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Discussion in 'Medical Students - MD' started by Gumbydammit, Apr 12, 2001.
Can and should a physician incorporate religion in his or her practice of medicine?
I personally believe that it is a personal decision. If you have strong beliefs then absolutely. If not, I think it would be wrong to try and fake it. Patients who want a physician with a strong faith background will ask. On, the other hand I don't believe you should push beliefs on a patient either.
...and if you're the only doc in an area with a diversity of beliefs?
I believe you can only go with your beliefs. If you are the only doc in the area, your patients are going to be glad you are there whether you are religious or not.
I think that it is ok to incorporate *some* religion into your practice such as...if a patient is really really sick asking if you can pray for them. Keep it generic, though so that if your patient is Christian and you're Norse Pagan (Asatru), they can take it how they want and you can do it the way you want - after all prayers are good - and of course, they could always say no! As for prosetlyzing in the office or something similarly intrusive, I think its inappropriate. (as an eclectic pagan, ive had to think about this one a lot)
[This message has been edited by Starflyr (edited April 12, 2001).]
I think there is a more fundamental question, namely, can a physician NOT incorporate their religion or philosophy into their practice?
Whether a person is a Buddhist, Christian, Muslim, atheist, agnostic, something in between or not mentioned--whatever--it is impossible for one to neatly remove their religion and/or philospohy, at least in significant measure, from the thing they do all day with their life.
I agree with you, Stephen..but there *is* a difference between living your philosophy and pushing it on other people - or even "incorporating it" explicitly into your practice like some people do (ex: bibles as reading material in waiting room). Personally, I'll live my life according to my philosophy. I wont push it on anybody, and I wont bring up religious discussion myself. Honestly, if my doctor did push religion on me, I'd probably never go back.
Yes, the topic is not Jerks and Medicine.
I thought this article fit in nice with the religion topic. Many of you may have seen this already--if not, enjoy.
"Taking Your Spiritual Pulse
More patients want doctors to ask about faith as well as symptoms. Finally, some practitioners are listening.
By Ann Japenga
WebMD Medical News
Medically reviewed by Dr. Jeannie Brewer
Oct. 2, 2000 -- Have any allergies? Past surgeries? Do you use caffeine, alcohol, cigarettes? Rhonda Oziel has been asked the same questions by doctors so many times she thought she could recite the checklist by heart. Then one day a doctor deviated from the drill.
The occasion was a checkup with her new internist, Christina Puchalski,MD. Near the end of the visit, the doctor asked Oziel if she considered herself spiritual or religious. What sorts of beliefs sustained her in difficult times?
"I was receptive to the questions, and it made me feel very good to have that discussion," says Oziel, a 50-year-old Washington, D.C., librarian. "It made me feel my doctor looks at me as a human and not just a medical specimen."
We'd all prefer that our doctors see us as more than just another backache or sore throat. But do we really want strangers with stethoscopes inquiring about our spiritual beliefs? Increasingly, researchers say we do. And, in response, medical schools are now beginning to teach doctors-in-training to take a spiritual history along with the patient's medical history.
Many Nonbelievers Agree
Researchers at the University of Pennsylvania surveyed 177 outpatients at the university hospital and found surprisingly high support for such "spiritual intakes." Some 94% of those who had religious or spiritual beliefs felt physicians should ask about those beliefs, according to the study published
Aug. 9, 1999, in the Archives of Internal Medicine. And more than half of those who professed no significant beliefs still thought doctors should at least inquire. In comparison, just 16% of patients said they would not welcome such questions from their doctors.
Yet despite these strong sentiments, only 15% of the patients surveyed said a doctor had ever asked about their religious or spiritual convictions.
The Medical Benefits of Faith
There are sound medical reasons to take these beliefs seriously. An analysis of 42 studies involving 125,286 patients, published in the June 2000 issue of Health Psychology, found that those with some sort of religious involvement live longer -- though no one knows whether longevity is due to their faith or their community ties.
