Discussing Spirituality With Patients: A Rational and Ethical Approach

Research by McCord et. al.(1) shows that most patients, but not all, want their physicians to ask about spiritual beliefs and it provides useful information on which patients to include. Many physicians are interested in discussing spirituality with patients, however, most do not, citing lack of time, and lack of training in what to say and which patients to address, particularly if the patient is of a different spiritual background than the physician.

At Stanford University School of Medicine, as part of a Templeton Spirituality and Medicine Curricular Award (2) we have developed a required curriculum that teaches students how to identify and respond to a patient’s spiritual needs and concerns as well as those of the students themselves.

This curriculum is presented to groups of 8-10 medical students during their required 4 week Family Medicine Core Clerkship. It has been presented to approximately 300 students who represent a wide variation of cultural, ethnic, religious and scientific backgrounds, and differing predispositions to including spirituality in their role as a physician.

To integrate spirituality into medical practice, we teach medical students to discuss spiritual and religious beliefs with patients, using the HOPE or FICA tools(3,4). We address how to do this in a busy outpatient clinic, what to ask, and how to listen and respond including when patients are from unfamiliar or different cultural and religious backgrounds.

We have come to recognize that discussing spiritual and religious beliefs and practices is applicable for select patients and can produce resistance in others. It is a slice of the broader domain of spirituality.

However, when we widened our focus to emphasize meaning and concern, including “meaningful life activity”, we found an approach that applies to all patients, that includes but doesn’t require an explicit discussion of religious and spiritual beliefs, and is less likely to trigger resistance.

Informed by principles of spiritual care, we demonstrate how to focus one’s intention and attention before going into the exam room, and how to quickly identify and respond to what matters most for the patient, what we term the “chief concern”, in a compassionate, respectful and trusting way that produces meaningful connection and comfort. For the purposes of coping, increased understanding, comfort and medical decision making, one may include an explicit discussion of sources of hope and strength, and cultural, spiritual and religious beliefs.

In terms of providing spiritual care, what counts more than the right information, is being in right relationship with the patient. Research is needed to further develop the educational approach and process we have outlined.

References:

(1) Gary McCord, et. al. Discussing Spirituality With Patients: A Rational and Ethical Approach. Annals of Family Medicine, July/August 2004 2(4):356-361.

(2) www.gwish.org

(3) Gowri Anandarajah et. al. Spirituality and Medical Practice: Using the HOPE questions as a Practical Tool for Spiritual Assessment. American Family Physician 2001 63(1):81-88.

(4) Christina Puchalski, et. al. Taking a Spiritual History Allows Clinicians to Understand Patients More Fully. Journal of Palliative Medicine 2000 3(1):129-137.

Competing interests:   None declared

In reading over all of the comments made thus far, I am struck by what appears to be the lack of willingness of doctors to calling on others members of the medical team, be it social worker, chaplain, etc. who also contribute to the care of the "body, mind and spirit" of each patient. Any doctor who has worked with a hospital chaplain in a situation where there are patient and family issues (and sometimes doctor issues), knows the value of having a chaplain as part of the healthcare team. Chaplains often can save time and resources when involved in the discussions and decisions made.

When someone is in "spiritual distress" or believes that "God did this to me because I did __________" he/she needs more than a compassionate doctor to walk this road with them. Only a chaplain can help the patient to seek and receive forgiveness for something that the patient thinks he/she has done to bring on their condition. In my many years of chaplaincy, I have talked with people who are in spiritual pain because they think that God has deserted them at the very time that they need God close to them. A chaplain brings the reminder of God's presence to the patient and family. And this reminder can often help the patient to find his/her way back to health or acceptance of approaching death.

While I applaud the willingness of doctors to ask the questions and perhaps even be able to integrate the answers into care plans, how much better off our patients would be if they were surrounded by a multi- disciplinary team that could handle all of their concerns as a TEAM. There are even some doctors' offices who have a chaplain at the office who assists patients in difficult times. This frees the doctors up from already tight schedules and rushed patient visits.

When we work as a team, all benefit, but mostly importantly, the patient benefits. And, after all, that is what we are all striving for.

