Embracing the spiritual

Most patients don't want their physicians to play God, but discussing God is another matter.

Most patients don't want their physicians to play God, but a significant portion may want them to talk about him, according to a new study.

Farr Curlin MD Courtesy of Dr Curlin
Farr Curlin, MD. Courtesy of Dr. Curlin.

More than 3,000 inpatients treated on the University of Chicago general medicine service were recently surveyed about how their religious or spiritual concerns were addressed during hospitalization. According to results published in the November 2011 Journal of General Internal Medicine, 41% of the patients desired a discussion of religious or spiritual concerns while hospitalized, but only half of that group got one. Patients who were religious or experiencing severe pain were most likely both to desire and to engage in spiritual conversations.

Josh Williams MD Courtesy of Dr Williams
Josh Williams, MD. Courtesy of Dr. Williams.

The study concluded that many more inpatients want conversations about religion and spirituality than get to engage in such talks. Two of the researchers recently spoke with ACP Hospitalist about their findings and how hospitalists can better handle their patients' spiritual needs. Josh Williams, MD, is now a resident at Beth Israel Deaconess Medical Center in Boston and Farr Curlin, MD, is an associate professor of general internal medicine and co-director of the Program on Medicine and Religion at the University of Chicago.

Q: What was the motivation for this study?

A: Dr. Williams: I can recall a number of times where I've seen a chaplain play the pivotal role in patient care, whether as a neutral mediator in a time of conflict or a quiet support for patients and their families in a time of confusion and vulnerability. I became curious about how often chaplains are invited in to see patients and how patients react to these encounters. What impact does this have on the quality of their care? [Dr. Curlin] had spearheaded inclusion of questions such as these in a large survey conducted by the hospital service and I was eager to see the results.

Q: Your study found that 32% of total patients had a religious or spiritual conversation and only 8% of those involved a physician. What is the proper role for physicians in this area?

A: Dr. Curlin: I think the role for physicians is to pay attention for signs that patients give that suggest there are religious and spiritual concerns, and to do their best to respond to them in a respectful and helpful way. The signs are sometimes explicit, as when a patient says, “I'm hurting spiritually” or “I'm thinking about what it may be like to face God.” Sometimes they're not explicit. It may be tears. It can be a sense of conflict with the family. It can be struggling over a decision.

When physicians sense that, they want to have a posture of receptivity. They can ask if there are things the patient wants to talk about, they can ask if the patient is receiving the support that they need from their own community, and they can offer to help the patient connect with a chaplain or one of their religious leaders or someone else who can help them work through those issues.

Dr. Williams: Making a personal connection and becoming a resource for patients for those things that lie beyond the immediate concerns of the body does not come naturally to many physicians. Dealing with the illness, and with the impact of that illness upon the patients and their families, now that is very, very difficult. You have this checklist in your head of things you want to accomplish when you go in and see a patient and it's usually supposed to done in an incredibly short amount of time. I don't believe it's that physicians don't find these things to be important. They weren't really educated to do that, especially older physicians. Younger physicians like myself were taught in medical school to stop first and see the patient as a person, but there is certainly more work to be done.

Physicians [should be] educated from an early point in their training to be comfortable asking questions like “This is a really tough time for you right now. It looks like you're suffering a lot. Who are the important people in your life? Who is someone we can talk to? What else can we do for you while you're here to make your experience better? Can we have a social worker come and see you and talk about things at home that you need? Can we have a chaplain come and see you? Do you have any religious or spiritual concerns that you'd like to be addressed during this hospitalization?”

Q: You found that one in four patients who did not desire a spiritual discussion had one anyway, but those patients (11% of the total study population) had higher patient satisfaction those who didn't have a discussion. What do you think that indicates?

A: Dr. Williams: That was a very surprising finding for us. That there was a significant group of patients out there who had said they did not want a discussion of religious or spiritual concerns and had one nonetheless is not as surprising. In many hospitals with chaplains, they make regular rounds and often drop by rooms at random. What was striking was the degree of satisfaction with their care expressed by this cohort. It points to the fact that even if religion/spirituality is something they don't like to talk about, people appreciate the fact that a member of the hospital staff cares about them in a truly holistic way.

Dr. Curlin: Many people who think about this area and have experience in this area have commented that most patients won't ask for this and they're not even often conscious of a desire to have this conversation. Some are, but many aren't, but if the conversation is engaged in a respectful way, even those who aren't looking for it appreciate it.

Q: What systemic changes would you like to see hospitals make in response to these findings?

A: Dr. Curlin: I think what our study suggests is that when anybody on the health care team pays enough attention to a patient to talk to them about their spiritual or religious concerns, most patients experience that as something that they appreciate—enough so that it significantly improves their assessment of their entire hospital stay. What it suggests is that hospitals should invest more in their spiritual care departments, frankly.

Dr. Williams: I think that advocates of spiritual care departments now have a way to discuss these issues with hospital administrators in language that these administrators understand well. Showing the impact of spiritual care on patient satisfaction—something administrators and other physicians are well attuned to—now that's a powerful tool. I'm hoping it will also be a way for medical schools to have these conversations with their students in new ways and look at the curriculum and make sure this is being addressed in some way.

Q: Have you seen any increase in interest in this topic?

A: Dr. Williams: This is something that organizations that look at hospital quality have started to pay attention to in a real way in recent years. Physicians are also starting to pay attention. Both in my medical school years and as a resident, I have been heartened by the conversations that I have with my colleagues and teachers about addressing these issues and the impact this can have on healing. There is a real interest out there about these topics.

Dr. Curlin: I think slowly hospitals are developing more consciousness about how crucial this element of their care is. It's probably going to be only that much more crucial as patients are in the hospital for short periods of time. They have very brief interactions with physicians. Often it's the pastoral care professional who is the person they may feel the most human connection with and spend the most time with during their brief hospital stay.

Q: Are there any other lessons you'd want hospitalists to take away from your findings?

A: Dr. Williams: One of the big lessons is not to be afraid that if you ask patients questions about these issues you are necessarily crossing a professional boundary or wandering into waters you cannot navigate. Don't presume that if you as the physician ask these questions, then you will necessarily be the one to engage patients in conversation about their experience of illness, their spirituality or religion, or deep existential questions. Make a referral to the hospital chaplain or a member of the person's own faith if they prefer. I would urge physicians to realize that there are resources there to help them.

Dr. Curlin: Find out who your chaplains are, learn their names, and put on a card in your pocket the number to call them whenever the thought crosses your mind. If doctors make more referrals to the pastoral care department, the care for patients is going to be improved. That's the takeaway.