histories, to help train medical students; the GWISH group has been working up an SP case involving spiritual issues, and is also encouraging the students to incorporate FICA questions into the medical history.

But we spent most of the last meeting talking about why the GWISH project has been, in the words of one participant, "a tough sell." The meeting had been originally intended as a welcome dinner for new family-practice interns and residents, who would be invited to contribute to the project. Only three of about eighteen showed up.

The main reason for this, of course, is lack of time and energy; if you're working eighty hours a week in a physically, emotionally and intellectually draining new job, you won't be inclined to spend your limited resources on a topic that might seem extraneous or "soft." So the question for the GWISH group became: How can we make spirituality-and-health issues seem essential, worth taking the time to learn about, rather than irrelevant? Evidence-Based Medicine (EBM) is all the rage these days, and spiritual issues, almost by definition, defy scientific inquiry. So how do we sell them to medical students and new doctors?

The most EBM-friendly doctor in the GWISH group (although of course he's also sympathetic to spirituality too, or he wouldn't be there) took it upon himself to play Devil's Advocate. The best way to sell spirituality, he told us, would be to find rigorous, double-blind scientific studies demonstrating its impact on health. No one was quite sure if that sort of evidence exists. There has been some research on the helpful role of spirituality in depression, for instance, but no one knew how extensive or scientifically bullet-proof such studies have been.

I asked if, in the absence of double-blind studies, anecdotal evidence would be acceptable. Our EBM doc allowed that it was a distant second, but would have to do if nothing better were available. One of the residents, who'd just finished a rural rotation with a family-practice doc, told us a story about how that physician offered a brief nondenominational prayer at the end of each office visit, but only for patients he already knew would welcome it. The resident was intrigued by this, and observed that the prayer process seemed to smooth any preexisting tensions and end the visit on a positive note.

With all this in mind, I'm hereby conducting an extremely informal and unscientific survey of blog readers, consisting of four questions, some with subsections. It's probably worth mentioning here that I define spirituality as "how we define the larger meaning of our lives." I'm not sure exactly how GWISH defines it, but the FICA questions should give you a good idea of what they're looking for.

1. Do you know of any research categorically demonstrating the impact of spirituality on health, or its value in medical care?

2. If you are or have been a medical student:
a) How important do you consider spirituality in medicine?
b) Have you been taught about spiritual issues in medical school?
c) If you have been taught about them, what was most valuable to you in the information you were given?
d) If you haven't been taught about them, do you wish you had been? If so, what form would you want that to take?

3. If you're a practicing physician:
a) Have you had patients for whom spirituality was a vital element of medical care? If so, can you venture a guess as to the percentage of your patients in this category?
b) Are you comfortable discussing spiritual issues with patients?
c) Do you incorporate spiritual questions or content into interactions with patients? If so, under what conditions, and in what form?
d) How do you think healthcare professionals can become more comfortable with and better informed about spiritual issues?

4. If you're a patient (and that includes all of us, right?):
a) How important is your spirituality to your health?
b) Are you comfortable discussing spiritual issues with your healthcare providers?
c) Have any of your healthcare providers raised spiritual issues? If so, in what context? Were you comfortable with their doing so?
d) Do you think healthcare professionals need to be more "spiritually literate"? If so, how?

Note: I know that nurses deal with spiritual issues also, as much as (if not more than) doctors do, but since I'm trying to get information for our medical school, I'm phrasing the questions mainly in terms of physicians. But if you're a nurse and want to give me your two cents, I'd be delighted!

You can either leave your responses in the comments section, or e-mail me privately at SusanPal at aol dot com.

Thanks so much!

8 comments:

  1. I'll try and adress your questions in the order in which they apply.

    1) If you stick the word "spirituality" into PubMed, you get 2,995 hits. I did not explore them all, but I scanned them. I noticed many survey/cross-sectional studies, a number of analyses correlating outcomes to particular spiritual attitudes, definitely some of the gold-standard randomized controlled trials. Most of them tend to adress specific illnesses or health outcomes, like depression or aging, but some are in well-respected journals. I think you've got an evidence-base that you can use. There are also a lot of review articles which probably have great reference lists. There are also a fairly large number of "how to" articles on the ethics and approach to spiritual dialogue in the clinical setting. You may want to conduct your own PubMed search using multiple keywords like "spirituality" and a given disease.

