The article by Anadarajah and Hight suggests that family physicians should use their “practical tool for spiritual assessment.”[1] Is such a tool either wise or ethical? Recent commentaries would suggest not. Two PhD’s and several theologian/chaplains from New York City wrote in the New England Journal of Medicine that “…it is not clear that physicians should engage in religious discussions with patients as a way of providing comfort.”[2] Other academics have suggested, “…it is a general mandate of modern developed societies to keep professional roles separate…(as) distinct spheres of activity …(to) ensure competence and boundaries.”[3] They allege, “…physicians might need to explain to patients why such activities usually better fall under the purview of competent pastoral care.”³

Are such statements the astigmatic, nearsighted vision of academic, ivory tower specialists, who are neither trained nor experienced in day-to-day primary care? Or, are their warnings and concerns of such validity that readers of AFP should simply skip this article – or give it to their hospital chaplain (if indeed they are so fortunate as to even have a chaplain in their local hospital)? I would propose the former, as these subspecialty-based protestations – that primary care physicians should not consider applying basic spiritual care skills to their clinical practice – sound remarkably similar to those made by other specialists. Far too often, family physicians are vociferously regaled with the protester’s belief that it is in the patient’s best interest to be referred to the protester. Family physicians are told that endocrinologists should “disease state manage” our diabetic patients, psychiatrists should manage our depressed patients, cardiologists should read our patient’s EKGs and Holters, gastroenterologists should endoscope all patients with bowel complaints and obstetrician-gynecologists should deliver all our patient’s babies. Yet, these assertions are usually not accompanied with outcomes based research. Further, when such research is examined, it appears to make the case that basic patient care is most economically, efficiently and expeditiously provided by the primary care physician interested in and trained in handling such basic care. Just as “obstetrics is just too important to be left to obstetricians,”[4] I believe the practice of basic spiritual skills is just too important to left to pastoral professionals.

For the last several years, I have taught CME courses to physicians on incorporating spirituality or religion into their clinical practice to just over 6000 practitioners – most are family physicians. These learners seem interested in the ethics and practical “how-to’s” of incorporating these skills in practice – basic skills such as “How to take a spiritual history,” “How and when to provide a spiritual consult or referral” and “How and when to pray with a patient or family.” Can my experiences and observations be generalized? There are data that speak to this question.

A survey of 296 family physicians at a 1996 meeting of the AAFP revealed that 99% believe religious beliefs can heal and 75% believe that others’ prayers can promote healing.[5] A survey of family physicians in Missouri reported that, “Most family physicians believed spiritual well-being is an important factor in health. Despite this belief, however, most reported infrequent discussions of spiritual issues with patients and infrequent referrals of hospitalized patients to chaplains.”[6] Why? A lack of training seemed to be the common refrain. For example, Ellis reported that 59% of family physicians feel “uncertainty about how to take a spiritual history” and feel they “lack experience or training;” while 56% report uncertainty how to “identify patients who desire discussion” and 49% report uncertainty in how to “manage spiritual issues.”⁶ There are at least three arguments which support the teaching of these basic skills in the practice of medicine in an attempt to overcome this lack of training:

First, the overwhelming majority of the medical literature demonstrates a positive association between the depth of religious belief/practice and mental/physical health outcomes. Anadarajah and Hight ¹ outline these data. Many are surprised to learn that there are over 260 research studies and 35 review articles that reflect positively on the often forgotten but generally beneficial factor of faith on physical and mental health. One systematic review concluded: “…the published empirical data suggest that religious commitment plays a significantly beneficial role in (1) preventing mental and physical illness, (2) improving how people cope with mental and physical illness, and (3) facilitating recovery from illness.”[7] If we had a pill that accomplished these three objectives, it would outsell Viagra. Another review concluded that infrequent religious attendance or poverty of personal faith should be regarded as a risk factor for morbidity and mortality that is nearly equivalent to tobacco or alcohol abuse.[8] Therefore, it should not be “alternative” or “optional” to take a spiritual history. This is not a routine clinical skill that should be, nor routinely can be, referred to a religious or spiritual subspecialist. Others agree that spiritually based clinical skills should be taught and routinely practiced in clinical medicine.[9]^{,[10],[11],[12]} There are a number of published works which discuss not only the grounds upon which to ethically approach the subject of spirituality with patients.^{9-12,[13]–[14]}