Moreover, two-thirds of the patients in the University of Pennsylvania study said that being asked questions about their beliefs would increase their trust in a doctor, which has also been linked to better medical outcomes in some studies.
"We're not doing our jobs if we ignore these questions," says Daniel Sulmasy, MD, director of the Bioethics Institute at New York Medical College, a Catholic university. "After all, it's not just bodies that become
sick. Any illness raises issues of spiritual or religious meaning and values."
The point of a spiritual history is not to quiz patients on their formal religious
affiliation, says Puchalski, who is medical director at the National Institute of
Healthcare Research, a group promoting the integration of spirituality and health care. "We're really just trying to understand what's important to a patient and how those beliefs and values might affect how the patient copes with illness."
The "Spiritual Intake"
Puchalski has developed a series of four questions that attempts to get at a
patient's belief system, which could include nature, philosophy, family, and community -- along with formal religion. Such so-called "spiritual intakes" have been taught at 64 medical schools in the United States, including Johns Hopkins and Harvard.
"Physicians are not being trained to be spiritual directors," she says. "The idea is simply to open the door to discussion." If a more in-depth exploration seems warranted (for instance, if a patient believes that an illness is a deserved punishment from God), a doctor might then refer the patient to a
clergy member or counselor -- in the same way physicians refer patients who bring up issues of domestic abuse or family troubles. Puchalski calls her system FICA; here's what the letters stand for:
F: Faith or beliefs. Do you consider yourself spiritual or religious? What things do you believe in that give meaning to your life? (If the patient doesn't want to discuss such questions, this is the time for the doctor to end the spiritual history interview.)
I: Importance and influence. How might your beliefs influence your behavior during this illness? What role might your beliefs play in helping you regain your health?
C: Community. Are you part of a spiritual or religious community? Is there a person or group of people who can help support you in your illness?
A: Address. What can I, your doctor, do to address and support spiritual issues in your health care?
In this time-pressed era of managed-care medicine, do doctors really have time to get into patients' spiritual beliefs? Puchalski and others say they're merely urging physicians to broach the subject -- not conduct an in-depth interview. Her interview format can take as little as two minutes, she says.
Ask But Don't Push
Despite patients' hunger for such discussions, Pulchalski and Sulmasy at
New York University recognize that some doctors could potentially take advantage of their position of influence to evangelize about their own beliefs.
"That would be absolutely wrong, a serious affront to patients," Sulmasy says.
To avoid misuse of the technique, patients should be allowed a quick exit from the discussion if spirituality is not an issue for them or they feel it is none of the doctor's business, they say.
When the conversation is conducted with care and respect, however, Sulmasy says it can help doctors engender trust and open discussions about end-of-life decisions in the event the patient becomes seriously ill.
In Rhonda Oziel's case, she was glad her doctor had broached the subject of belief at their first meeting. "I don't pray very oftenn," Oziel told her doctor,"but I know there's a spirit looking out for the world." Their talk was enough to open the doors of communication. Several months later, when Oziel's husband died, she felt comfortable turning to her doctor to discuss her loss
and what might happen after death. The conversation, though brief, provided
just the sort of comfort she craved.
Ann Japenga, a contributing editor at Health magazine, writes frequently about psychology
for WebMD. She lives in Palm Desert, Calif.
From the article: "...found that those with some sort of religious involvement live longer."
One big confounder of this (that I certainly hope they addressed in the study) is that some of the world's religions, and certainly many of the Christianity doctrines, have a view of suicide as the one transgression from which no forgiveness is possible (since one is obviously dead immediately after committing the act of taking the human life). This expands longevity of that group of faith in two window periods: (i) Teens who don't commit suicide and go on to live a full life (ii) Aged terminal patients who don't want to perform an earlier end-of-life decision.
I hold two diploma's in Christian theology and have never heard anyone seriously postulate that the Christian who commits suicide--very rarely does one do this--is damned.
In Christian theology, the only sin which is unparadonable is the blasphemy of the Holy Spirit, as Jesus said, "Any sin and blasphemy shall be forgiven people, but blasphemy against the Spirit shall not be forgiven" (Matthew 12:31).