    2):

    a) I consider spirituality to be an important component of health. Thus, it is an important component of medicine. That said, I don't think it is involved in every medical visit. If someone's getting a mole removed, for example, a discussion on spirituality isn't, in my view, appropriate. Nor would I feel comfortable closing every visit with a prayer, no matter how non-denominational. There are patients who have made the conscious decision to reject any standard expressions of spirituality, and I need to be sensitive to that. I would, however, be comfortable praying non-denominationally with a patient if they expressed that desire. I also believe it's worthwhile to create the kind of dialogue/relationship in which such desires can be comfortably expressed. There are key places where I think spirituality must be included in medical discussions and care, the obvious ones being end-of-life care, addiction, and mental health. I think your evidence base for supporting these ideas is pretty strong.

    b) We are taught about them in a general sense. We have lectures on diversity and sensitivity, emphasizing that it's important to enquire as to people's cultural and spiritual preferences and beliefs in order to better communicate. Part of our interview checklist includes two places where spirituality can be assessed: the social support system section and the cultural/religious beliefs section. Our curriculum places such dialogue in the realm of the medical interview at times when a full interview is being done (such as during an annual physical exam).

    c) The most important part of this for me was simply practicing asking such questions nonchalantly, because if they're standard, then you can use them easily when you want to. Simple things like: "What's your social support system like?" "If your spirituality is important to you, do you have a source of spiritual support?" "Do you have any particular spiritual beliefs that you would like me to know about?" I find that if I ask them as if they are no different than "Do you wear your seatbelt?" then they are answered in the same way.

    3) N/A, though I will say that in my shadowing epxerience, there's often simply not enough time to ask any questions beyond the most immediate ones. It's sad, really.

    4) I don't go to the doctor much, so I can't comment too deeply on this. Every time I've gotten surgery, someone - doctor or nurse - has asked me if I'd like to speak to the chaplain. I don't think that's standard, however, just something about the hospital in my hometown. If I had a serious or chronic or terminal illness, I would want my practitioner to make spirituality part of the discussion.

    That's my two cents for the moment :). Good luck with your committee!

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  2. OtterB1:50 PM

    Interesting. There is a guest opinion entitled "First, Do No Evangelizing" on today's "On Faith" at washingtonpost.com (URL too long, but it's been on the front page of the site, bottom left, all day). It seems to almost entirely view the intersection of religion and faith as a problem because doctor's religious faith will control how they treat their patients. Other than calling it a "comfort" he's not much interested in patients' faith. I admit that as a patient and parent of a child with special needs, I'd rather medical personnel other than counselors stayed out of the faith arena. I think I'd feel like I needed to defend my beliefs at a time when I'm vulnerable.

    Have you read Kitchen Table Wisdom or My Grandfather's Blessings by Rachel Naomi Remen? Excellent books by a physician on incorporating a spiritual perspective.

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  3. Anonymous2:20 PM

    I can only answer as a patient.

    My spritual condition is a part of my physical/mental condition - holism rules, ok. Given being prey to clinical depression (under treatment at the moment) I don't like to think what my condition would be like without a fairly robust spiritual attitude on my part (God loves me, so maybe I should love me too . . .)

    No carer has ever raised it - not even when I thought I was about to go to sleep and wake up dead.

    I wouldn't expect them to raise it, if only because there is absolutely no consensual common ground here, and a seeming conviction among the professional caring sector that anyone who suggests there is a spiritual dimension to life is beneath their intellectual contempt.

    I should like there to be some compenent - see holism about - but I doubt there are enough hours in the day.

    Come the day, but I feel we are talking about a revolution here, the reversal of three centuries of materialist thinking.

    Martyn

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  4. Thanks for the responses, everybody!

    Alexis: Very helpful PubMed info. Odd that no one on the committee's done a literature search -- I guess I assumed they'd already have done that. (But we all know where assumptions get us . . . .) Also, I think that an offer of a pre-surgical chaplaincy visit is standard, at least in hospitals that have chaplains in the first place.