Second, research shows that the majority of patients are open to and desire a personal physician who knows how to discuss spiritual matters. Given the importance religious beliefs have for patients, it is not surprising that more than 75% of patients surveyed believe their physician should address spiritual issues as a part of their medical care. Over 40% of patients actively desire that discussion of spiritual issues take place.[15] These data indicate that patients desire physicians who do not just focus on the pharmacologic or technical aspects of care when a spiritual dimension is central to their lives. Furthermore, most of the evidence that patients want spirituality incorporated into clinical medicine “…generally comes from studies in family practice settings.”²

Nevertheless, patient surveys also indicate that the physician must introduce spiritual subjects with permission, sensitivity and respect. Patients can and should expect their family physicians to respect their beliefs and to talk about spiritual concerns in a respectful and caring manner. If the patient gives a clear message that they are not interested in questions about their religion or faith, the subject should not be pursued. Professional problems for well‑meaning physicians can arise when a personal faith or religious beliefs are “pushed” on a patient opposed to discussing it.^2,3,9,[16]

Lastly, research reveals that physicians are in need of and desire further education when it comes to incorporating spiritual skills into their clinical practices. Although nearly 80% of Americans believe in the power of God or prayer to improve the course of illness,[17] one study found that even though the majority (63%) of patients desired that their physician address spiritual issues, less than 10% of family physicians actually did so.[18] Another study found that nearly one in every two inpatients desired their doctor pray with them, yet these same patients reported that spiritual matters were rarely discussed by their doctor.[19] A Time/CNN poll[20] found that 64% of patients felt that doctors should join their patients in prayer if the patient desires prayer, but 92% say they never had a doctor offer. Furthermore, only 5% of family physicians report that religious and spiritual issues were addressed in their training.[21] Learning to respond to these patient needs is long overdue in clinical medicine.

It appears that family physicians should learn how to ask for permission to discuss and support a patient’s spiritual or religious commitment. The argument that interested patients should then always be referred to a pastoral professional seems disingenuous at best and self-serving at worst. Without doubt, there are particular patients or particular spiritual problems that may need to referred to a pastoral professional with more time, training or experience. However, there is no outcome data, of which I am aware, to support such a recommendation or to suggest that the application of basic spiritual skills in primary care would be harmful to patients. Nevertheless, like any other new and sensitive area of patient care, family physicians must be taught the skills to approach spiritual issues appropriately and sensitively. Doing so is not only apropos, germane and relevant, but may promote both the health of the patient and the doctor-patient relationship.

The tide of ignoring faith as a factor in health is now turning. Nearly half (60/126) of American’s allopathic medical schools¹ now provide training on addressing faith and spiritual issues with patients;[22]^,[23] a curriculum for primary care residency programs is currently being completed;^17,18 and CME courses on these topics are available for practicing physicians. Unfortunately, these CME talks are usually inappropriately assigned the label of being either “alternative” or “complementary” – even by the AAFP. Therefore, they are improperly denied the prescribed credit designation from the AAFP that the evidence based literature would seem to support.

Increasingly, evidence-based educators are arguing that this type of training should be provided as a part of modern, evidence-based  “conventional” medicine and, in my opinion, the AAFP can and should become a leader among medical organizations by offering prescribed credit for these types of skill-building CME courses. To continue to provide prescribed credit for medical intervention with no supporting evidence (such as the routine use of continuous electronic fetal monitoring in the routine, low-risk maternity care patient), while denying prescribed credit to courses teaching basic spiritual skills is inconsistent and indefensible.

In 1910, in the first editorial published in the British Medical Journal, Sir William Osler wrote about “the faith that heals” and said, “Nothing in life is more wonderful than faith…the one great moving force which we can neither weigh in the balance nor test in the crucible, – mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potence.”[24] Kornhaber concluded: “To exclude God from a consultation is a form of malpractice. Spirituality is wonder, joy and shouldn’t be left in the clinical closet.”[25]

The family physician of the 21^st Century should be a highly skilled diagnostician, an excellent health care advocate and guide, a superb information manager, as well as a compassionate caregiver who respects all the dimensions of a patient’s life – mental, physical and spiritual. Our CME systems need to foster such well-rounded medical practice and provide environments in which this medically appropriate, evidence-based care can be taught so as to improve the care family physicians provide to their patients.