The sin is when one perpetually rejects Christ and His work as applicable to their fallen, sin-ridden condition, and dies having done this. When one dies having rejected *the only* remedy for their condition, that, in Christ's words, is the unforgiveable sin.
In common venacular, the blasphemy of the Holy Spirit is "dying in your sins," having rejected in life the sole remedy for them, namely, Christ and following Him. The ability to do this comes by the Holy Spirit, so to reject Him is to reject who He brings, Christ, and His atoning work on the cross, and justifying work in the resurrection.
[This message has been edited by Stephen Ewen (edited April 23, 2001).]
It seems that what this article shows is that it may be appropriate for physicians to incorporate their patients' religious beliefs into their practice of medicine, not their own.
From the article:
'Despite patients' hunger for such discussions, Pulchalski and Sulmasy at
New York University recognize that some doctors could potentially take advantage of their position of influence to evangelize about their own beliefs.
"That would be absolutely wrong, a serious affront to patients," Sulmasy says.'
A patient's religion may have some place in their health care, a doctor's should not.
I agree with what you have said, but it only seems natural that a physician could incorporate his or her religious views in an effort to better understand and therefore help the patient. Granted the physician is NOT entitled to in any way push religious views by proselyting etc., but a common ground (which could be a general belief in any higher power) may prove to be helpful depending on the situation.
For example, a young mother gives birth to a baby whose left side of his heart is underdeveloped. Surgery is necessary to save the baby's life, and the parents opt to have the procedure performed. When consulting with the physician, he asks about their religious background which is Christianic. The surgeon then mentions that he recognizes a higher power that many times intervenes with the actual surgery, and he often feels like an instrument in the hands of this greater being. This statement provides great comfort to the couple and their decision to have the surgery done is fortified greatly. In this case, common religious ground provided a foundation of trust for the parents of this little baby.
I'm not saying that doctors should always do this but for this particular case it was effective.
My reason for this question in the first place was that as healthcare providers, we need to integrate social, economic, and yes, religious factors when caring for our patients. Hopefully this capacity to look at the big picture will ultimately result in better healthcare.
Wow. Out of my ever-present respect for you Stephen I will avoid commenting on this. I will only say that I missed my weekly dose of you while the boards were down.
I think this is a really interesting post. As many of you may know, I consider myself to be a religious person and this thread brings up some interesting ideas.
I will agree that pushing your beliefs on someone and making them really uncomfortable would be unethical, not to mention irrelevant. I mean, if you are pushy, they wouldn't listen anyway.
However, I do not see why if a patient is searching for the Truth, why as a doctor you couldn't refer them to your own church leader (a preacher or evangelist, for example). They would be at liberty to follow up on it or ignore it. All you would be doing is giving the patient your preacher's business card, or whatever.
Maybe someone could explain why this is considered "unethical".
Also, if doctors aren't going to incorporate some type of spiritual history taking or religious discussion into the conversation...then I would think it would be useful to at least incorporate something of personal interest to the patient.
I visited the dermatologist about three or four months ago and the check-up lasted no more than 5-7 minutes. However, I spent at least that much time talking to him about becoming a doctor, about tennis, and about my shirt (long story). Anyway--I found it very nice that he was willing to discuss things that interested me. It was a departure from the arrogant, golf-playing, uninvolved stereotype that many doctors sometimes exhibit.
So, I guess what I'm saying, is that it would be nice if doctors would exhibit some interest in the patient as a person and not just as a client who needs to get well. Whether they do this through religion or whatever, that's their prerogative.
Well said Firebird. I concur.
hear, hear. I'm all for docs taking personal interest in their patients. This takes only a few minutes and makes the patient feel a lot better. And it applies to all areas, especially surgery (we could use a few more surgeons w/ a good bedside manner). And especially if you're in a long-term relationship with your patient, ie, IM, FP, oncology, OB/GYN, etc, I think that some sort of spiritual component to the history-taking is a good idea. Spirituality is, after all, very important to a lot of people. I don't think that pushing your own faith on someone is right, though. I guess I would consider it unethical, and primarily because I would see it as an abuse of the doctor/patient relationship. There's a huge power imbalance going on there, and any time you're really forcing your personal beliefs on someone in those circumstances, I consider it a breach of ethics.