Competing interests:   None declared

Reading the article "Discussing Spirituality With Patients: A Rational and Ethical Approach" and viewing the research of Department of Family Medicine, Northeastern Ohio Universities College of, Medicine, I think it is a great experiment. In my opinion, physicians should know some more information about spirituality or religious beliefs of patients if they can besides figuring out how to treat them. In my experiences, when a person who has illness, or stress, or operation, etc, he/she often thinks negatively at first. For instance, they might be afraid of death, or pain. They might worry about other people who they care for like their kids, or their old parents, and so on. Thus, the patients lose their confidence in treatment. If patients have worries and lose their belief in treatment, it might influence the treatment too. For instance, they might not eat, or take medicines as required, or follow the instruction of the doctors, etc. Hence, it's hard for doctors to take care of them. Generally, physicians should talk to patients about illness, treatment, and spirituality or religious beliefs. I believe that when physicians talk about those, it shows that physicians care more about their patients, and this creates a closer relationship between physicans and patients in order to understand them from mind, spirit to illness in the body, and to have a better treatment.

Competing interests:   None declared

Gary McCord and all:

I resonate with the comments listed particulary the ones having to do with the frustration of having to prove the "right" of spirtuality to exist in medicine. Chaplains have been involved in institutions 'doing spirituality' in medical institutions for most of the 20th century and yet many people do not know the difference between local clergy, certified Chaplain, certified CPE Supervisor, and a certified pastoral counselor. Spiritual care is important in the care of patients and as Gary McCord points out takes time and energy that many physicians do not have. I would point out that expertise is needed as well, since many spiritual care issues are complex. I appreciate the opportunity as a Chaplain to provide feedback to this forum on Spirituality, it is my firm belief that patient care is maximized when the physician and institutional chaplain work together. Maybe national professional Physicians and Chaplains groups need to have dialogue about this thing called spirituality.

Competing interests:   None declared

I would like to thank all of those who took the time to respond to the spirituality study. The reaction to our research exceeded my expectations. The commentators on the article provided insightful, heartfelt and thoughtful observations on our study as well as the current state of spirituality in medicine. It is obvious to me that there are many individuals who are very passionate about the inclusion of spirituality in medicine and who believe it is a vital element in the overall wellness of human beings. I noticed that most of the commentators on our article have published spirituality studies of their own. Because of your continued interest and work in this area, spirituality in medicine stays alive. Like Dr. Marchand, I am tired of a seemingly endless need to prove to certain individuals that spirit has a right to exist in medicine. The complex interactions between body, mind and spiritual elements define who you are as a person. None of these elements exist independent of the others. Illness in one component intimately affects the others. Ask anyone you know who has suffered a serious physical, mental or spiritual illness whether the illness had an important effect on the other elements.

Research needs to move beyond whether spirit has a right to exist in medicine to how patients’ spiritual concerns can be incorporated in medical care in a meaningful and workable way for both patients and physicians. As Dr. Craigie pointed out, the challenge may be to define a unique Family Medicine perspective on understanding and nurturing patients’ spiritual resources as part of delivering holistic health care. Development of alternative investigative methods or scientific paradigms may be necessary in order to adequately study how understanding, compassion, belief and hope can be incorporated into medical patients’ spiritual care, but this is a worthy and necessary goal if one is to provide some measure of spiritual care for which patients are asking.

However, I do have an important concern. During the 20 years that I have done research at the medical school, I have worked with dozens of primary care physicians. Every single one of them who are full-time physicians are too busy. Most are way… too busy, and this situation has become much more acute in recent years. The health care system in this country continues to place an ever increasing number of requirements on practicing physicians. Additionally, the pace of medicine is getting faster and faster with no end in sight. This kind of environment is not particularly conducive to spiritual exploration, especially for someone in spiritual distress. Spiritual investigation and resolution of issues requires a relaxed environment and a lack of time constraints, even with someone not in distress. Dr. Anandarajah points out that if one were to use the results of our study as a screening tool, the spiritually distressed may not be adequately identified. I absolutely agree. The patients needing the most help may be the least likely to get it. Therefore, challenges for family medicine include not only how to incorporate spirituality into health care delivery, but also how to accomplish it within the current health care system.

