In backward-elimination multivariable analyses, believing that one should play a role in patients’ spiritual or religious lives was associated with greater organized religious activity (OR 1.55, 95% CI 1.20–1.99), older age (OR 1.11, 95% CI 1.02–1.21), and greater spiritual well-being (OR 1.05, 95% CI 1.02–1.08, C-statistic = 0.76; see Table 5). Believing that a doctor should be aware of patients’ spiritual and religious beliefs was only associated with program type, with internal medicine residents being less likely to agree with the statement than were family medicine residents (OR 0.25, 95% CI 0.10–0.63, C-statistic = 0.66). Believing that it is important to a patient that his or her doctor has strong spiritual beliefs was associated with higher levels of both positive (OR 1.23, 95% CI 1.15–1.32) and negative (OR 1.18, 95% CI 1.01–1.39) religious coping (C-statistic = 0.78).
Asking about patients’ spiritual and religious beliefs
Eighty-two (36%) residents felt that they should ask patients about spiritual and religious beliefs during an office visit, but 175 (77%) felt they should ask about spiritual and religious beliefs if the patient was near death (p < .0001). Family medicine residents were more likely than were other residents to agree with asking about patients’ spiritual and religious beliefs in each of the three clinical settings (see Table 5). For office visits, for example, factors associated with favoring asking about patients’ spiritual and religious beliefs in univariate analyses included family medicine residency, fewer years of residency (lower PGY level), better self-rated health, fewer depressive symptoms, greater spiritual well-being, greater religious activity (organized, nonorganized, and intrinsic religiosity), and greater levels of positive religious coping. In backward-elimination multivariable analyses, internal medicine (OR 0.14, 95% CI 0.05–0.41), pediatrics (OR 0.24, 95% CI 0.09–0.64), and internal medicine/pediatrics (OR 0.24, 95% CI 0.07–0.81) residents were much less likely than were family medicine residents to agree with asking about patients’ spiritual and religious beliefs during a routine office visit. PGY (OR 0.68, 95% CI 0.47–0.98) and spiritual well-being (OR 1.05, 95% CI 1.02–1.08) were also significantly related to agreeing with asking patients about spiritual and religious beliefs during a routine office visit. The C-statistic for the logistic regression model was 0.74.
Sex and race were inconsistently associated with asking about beliefs. Men were less likely than were women to agree with asking about the spiritual and religious beliefs of hospitalized patients (OR 0.50, 95% CI 0.27–0.92), while white residents were more likely than were nonwhites to agree with asking about the spiritual and religious beliefs of dying patients (OR 2.40, 95% CI 1.15–4.99).
Prayer in the clinical encounter
Across all patient settings, residents were less likely to agree with praying silently than with inquiring about beliefs, and were least likely to agree with praying aloud with a patient (see Figure 1). Residents were more likely to agree with praying (silently or aloud) in the clinical encounter as the gravity of the patient's condition increased. Eighty-seven (39%) residents agreed with praying with a dying patient, while only 26 (12%) agreed with praying with a patient during a routine office visit (p < .0001).
Of the three instruments used to assess residents’ spirituality and religiosity, scores on the Brief RCOPE subscales were most frequently associated with agreement about prayer in the clinical encounter, particularly for saying a silent prayer for a patient during a routine office visit and praying (aloud) with a patient during a routine office visit. For silent prayer, positive religious coping was the only significant variable in the logistic regression model (OR 1.40, 95% CI 1.27–1.54; C-statistic 0.87). In the multivariable analysis for praying (aloud) with a patient during a routine office visit, only positive religious coping (OR 1.30, 95% CI 1.16–1.47) and religious discontent (OR 0.70, 95% CI 0.52–0.94) were associated with favoring praying (aloud) with a patient during a routine office visit (C-statistic 0.84).