[This message has been edited by ringo643 (edited April 25, 2001).]
Ah, the myth of neutrality. A doctor's WHATEVER--religion, philosophy, atheism, etc., and his ethics that flow from these, simply cannot be neatly removed from what he or she does with his or her life all day (and sometimes night) long, year in and year out and so on. I am speaking of docs with Pt contact (with conscious patients), most particularly in primary care, where counsel on manny matters is often given.
Don't believe me? Then give replies to:
1. 15 y/o female into heavy petting with her boyfreind, wants a depo shot so she can go all the way with him on his birthday which is coming up. How would you respond, why and on what basis?
2. Single 47 y/o male, some history of STDs, is used to being able to cruise the clubs for chicks. Having a bit of problem continuing with this now, and wants Viagra. How would you respond, why and on what basis?
3. Couple wants advise on the best philosophy of care and feeding of their newborn. How would you respond, why and on what basis?
4. 19 y/o Pt became a quadroplegic in a diving accident. Asks you, "How am I going to live the rest of my life?" How would you respond, why and on what basis?
I'll stop there.
My point in articulating the most widely help position in Christian theology on suicide was to show that that one position is the most widely held position among Chrstians. Other of their viewpoints, not very seriously postulated or held, would very likely not have been incorporated into the mentioned study.
[This message has been edited by Stephen Ewen (edited April 26, 2001).]
I totally agree.
The following are to the Christian Medical and Dental Society's Saline Solution conferences, that teach Christian physicians to address spiritual matters with their patients in an ethical, non-pushy way.
So ringo, help me understand where you draw the line at personal beliefs. Isn't believing that medicine can cure as opposed to God curing a belief? What if I don't believe in antibiotics? Is it a breech of ethics to convince me otherwise?
My guess is that you would say no, because it's best for the patient, healthy for their body, your job as a doctor to treat patients, prescribe medicine. So what about all the studies that show that people who are spiritual tend to live longer, healthier, happier lives. For whatever the reason, there is a solid correlation between health and spirit.
Stephen and I actually agree on something (talk about shaking someone's faith ). No matter what you believe or don't believe, it affects how you interact with others. The best we can do is understand our biases and work for openness and respect with patients.
PS "cruising for chicks"...you need to get out more Steve
Hey, the guy is 47!
In all of these cases I would discuss options with the patient and provide whatever services they felt were best, without making moral judgements about their behavior. Discussing options would include discussing the consequences of these actions, but my personal beliefs really should play as small a part as possible. You seem to have chosen cases with the intent of baiting me into telling patients what is right or wrong behavior instead of doing what a doctor ought to do: provide information and services with regard to patients' health.
Whatever happened to the notion that some actions are simply NOT in the best interest of patients? And perhaps more importantly, I think what this shows is a SUPREMELY false dichotmy, namely, that of seperating behavior and health.
Take it out of the controversial realm a moment for illustration purposes. You have a Pt that smokes ciggarettes and drinks alcohol addictively, and eats like a deep fat fryer. There is a question of his marital fidelity in the wife's mind, and who knows what else he is doing. All totalled, he is destroying not only himself but his increasingly dysfunctional and codependent family, also in your care, with his behaviors.
Shall we nuetrally discuss with this patient the option of continuing with all this as though it were a set of behaviors that have no moral implications, and that whatever his decision is is just fine, and his decision to continue in them is just as respect worthy as a decision toward making a change?
Or shall we tell such a one that he is day-by-day killing himself, and that his behavior is concurrently damaging his family--wife, two sons, and two daughters--and that he is living irresponsibly, damaging everyone involved, and that this is thus wrong?