To digress just a little, in the movie Dark City, a self-serving race of beings created what they believed was their ideal world. They had some measure of success at achieving their goals, but their plans fell apart when another person intervened. The person who won the battle created a world of his own, a wonderful, beautiful world. If I were that person and could create my own world, my health care system would be one where no one fell through the cracks. My health care system would give physicians all of the time and resources they needed. My physicians would be caring, kind-hearted people who were qualified to heal the body, mind and spirit (i.e. my definition of primary care) and who derived a great deal of satisfaction from making people feel better. Most of the physicians that I know fit most of those criteria already. The structure of the health care system itself is the most problematic factor in delivering comprehensive care. Nevertheless, if all you do is to remember to express understanding, compassion and hope to your seriously ill patients, it may go a long way in helping them to better cope and deal with their illness.

Competing interests:   None declared

As physicians, what have we learned about the place of religion and spirituality in the clinical encounter from this study by McCord and colleagues?1 First, the data suggest that most patients are unsupportive of spiritual-history taking during initial or well-care visits. This is consistent with a recent multi-site study which found that patients want physicians to be “spiritually-sensitive” providers of care, however not in an office setting and not at the expense of foregoing time spent discussing medical issues for a conversation about spiritual or religious concerns.2 Physicians should consider redirecting their clinical attention from away from routine spiritual histories. Second, context matters. Patients are more accepting of physician discussion of religious and spiritual issues if they perceive their health as declining, largely as they consider and visualize their own serious, chronic illness or care at the end-of-life. If pastoral care referral rates are one measure of spiritual sensitivity, family physicians are already tuned into the spiritual needs of their seriously ill patients.3

Spirituality and religion touch upon multiple, ill-defined, overlapping dimensions of the human condition, such as belief, faith, and hope. Yet, according to McCord’s work, belief and hope are considerable forces at work within the patient-physician relationship, forces that can heal or wound.4 The primary challenge not only lies in how we physicians grasp the nuances and complexities of spirit and belief in patients and within ourselves, but also how we –patient and physician – negotiate the movements of this unique human dimension across health and illness.5

REFERENCES

1. McCord G, Gilchrist VJ, Grossman SD, et al. Discussing Spirituality With Patients: A Rational and Ethical Approach. Ann Fam Med. July 1, 2004 2004;2(4):356-361. 2. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. Journal of General Internal Medicine. 2003;18:38-43. 3. Daaleman TP, Frey B. Prevalence and patterns of physician referral to clergy and pastoral care providers. Archives of Family Medicine. 1998;7(6):548-553. 4. Groopman J. God at the Bedside. N Engl J Med. March 18, 2004 2004;350(12):1176-1178. 5. Daaleman TP. Religion, spirituality, and the practice of medicine. Journal of the American Board of Family Practice. in press.

Competing interests:   None declared

McCord and colleagues are to be congratulated for an ambitious and timely project. They explore the situations in which patients would be open to conversation about spiritual and religious beliefs and, significantly, begin to examine what respondents want physicians to do with such information.

The direction in this project that is most exciting to me is the consideration of how information about spiritual and religious beliefs may be incorporated into clinical care. Reporting in Table 3, they find a number of reasons that patients would want conversation about spiritual and religious information, having to do with understanding, decision- making, compassion, and hope. My sense is that these reasons capture the basic features that patients value in relationships with physicians, as we may see from the similar findings reported in the landmark Future of Family Medicine collaborative project (published as an Annals supplement earlier this year).

I would be very interested in a continuing exploration of how physicians use such information on behalf of understanding, decision- making, and so forth. We now have some good data that patients value this level of understanding and why this is important; I think we would do well to examine further what physicians may do with information they elicit about spiritual issues and spiritual values. My sense is that it is not hard for a physician whose heart is in the right place to elicit such information, especially with the availability of several assessment instruments, as Dr. Puchalski describes. The more pressing question (and the reason many of us as practitioners often hold back from entering this arena) often is, “gee whiz, what do I do now?”

I think we would do well to explore this question more richly in Family Medicine research. How do we not only enter the spirituality arena, and not only elicit information about spiritual issues and resources, but how do we provide caring for patients around their fundamental life values and questions? What is it in our presence and/or our clinical approaches that provides comfort and healing for our patients?

