The results of this study show that although patients express a general interest in spiritual dialog with their physicians, only a minority would welcome spiritual interaction in an office visit setting and fewer than 10% would forego time spent discussing medical issues for a discussion of spirituality. Sixty-six percent of our subjects feel that their physician should generally be aware of their religious and spiritual beliefs, but only 33% would welcome physician inquiry into their spiritual beliefs in an office setting. The only scenario in which more than 50% of patients agree that any form of physician spiritual interaction is appropriate was the setting where a patient is near death.
The finding that two thirds of our subjects feel their physicians should generally be aware of their religious and spiritual beliefs is consistent with Oyama and Koenig's findings that 73% of outpatient subjects indicated that physicians should have knowledge of their patients' religious beliefs.20
The finding that 33% of our subjects agree that physicians should inquire about religious or spiritual beliefs in the office setting is also consistent with previous research with smaller single-institution samples. Maugans and Wadland, in a survey of 135 outpatients in Vermont, found that 30% of respondents felt that their physicians should address religious issues with them.14
Daaleman and Nease, in a survey of 80 family practice patients in Kansas, found that 41% of their sample felt doctors should ask about religion and personal faith.16
King and Bushwick, in interviews with 203 medical inpatients, found that 77% felt that physicians should consider their patients' spiritual needs and 37% wanted more physician discussion of their religious beliefs.15
Previous studies have not examined the range of clinical scenarios (office setting, hospitalization setting, and terminal illness setting) and religious behaviors (physician inquiry, physician silent prayer, and physician active prayer) that we have addressed. illustrates that as the severity of the illness setting increases, patient interest in a spiritual dialog increases. In an office visit setting, fewer than 20% of patients would welcome physician-patient prayer, whereas in our death-and-dying scenario, 50% of patients welcomed active prayer with their physician and 70% agreed with physician inquiry into their religious or spiritual beliefs. This is consistent with our expectations that the level of spiritual concern would increase as patients face a graver illness. It is only in our terminal illness scenario, in which issues of mortality, faith, and coping are critically important, that more than half the patients welcome any level of religious or spiritual interaction. Several studies have examined issues regarding the spiritual preferences of gravely ill patients. Kaldjian et al., in a study of 90 inpatients with HIV or AIDS, found that 46% of their patients wanted to pray with their physicians.21
Ehman et al. found that 45% of patients in an outpatient pulmonary clinic have spiritual or religious beliefs that would influence medical decisions if they were to become gravely ill.12
We have also demonstrated that as the intensity of the interaction moves from physician inquiry about patient beliefs to physician silent prayer to physician-patient prayer, the proportion of patients who would welcome religious engagement decreases (). For example, in the hospitalization scenario, the proportion of patients who agree with physician interaction decreases from 40% for physician inquiry to 39% for physician silent prayer to 29% for physician-patient prayer. This latter proportion is less than that found in the King and Bushwick study of hospitalized patients, where up to 48% wanted their physician to pray with them.15
Despite the relatively high level of patient general interest in spiritual interaction, surveys of physician behavior have shown that doctors rarely discuss spirituality with their patients15,22
or refer them to pastoral professionals.23–25
Reasons cited by physicians for not addressing spiritual issues include: a fear of projecting their own beliefs onto patients,14,23,24
lack of time or training,24
difficulty in identifying those who would welcome discussion,24
assumption that those in need would self refer,23
and lack of the physician's own religious belief.23
The primary care office setting is one in which physicians may feel overburdened with competing demands to address a variety of issues including: symptoms, screening and prevention, psychosocial problems, family violence, drug and alcohol abuse, preferences for care at the end of life, and others. Time pressures are important contributors to physician job dissatisfaction.26,27
To further explore this gap between patient interest and physician behavior, we developed a scenario that we felt was representative of outpatient clinical practice, in which we asked patients if they would be willing to forego valuable minutes of an office visit for a discussion of spiritual issues. Only 10% of patients were willing to make this trade-off. Our findings reinforce that the routine office visit may not be the optimal time and place for these discussions. Although we have not addressed this issue directly, the hospital setting may offer several advantages, such as: less time pressure, a greater opportunity to involve family and other members of the treatment team, including clergy, and an opportunity to re-address issues over consecutive daily visits.
In addition to examining the setting of a patient encounter, a physician could look to patient characteristics to try to gauge how best to incorporate a spiritual discussion into practice. Daaleman and Nease found that patients' frequency of religious service attendance (at least monthly) predicted their acceptance of physician inquiry into their religion and personal faith and acceptance of physician referral to pastoral professionals for spiritual problems.16
Levin et al., using data from 4 national surveys of religiosity, found a positive association between African-American race and religiosity, even after controlling for a wide variety of demographic factors.28
Our finding that African-American race is an important patient characteristic in the approach to spiritual issues is consistent with this and other findings of racial differences in religiosity.29,30
We would suggest that approaches to addressing spirituality should be done in a culturally competent fashion and should avoid racial or cultural stereotyping.
Our study population is one of the largest and most diverse on this topic, covering a wide variety of patients, including veteran Americans and the urban underserved. We feel that it is representative of patients seen in general internal medicine settings in the United States. This is the first survey instrument to explore in detail how patients and physicians might concretely interact around spiritual issues.
A few limitations in this study must be noted. Although our patient population reflects a wide range of ages and socioeconomic and geographic backgrounds and is representative of populations seen in many medical centers, it is still drawn heavily from the southeastern United States. Additionally, our patient population was predominantly Protestant. The preferences reported here were obtained from hypothetical scenarios outlined in the survey and may not represent patients' actual behaviors when facing any of these situations.
Our study provides evidence to support the concept that proper timing and a patient-centered approach are important elements in taking a spiritual history, as suggested by Koenig.31
A variety of spiritual assessments and questionnaires have been proposed as aids to the practicing physician for exploring the broad dimensions of spirituality, although none of these tools has been tested prospectively.13,32–34
Future research is needed to explore the overlapping and intersecting roles of physicians, clergy, and other faith-based social support in the community and in the hospital. Further work is also needed to test the feasibility and acceptability of incorporating specific spiritual assessment tools into appropriate clinical settings. We hope that our results have highlighted the importance of assessing these approaches across a range of settings in which patient acceptability may vary considerably.