From the first year of medical school, we are trained in probing into the most personal aspects of patients’ lives; but when it comes to spirituality, we shy away. In a survey of the U.S. general public, the 2008 Gallup Report demonstrated that 78 percent of people believed in God and an additional 15 percent believed in a higher power. Other studies have shown that religious beliefs and spiritual practices are important factors for many when coping with serious illnesses and making decisions about treatment options and end-of-life care. So why aren’t doctors asking about spirituality? According to one study, only 48 percent of doctors said they had insufficient time, and 40 percent cited concerns about offending patients. By failing to ask these critical questions, we may be missing golden opportunities to better care for our patients.
I recently cared for a refugee patient with several medical problems and a very prolonged hospital course. He had been in the hospital for eight months and had a new puzzling diagnosis of psychogenic nonepileptiform seizures (PNES), or commonly known as pseudo-seizures. This was a new occurrence, and they proved very difficult to manage by both the medical and nursing staff, and much to his distress, the patient was ultimately put in restraints to ensure his safety. Only after asking about his spiritual beliefs did it become evident that the patient was a devout Christian who was depressed because he had not received communion in the eight months that he was hospitalized. The medical team arranged for a priest to come into the hospital to give him communion and one week later, his PNES episodes subsided. He has been pseudo-seizure free ever since.
Asking about spirituality is also tremendously valuable in the setting of chronic illness. In a study of 456 outpatients at six academic medical centers, if they were dying, 70 percent of patients would want their physicians to know their beliefs and 50 percent would want their physician to pray with them. In one instance, a man with longstanding alcohol use disorder was seen in the ambulatory clinic intoxicated and expressing passive suicidal ideation. When asked if he was religious, he removed a small pocket Bible from his pant leg pocket and broke down in tears, explaining that his belief in God was the only thing keeping him from ending his life. He asked for a passage to be read to him, after which he agreed to go to the emergency department. This example demonstrates that caring for a patient’s spiritual needs is as important to their health outcome as caring for their physical ailments. There is a profound connection between the mind and the body, and so both must be cared for equally. It is time that we took a more holistic approach to patient care and started asking the fundamental questions about spirituality, especially in the setting of chronic illness.
But is it the physician’s role to ask? I do believe that it is, just as we inquire about many other things that may or may not be relevant to certain individuals. If the patient responds positively, then the benefits are potentially great. Making it a routine part of our history-taking practices will normalize it for us as providers as well as for our patients. Several tools have been validated for use, namely the FICA Spiritual History Tool and the HOPE Questions for Spiritual Assessment.
For a medical student or physician who has never assessed a spiritual history, it is reasonable to start with the first FICA question, “Do you have spiritual beliefs that help you cope with stress?” and letting the patient dictate the rest of the conversation, using open-ended questions. The spiritual assessment is a powerful resource. It can be used to build meaningful relationships with our patients, navigate difficult clinical encounters, and create a nurturing atmosphere for shared decision-making.
Veronica J. Meawad is an internal medicine resident.
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