Personally, I think that such questions are often richly approached with stories. Building on the present study, I think that qualitative research about how physicians use spiritual information on behalf of understanding and healing would be an important priority. I note, with some eagerness, that McCord and colleagues seem to have an enormous amount of qualitative data, and I would urge them to consider whether organized content analyses of these data might provide some helpful narratives and further illuminate themes in how patients and physicians work together in this area.

As Chaplain Austin aptly comments, I think that our colleagues in the pastoral care world can be very helpful resources in such a project. I would emphasize, however, that the goal is neither to turn physicians into pastoral caregivers, nor is it to have physicians summarily refer all patients with spiritual issues to specialty professionals. Rather, I think the challenge is to define more clearly a unique Family Medicine perspective on understanding and nurturing patients’ spiritual resources as part of the fabric of whole-person primary care.

A final comment in this short reflection is that I appreciate the authors’ recommendation that we investigate further the possibility of routine questioning in these areas as part of intake histories. Yes, indeed. For years, I have been suggesting to our residents that they replace the obligatory 90 seconds of “screening for depression” with 90 seconds of “screening for joy,” or “screening for passion,” or “screening for meaning and purpose.” May we add this to our list of future directions.

Competing interests:   None declared

What amazes me about the results published by McCord and colleagues is the very high rate of interest in spiritual/religious matters and health by OUTPATIENTS. Most previous studies document, as McCord did, that patients are most willing to discuss spiritual issues when they are facing terminal illness, serious illness, or suffering from addition to drugs or alcohol. Such situations are much more likely among inpatients than in the office setting. The participants in the McCord study were not facing such situations for the most part, but were likely seeing the doctor for colds, blood pressure check-ups, etc. Perhaps some of them were facing serious illness, but the situations were largely hypothetical for many of them. That so many outpatients, well outside the Bible Belt, were interested in discussing spiritual issues with their physician is actually quite amazing. That so many physicians and other health professionals still shy away from this discussion is also quite amazing. The responses to McCord's article emphasize the varied beliefs and views that patients can have---all the more reason to explore them!

Competing interests:   None declared

The culture of medicine has its roots in wholeness, which embraces the physical, emotional, intellectual and spiritual dimensions of human beings. The notions of Descartes attempted to separate the human being into a body isolated from its other dimensions, and created a dichotomy in the practice of medicine that favored the scientific, “rational” approach. With the explosion of technology in the 20th century, medicine reached a point of arrogance that the spirit and person didn’t matter, and that conquering the body and its ills could actually occur if enough intellect was applied to finding the right causes and treatments for disease. Eventually the battle against cancer and heart disease would irradiate these diseases, and the unknown would become known through science. There was no need for spirit and emotions in this paradigm, and in fact, these other dimensions were a weakness that could subvert the scientific mission. Yet, in the past few decades, health professionals and patients have realized the shortcomings of this purely scientific, body, doctor centered approach. Integrative medicine, patient centered and relationship centered care, humanities in medicine, ethics and shared, relational decision making, hospice and palliative care, and spirituality have all crept back into the health care of human beings (and for many physicians, never left). Medicine remains skeptical of its wholeness, and thus the subtitle to the present article, “A Rational and Ethical Approach.” No, we are not satisfied to let spirituality exist without the consent of science, and perhaps the title reflects the dis-ease we have with wholeness and caring for people in 2004.

Spirituality is hard to define. The authors acknowledge that. And so, they created questions about connection between the doctor and patient. Some questions were more specifically about prayer. There were no questions asked about physicians centering with patients, such as using a moment of silence, deep breathing, or meditation with patients. Religious affiliation was specifically not asked so that patients could define spirituality for themselves. The results showed that patients want understanding. Who wouldn’t? I wonder about the patients who voted against this. The predictive factors for those patients that wanted their physicians to know about their spiritual beliefs include those that have beliefs that provide hope during times of illness, are 30-64 years of age, have beliefs that influence decision making, and patients that rate themselves as more spiritual. How does knowing this really help us, and give us a more rational and ethical approach? Do we ask these questions on an intake form? Do we not ask patients over 64 about their beliefs? How do we identify the 17% of patients that do not want physicians to ask about their spirituality? I do however agree with the conclusions of the authors. As physicians, our discussions with patients, especially those dealing with serious illness, need to include questions to better understand patients and their wholeness, and through this dialogue offer compassion and hope. This is one human being reaching out to another human being in relationship, in wholeness, in service, and touching the spirit and essential being of the other person. To a technician this might be fluff, but to a physician, this is our everyday, essential mission. In our narrow, science oriented perspective on what medicine is, we perhaps will need to continue to have research such as this study on spirituality that somehow “proves” that attending to the spirit and reaching understanding of patient beliefs is important in caring for patients. I, for one, am tired about needing to prove that spirit has a right to exist in medicine. All physicians will eventually become patients, and will discover for themselves that medicine without understanding, compassion and hope is very empty medicine.