Of course, things should be communicated appropriately, sensitively, at the right time, and with wisdom, and in an empowering way without condemnatory attitudes. But anything less than telling the truth in such things is deriliction of duty, in my opinion.
The physician does not operate in a moral vacuum. He or she should be wholitstically responsible, and wholistically ethical. His or her every day actions, and that of his or her patients, have broader implications than within just their own personal arena. And in this, just as good behaviors need moral support to continue, poor behaviors require moral guidance to change. These behaviors, no matter their nature, collectively form our society and its character. Frankly, a value-free notion of medical practice--which is actually a brand of value-laden medical practice--is very scary; look at history.
It is a notion of medical care that indeed stems straight from a philosophical framework. It is a notion that greatly divorces the emotional, social and mental aspects of patients from the physical part of them, and greatly divorces the physician him or herself from huge chunks of the moral implications, and moral obligations, of his or her profession. It is the so-called "neutral stance," and it is anything but neutral, especially in the long run.
As I have maintained, the physician's philosophical framework, whatever it is, will certainly come through in what he or she does all day long with their life...and this case, I suppose, shows that initial point which I have tried to maintain all along. And indeed, any replies that will ever be given to the above four scenarios, or others, will do nothing other than show this further. The physician's religion and or philosophy simply cannot be seperated from the practice of their profession. To maintain a stance otherwise is to maintain a very common myth, but a myth nonetheless.
Thanks for hearing me out.
In other words if you choose to do nothing, not to counsel from a moral stance, you are still choosing. Even your opinion on what is a moral question and what is a medical question is a reflection of your personal beliefs.
Wow Stevie, two for two...you're scaring me.
But I liked your first edit the best
MJ, I agree with you that we need to realize our own biases and work for tolerance. I have no issue with this statement.
I also agree with Stephen that we do not practice within a moral vacuum. We cannot separate our morality, which may be informed by our religious beliefs, from our philosophy of medicine, nor from who we are as people. I had a medical ethics professor, an MD and a priest, whose favorite turn of phrase was "I'm not your little doctor-slave!" In other words, the physician must behave as an independent moral agent, and not merely as an instrument to providing whatever the patient deems appropriate. They give us medical education for a reason - because we know, often and in large part, what's good for the patient. Obviously they also frequently know what's good for themselves, so there should be a dialogue between the two parties, but the doctor cannot exist merely as a means to the patient's ends. As such, we must exercise our own moral judgments from time to time, however much this may upset some. Ask yourself this question: is there no imaginable situation under which you, as a practicing physician, would remove yourself from the patient's care because of a moral conflict? If not, then I must say that your sense of moral obligation is different from mine. The doctor's own personal morality, whether it is informed by religious beliefs or not, must be a part of responsible patient care.
PS - Woohoo! 100th post!!
I would certainly counsel a patient against these behaviors, but not becasue they are immoral. They are unhealthy. Doctors recieve very specialized training so that they can provide healthcare. They have very limited training in other areas. Even though doctors are often asked to act as police, social workers, laywers, psychologists, or clergy, they usually have little or no training in these areas. A physician cannot expect to provide truly holistic care for patients without compromising the care provided in certain areas. Furthermore, I don't think moral judgements of patients have any place in healthcare. If you tell a patient something is bad for them, it ought to be becasue it is unhealthy. If they seem to be in need of counseling or spiritual guidance, refer them to the appropriate professional in one those areas.
Morality and medicine just don't mix and moral judgements can only undermine good healthcare. What if a patient disagrees with your morals and is non-compliant when it comes to your medical decisions as a result? It is hard for patients to separate these things out. If they feel threatened by your moral judgements, they will be much less inclined to listen to you when it comes to their health.
That being said, I understand that a physician's personal philosophy will influence how he leads his life and how he practices medicine. However, this does not mean that patients should be forced into their physicians' spiritual or moral framework.
mj- Your assertion that leaving morals out of medicine is making a moral judgement is irrelevant. I don't think this is true, but even if it is, it is the right moral judgement. Who are we to tell our patients what is right and what is wrong?