As Matthews concluded in his recent systematic survey of the medical literature “…the available data suggest that practitioners who make several small changes (emphasis mine) in how patients’ religious commitments are broached in clinical practice may enhance health care outcomes.”⁹ Therefore, primary care physicians should carefully read Anadarajah and Hight’s excellent article and consider the “small change” they recommend. They should not be dissuaded by the myopic naysayers who say they neither should nor can practice these basic spiritual skills in their clinical practice.

Family physicians usually desire to draw upon all available resources to help promote their patients’ health. The reemergence of age-old spiritual principles and their appropriate use in clinical medicine is new to many practicing family physicians – but can and should be taught and practiced by family physicians in any practice situation. These basic spiritual skills are just too important to be left to the chaplains. Let’s don’t.

[1] Anadarajah G, Hight E. Spirituality and medical practice: Using a practical tool for spiritual assessment. Am Fam Physician 2000:__________.

[2] Sloan RP, Bagiella E, VandeCreek L, Hover M, Casalone C, Jinpu Hirsch T, Hasan Y, Kreger R, Poulos P. Should physicians prescribe religious activities? N Engl J Med 2000;342(25):1913-6.

[3] Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 2000;132(7):578-83.

[4] Klein M. Obstetrics is too important to be left to the obstetricians. Fam Med 1987;19(3):167-9.

[5] Waring N. Can prayer heal? Hippocrates 2000;14(8):22-24.

[6] Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians’ attitudes and practices. J Fam Pract 1999;48(2):105-9.

[7] Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-124.

[8] Levin JS, Vanderpool HY. Is frequent religious attendance really conducive to better health?: Toward an epidemiology of religion. Soc Sci Med 1987;24:589‑600.

[9] Maugans TA. The SPIRITual history. Arch Fam Med 1996;5:11-16.

[10] Magaletta PR, Duckro PN, Staten SF. Prayer in office practice: On the threshold of integration. J Fam Pract 1997;44:254-256.

[11] Bearon LB, Koenig HG. Religious cognitions and use of prayer in health and illness. Gerontologist 1990;30:249-54.

[12] Marwick C. Should physicians prescribe prayer for health? Spiritual aspects of well-being considered. JAMA 1995;273:1561-2.

[13] Foglio JP, Brody H. Religion, faith and family medicine. J Fam Pract 1988;27:473-74.

[14] Mulligan T. Must physicians ignore God? J Am Geriatr Soc 1995;43:944-45.

[15] Maugans TA, Wadland WC. Religion and family medicine: A survey of physicians and patients. J Fam Pract 1991; 31:210‑213.

[16] Post SG. Ethical aspects of religion and health care. Mind Body Med 1997;1: 44‑48.

[17] Wallis C. Faith and healing. Time, June24, 1996:58-63.

[18] McNichol T. The New Faith in Medicine: Believing in God May be Good for Your Health, According to this Research. USA Weekend, Apr 5‑7, 1996:4‑5. (Poll of 1,000 adults by ICR Research Group).

[19] King DE,  Bushwick B. Beliefs and Attitudes of Hospital Inpatients About Faith and Prayer. J Fam Pract 1994;39:349‑352.

[20] Wallis C. Faith and Healing. Time, June 24, 1996:62.

[21] Shafranske EP, Malony HN. Clinical Psychologists’ Religious and Spiritual Orientations and Their Practice of Psychotherapy. Psychotherapy 1990;27:72‑78.

[22] Puchalski CM, Larson DB. Developing curricula in spirituality and medicine.

Acad Med 1998;73:970-4.

[23] Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine: research and education. JAMA 1997;278:792-3.

[24] Osler W. The faith that heals. BMJ 1910, June 18:1470-2.

[25] Kornhaber. Newsweek, 1992, January 6:40.