Competing interests:   None declared

Dear Dr. McCord,

In your response you point out that an initial physician concern in your research project was that they might not know all the intricacies of a patient's 'specific religious orientation'. What your study finds is that " patients want a holistic healthcare role from their physician, not a religiously interpretive one.'

In my opinion this is one of the major weakness in physician based religiosity research. To reduce the multidimentional complexities of spirituality to a single outcome based professional response of "religious interpretation" , presuposes that anyone can do spiritual assessments. It also provides a false rationalization for other professionals, alowing them to avoid asking for: instruction in spirituality content, interventions methodologies, and outcome based treatment proceedures having to do with a patients spirituality.

There are some fairly universal spiritual issues that are recripricoal to many faith systems. Spirituality encompasses isues such as : Nature of the deity or holy, Actions of the Holy, Meaning, Hope, Forgiveness, Grief, Personal responsibility, Emotional affective issues such as guilt, shame, anger, sadness, end of life responces, meaning and understanding of life, death, and rituals.

These above mentioned isues would be considered to be spiritual issues by many Certified, Professional institutional Chaplains but may not be recognized by other 'spiritual referral resourses', and or physicians. However the latest studies in Pastient satisfaction ( see Press Ganey material) points out that patient emotional and spiritual saitsfaction with health care institutions and care, is tied to these and other similar issues.

Holistic health care means more than the simple assimilation of data and facts. Holsitic healthcare involves treatment. If one is involved in the holistic treatment processes in and around religion, faith and spirituality, then the involved professional needs to take that process seriously enough to get training. Training at a minimum should consist of : Learning to recognize the spiritual issues, Learning to be self reflective, and Learning about the potential consequences of arrogant thinking that spirituality is an uncomplicated and unsophiscated endeavor.

Finally to come up with a list of competent resources to help the physician deal profesionally with religious/spiritual issues with patients, an understanding of chaplaincy training and certification is needed. Chaplain education, certification and training may differ greatly from community clergy educational processes and may be different as well from other 'spiritual referral respourses.'

Competing interests:   None declared

A broad goal of physicians is to attempt to help alleviate human suffering in whatever form we encounter it. The increasing interest in the role of spirituality in medicine underscores the need to understand that suffering and health can have spiritual as well as physical and mental components. The article by McCord et al.[1] is a valuable contribution to efforts to improve our understanding of the role of spirituality in health care. It supports previous studies by confirming that many patients (84%) are comfortable discussing spiritual issues with their physician, that conversations are increasingly welcome as severity of illness increases and that physicians only rarely (9%) discuss these issues with patients. The article adds to the literature by documenting that patients want these discussions because of a desire for understanding, compassion and the encouragement of realistic hope. It also attempts to identify patients desiring discussion about spirituality and offers a screening tool for spiritual discussion based on four predictive factors: having religious or spiritual beliefs that give hope or influence health decisions, age 30-64, and being more spiritual.

The finding that patients want discussions with their doctors regarding spirituality because of a desire for compassion, understanding and hope is something we should take careful note of. These are essential therapeutic elements of spiritual care as noted in the pastoral care literature[2] and are key themes present in the spiritual heart of religions throughout the world. This finding complements an emerging body of research on the effects of compassionate/altruistic love on health[3].

The issue of screening/assessment methods warrants some discussion. The screening approach offered in this article helps identify patients who are comfortable with their spiritual/religious beliefs and will help in many ways, including harnessing patients' spiritual resources for improving their health and well-being and identifying specific beliefs that effect health care. Unfortunately, there are other groups of patients that might be missed with this approach including: (1) those who feel uncomfortable with the terms religious or spiritual and (2) those who are suffering from spiritual distress.