    Otterb: Spirituality needn't be religious, and in fact often isn't. Many people find the larger meaning of their lives in family, work, or community service. Chaplains are taught NEVER to evangelize for a specific faith. No one's suggesting that patients should have to defend their beliefs, or lack thereof: we're just interested in how medical personnel can help patients gain strength from whatever they do believe in, whether that be baseball, a beloved pet, or macrame.

    I haven't read Remen, no, although I've seen her books mentioned many places. Thanks for the recommendation! I'll add these to my tottering to-be-read pile . . . .

    Martyn: "I wouldn't expect them to raise it, if only because there is absolutely no consensual common ground here, and a seeming conviction among the professional caring sector that anyone who suggests there is a spiritual dimension to life is beneath their intellectual contempt." I'm sorry this has been your experience! But I'm writing in a context where a major organization (GWISH) has given money to a medical school to try to incorporate a spiritual dimension, as many medical schools already do in various ways. So the revolution is underway!

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  5. Susan, Susan, Susan, why didn't you come to me?

    The first name you need to know is Harold Koenig, MD. Harold Koenig is an associate professor of psychiatry and medicine at Duke University. He is director and founder of the Center for the Study of Religion/Spirituality and Health at Duke University (http://www.dukespiritualityandhealth.org). He has been working for some time to document correlations between spirituality (primarily measured by religious practice) and health practices and outcomes. The Duke Center itself is also important as a resource.

    For something recent, look for articles in the past year from Farr A. Curlin, MD; Lydia S. Dugdale, MD; John D. Lantos, MD; Marshall H. Chin, MD. They have published several articles in the past year based on survey results of practicing physicians, asking questions about spirituality, religious practice and religiosity, and expression of spirituality in health care. The most recent article is "Do Religious Physicians Disproportionately Care for the Underserved?." in the July/August 2007 edition of the Annals of Family Medicine. In May I wrote about their recent article from the Archives of Internal Medicine, titled, "Physicians' Observations and Interpretations of the Influence of Religion and Spirituality on Health” (Arch Intern Med. 2007;167:649-654; April 9, 2007) href="http://episcopalhospitalchaplain.blogspot.com/2007/05/what-doctors-think-about-religion.html">here.

    A colleague is working on a "Physician Desk Reference" on spirituality and religion. I wrote the article on the Episcopal Church. My point with that is that there's a lot out there.

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  6. Marshall -- Thanks so much! I'd have contacted you directly if I had your e-mail, but iirc, it's not on your blog? Anyway, this is great info, and I'm grateful!

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  7. Anonymous3:04 PM

    A meditation teacher I once worked with had a long list of respectable traditional medical articles about how meditation could reduce stress. When I once asked her what she thought was the relationship between meditation and prayer, she didn't have an answer ready at the time. My own answer is that in my experience there's a large overlap between the two practices.

    Here in France, medical news has recently reported that reducing stress is not only good in obvious places like reducing high blood pressure or reducing anxiety, but also in less obvious places like reducing unhealthy weight gain. Apparently even if you still eat exactly the same foods in the same amount when you are stressed as you did when you were relaxed, you will still gain weight because your body will process the food differently.

    What this all suggests to me is that prayer, perhaps especially in its variant as meditation, should be able to reduce stress and all the diseases large and small that come with stress.

    I'm afraid that original list I mentioned is currently filed in a box in a storage unit on the other side of the Atlantic until next year sometime - but in the meantime perhaps PubMed, Duke, or some other database could help you track down the studies to support the intuition and attract the interns.

    Happy hunting,

    Jean

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  8. Just a quick comment...
    I'm a sociologist of religion and there is a lot of talk in our field about how you can barely get funding without including a health component in your research nowadays. Most of the research uses large-scale samples that incorporate some measure of spiritual practice (most often prayer or church attendance) with various health/public health/sexuality outcomes. I work in adolescent development with a colleague and we see a lot of literature that identifies the relationship but doesn't actually try to define the mechanism of why spirituality and religion have an effect. Nice to see more in-depth research done to establish more background on the relationship. Keep up the good work!

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