First off, stolen from Readers Digest:
A nationwide study of 21,000 people from 1987 to 1995 found a seven year difference in life expectancy between those who never attend religous services and those who attend more than once a week
A study by epidemiologist Jeff Levin shows that older adults who considered themselves religiousl had fewer health problems and functioned better than the nonreligious
a '95 Darmouth Med Shcool study found that patients comforted by their fath had three times the chance of being alive six months after open-heart surgery than patients who found no comfort in religion
Attendance at a house of worship is related to lower rates of depression and anxiety reported a 1999 Duke study of 4000 older adults
A 1997 study in India showed that Hindu's who prayed regularly were 70% less likely to have coronary heart disease than Hindu's who did not
on and on...
Not being religous/spiritual is unhealthy. It is in your patients best interest for you to counsel them toward religion. It is healthy for them.
And I'm an agnostic.
Secondly, med schools are realizing this. In 1992 only a few schools taught spirituality. Now over 50 do. Many like Georgetown's teach how to incorporate a spiritual history into the medical history in a nonthreatening way.
Thirdly, mind and body are very related and where medicine stops and religion/philosophy/spirituality/morality begin often get very grey very quickly. Without getting into a debate of abortion, is having an abortion healthy? That is a medical question, but how you view it morally often determines how you answer it medically. You can easily say, "well it's not my place to say" but your patient goes to you for answers to the "is this healthy" question.
Finally, focker, who said anything about "forcing" anyone into anything? The point is to be aware of where you come from so that you AREN'T forcing. But no matter how aware you are, you will always be influencing, there is just no getting away from yourself, no matter how hard you try.
Ring0, your 100th post was very well said.
Thank you, Stephen.
In the spirit of what mj's last post said, religion and 'right' become much more significant when we take psychosocial factors into the broad scope of health. Psychological well-being can very well be tied up in matters of faith and belief. Healthy social interaction can be affected by the same. So, especially if you're in psych (notwithstanding the disturbing trend in psych just to medicate everything) it seems that your patients' health could be affected by matters relating to religion and belief.
That said, however, we are not magicians. We are trained to treat patients. While that covers an enormous amount of ground beyond the realm of physio, path, and pharm, we cannot be expected to be everything to our patients. If you were an FP, you would be grossly negligent to make advanced cardiologic diagnoses without consultation. Why is it better to offer yourself as a cleric than as a cardiologist? There are professionals who handle these situations, and if you're in over your head, you refer out, just as in any other area of medicine. Sorry for the lengthy post.
My philosopohy is that it is wonderful when the doc has some--seeks some--compentency on all these levels.
For the strictly physical, I have long advocated for broadly skilled GPs, rather than only the narrowly defined gatekeepers we tend to have today, who see their primary role as either to stay in their own little niche, or else to simply determine to which specialist to refer the patient. This philosophy, in part, is why I am International by choice, not chance. Other places in the world blow the U.S. away in these regards. In fact, years ago, the U.S. decided to NOT follow other nations' lead and create a NEW speciality that would better encompass such skills, Rural & Remote Medicine, but instead simply tried to lump it all under FP, which tactic has not worked particularly well. This is not to say specialists do not have their place. It is just to say that we need more than JUST them.
As for functioning as cleric, psychologist, social worker...personally, I was these things before I even had an inkling toward medicine. Functioning wholistically within all of these areas, I freely confess!, stems straight from my religious beliefs, which includes following the example of Jesus, who cared for people on their every level, and St. Luke, the beloved physician, who did the same. Here is a short article I wrote for some people on St. Luke http://www.lukeproject.org/luke.html
Best wishes to you.
First of all, I want to apologize if I have come off as completely antireligious, as religion obviously plays an important role in many, if not most, people's lives.
I think this conception of how religion and other social/cultural factors fit into medicine is a good one. Patients do need to be treated as whole, but at the same time doctors are there primarily to deal with physical health issues. Each doctor will find his own balance in terms of how involved to become in these areas of their patients lives.
We were on a role Stephen. Ya just couldn't leave it alone could ya