Several authors have called for an inclusive understanding of spirituality[4] encompassing the rich diversity of the human spiritual experience including: the quest for meaning and truth; the values and beliefs we hold most dear; and the need for connection, love and hope. By limiting questioning to the terms "spiritual or religious belief", the authors omit other dimensions of spirituality and may be excluding patients who are uncomfortable with these terms. A future study including questions about core beliefs, meaning, values, hope, love and connection might capture the views of the 35% that refused to participate in this study or the 17% that never want to discuss "spirituality".

Patients in spiritual distress, suffering from lack of love and hope, are conflicted about their beliefs or are struggling with meaning, may only express their spiritual concerns in the form of metaphors or subtle clues. This is the subgroup of patients we most need to identify. An approach based on a trusting doctor-patient relationship in which a physician listens for spiritual themes in the patient's narrative and follows these with gentle probing question regarding specific spiritual issues, may be the most effective way to identify and offer help to these patients.

Caring for patients requires an understanding of the complex interaction between suffering on multiple levels - physical, mental and spiritual. Spiritual suffering may not be readily apparent on screening questions so, with compassion as the foundation, we need to continue to explore ways in which to best identify and help our suffering patients.

References:

1. McCord et al. Discussing spirituality with patients: a rational and ethical approach. Annals of Family Medicine 2004; 2:356-361.

2. O'Connor PM. Spiritual elements of hospice care. Hosp J 1986; 2:99 -108.

3. Post SG and Underwood LG (ed). Altruism and Altruistic Love. Oxford University Press. New York. 2002.

4. Thomason CL, Brody H. Inclusive spirituality. J Fam Pract. 1999; 48:96-7

Competing interests:   None declared

Thanks to John Ehman, David Parrish and Christina Puchalski for providing comments and observations concerning the spirituality study. There are eight family practice physicians who are members of our research group. When this study was being designed, some of our members expressed concern that patients would request discussion or intervention that physicians would feel unqualified to perform. One physician gave an example, “I have a Buddhist patient. What if this patient wants to talk about Buddha? How I am supposed to address this when I don’t know anything about Buddhism?” No patient in this study explicitly expressed a desire for their physician to know the intricacies of the patient’s specific religious orientation. The closest that anyone came to this was some patients’ desire for their physician to pray with them. However, patients endorsed physicians understanding them as people, understanding how they deal with being sick and understanding how they make decisions. This suggests that patients want a holistic health care role from their physician, not a religiously interpretive one. After reviewing the study results, most of the physicians in our research group felt comfortable and qualified giving patients what they asked for despite the apparent lack of spirituality training in medicine. In the event that physicians feel unqualified responding to spiritual requests, they should compile a list of spiritual referral sources from the community to use. In this study, patients considered referral as a viable option in addressing their spiritual concerns. A research project defining the parameters and scope of patient expectations concerning physician understanding may provide additional important insights.

In terms of other issues brought up by reviewers - we chose not to explicitly define spirituality to patients in this study. We reviewed many definitions and found most of them restrictive in some sense, so in order to have the broadest possible appeal to patients, we chose to let patients define spirituality for themselves. The age effect (65+ years are less likely to desire spiritual discussion) could possibly be an age cohort effect instead of an independent age effect. Additionally, our elderly sample may be biased. Anecdotal information from the research assistants indicated that older people who refused participation appeared to be sicker and this may have been one of the reasons for their refusal. Finally, the questionnaire was piloted before the study. All of the piloted questionnaires were completed in under 15 minutes. Readability and ease of use were highly rated so we believe that the length of the survey did not adversely alter the results.

Competing interests:   None declared

I enjoyed the article on A rational and Ethical approach to spirituality. There are some issues that would have enhanced the study. Spiritual assessment is used as a catch all term. There are distinctions between a spiritual screen, a spiritual history and a spiritual assessment. The authors quote " To bridge the gap between medicine and spirituality the physician must identify and utilize resources for patient generated requests." In the institutional treatment setting the Chaplain is part of the team process , to rely on patient generated requests for referral is to put Chaplaincy in a different category from other allied health professions. The patient is not expected to ask for a social worker, rather the physician sees a social work issue and informs the social worker team member of their need to be involved in the treatment of the patient. Spiritual Care should be handled in the same manner. It would be helpful for physicians and chaplains to sit down together to dialogue about the complexities of spiritualiy in the treatment process, and agree on some common language, terms and approaches that honor both professions' desire to help patients.

Competing interests:   None declared

The article by Cord, et al entitled Discussing Spirituality with Patients: A Rational and Ethical Approach is an important contribution to the field. One of the commentators noted that physicians are not trained to do this assessment. There are several key point to add to this discussion: 1. A recent consensus conference I co-directed with AAMC concluded that it is the ethical obligation of physicians to know how to respond to patient suffering, know how to respond to and elicit patients spiritual/exitential issues. Spirituality is very broadly defined to include religious adn non- religious beliefs and values. (I noted that the paper did not define spirituality and I am curious how the patients understood the term.

2. There are over 70% of medical schools that have courses and/or topics related to spiritualtiy and health. many of these teach spiritual history taking. ONe of the guidelines developed by the AAMC is that students should know how to do a spiritual history. The tools available are FICA, HOPE and Spirit. Fica is used in many of the schools and is integrated into many texts on clinical diagnosis.

3. Providing compassionate holistic care is central to our role as physicians. Understanding patients' beliefs and values impacts decision making and therefore key to what we do. (Further described in Puchalski, C in Principles and Practice of Palliate Care and Supportive Oncology 2nd ed Berger, Portenoy and Wiseman (editors)

Competing interests:   None declared

The study by McCord, et al. is a valuable contribution to the literature, but it is also a good example of how research into spirituality & health is currently at a slow turning point in its early development: namely, moving from the establishment of intriguing connections to an exploration of the factors underlying those connections, and that is a venture of much greater complexity. This study builds especially upon research that has indicated that many patients are interested in some interaction with a physician about their spirituality, and it suggests that this may be, at least in part, because patients want to be better understood by physicians. The final section of the instrument developed here (items 51-60) seems--to this reader--to be the heart of the study (though its placement at the very end of such a long questionnaire may not have been optimal). It is worth noting the careful wording of the lead-in to this section, which refers to “reasons why someone might want their [sic] doctor to know about their spiritual or religious beliefs.” Note that this is not precisely about physician inquiry or about discussion or conversation of beliefs; it is simply about motivation for providing spirituality information to a physician. Unfortunately, the specificity of this wording becomes a bit lost in the course of the article, where patients’ desires that physicians “know about” their beliefs becomes confused with the broader ideas of “conversations about spirituality” or “spiritual discussion” (e.g., p. 358). The difference is significant, because while the latter ideas play directly into various “controversial” aspects of physician-patient interaction that the authors list in their opening paragraph (p. 356), the opportunity for a patient to report any information, even of a spiritual nature, that may affect health care would seem to be entirely appropriate. The operative issue that is implicit in this research, but needs to be pursued explicitly in future work, is how much interpretation of spiritual information do patients want their physicians to make. How much are physicians expected simply to accept patients’ spiritual information or take from it a general sense of values or process it in some psychological or religious fashion? The findings of the present study seem to this reader to hint that patients do not want physicians in a highly interpretive role.

I offer one other thought about how this study may fit into larger trends in spirituality & health research: this field of research has the challenge of developing in the midst of significant societal shifts in attitudes and understandings of spirituality and of the physician- patient relationship. So, it is worth pondering whether the finding that persons who were “more likely to desire spiritual discussion were respondents 30 to 64 years of age” (p. 358) could be a function not of age itself but of age cohort. Might especially the refusal of older patients to participate in the study be tied to age cohort factors concerning what information is socially appropriate for the physician-patient relationship that has been institutionalized for most of their lives? Likewise, it is worth asking whether the finding that “the percentage of those welcoming inquiry increased with severity of illness” (p. 359) might be both presently true and yet soon subject to change as the popular sense of the place of spirituality in health care may be expanding beyond traditional views of the role of religion in end-of- life situations. Such is the moving target for spirituality & health researchers.

Competing interests:   None declared