Trends from additional multivariable analyses
Additional multivariable analyses illustrate general trends in how three different types of resident characteristics help to predict responses to the 12 outcome statements (see Table 6). In models testing only demographic variables, C-statistics ranged from 0.54 for agreeing with praying with a patient who is dying to 0.69 for agreeing with praying with a patient during a routine office visit. For models adding residency characteristics, C-statistics ranged from 0.61 for agreeing with saying a silent prayer for a patient who is dying to 0.76 for agreeing that physicians should be aware of patients’ spiritual and religious beliefs. Finally, for models adding the spiritual and religious variables to the prior models, C-statistics ranged from 0.73 for asking a hospitalized patient about his or her spiritual and religious beliefs to 0.91 for agreeing with saying a silent prayer for a patient during a routine office visit.
Studying physicians’ beliefs and behaviors regarding spirituality and religion in clinical encounters with patients is important because, on the one hand, a majority of the American public and patients believe that spirituality, religion, and health are connected, while on the other hand, there is disagreement about how health care professionals, specifically physicians, should take this belief into account.7,34,44–46 In a cohort of primary care house officers at a large training institution, we found that almost half of the residents felt that they should play a role in patients’ spiritual or religious lives. The percentage of residents who agreed with specific types of spiritual and religious involvement varied greatly by patient setting and by specific activity. Residents’ own spiritual and religious characteristics, especially levels of positive religious coping, were associated with favoring incorporating spiritual and religious activity in general, and especially with incorporating praying (silently or aloud) into clinical encounters.
As demonstrated in the multivariable analyses, only a small amount of the variance in residents’ responses to outcome statements could be explained by residents’ demographics. Residents’ age, sex, and levels of significant depressive symptomatology were all significantly associated with certain statements, but these isolated results are likely spurious because they do not follow any logical trends. Adding residency-related variables to the analyses explained more of the variance, most likely due to differences between family medicine residents and residents in other programs. Family medicine program type was significantly more strongly associated with agreeing with asking about spiritual and religious beliefs in all three clinical settings when compared with other programs. Substantially more variance in residents’ responses to outcome statements was explained by considering residents’ own spirituality and religion.
Ours was the first study to assess physicians’ spiritual and religious coping patterns in the context of their beliefs regarding spirituality and religion in the clinical encounter with patients. We found that higher levels of positive religious coping with the stresses of residency were associated with favoring most of the spiritual and religious activities in the clinical encounter. One subscale of negative coping patterns—religious discontent—was negatively associated with favoring praying with patients, except in the case of dying patients. Surprisingly, both greater levels of positive religious coping and negative religious coping were associated with a greater likelihood of believing that it is important to a patient that his or her doctor has strong spiritual beliefs. The finding of more frequent significant associations between religious coping and agreement with spiritual and religious activities in clinical encounters than between the other measures of spirituality and religion and the outcome statements suggests that religious coping may be a more meaningful variable to study in this context. The tendency for physicians to use religious coping mechanisms in a positive way in their own lives seems to be predictive of their attitudes toward favoring using spiritual and religious coping strategies (i.e., discussing beliefs or praying) with patients.
Our other findings corroborate and expand upon previous research.27–29,32 The RSME Study Group asked similar questions of a cohort of family practitioners and internists in residency or fellowship training, academic practice, or private practice.29 In their study, 31% of physicians felt that they should ask about spiritual or religious beliefs in an office setting and 74% felt they should ask about spiritual or religious beliefs if the patient was dying. Only 6% felt they should pray with a patient in the office, and 27% felt they should pray with a dying patient. Those percentages are slightly lower than corresponding percentages in our study. As in the RSME study, our physicians’ attitudes depended heavily on the clinical setting and specific behavior. Associations with favoring spiritual and religious involvement in the RSME study included training in family medicine and having a greater level of spiritual well-being.
Whereas the RSME Study Group found a consistent association between family medicine (versus internal medicine) residency and almost all of the primary outcome statements, we found a consistent association between family medicine (versus internal medicine, pediatrics, and internal medicine/pediatrics) specialty and agreement with asking patients about spiritual and religious beliefs across the spectrum of clinical settings, but we did not find consistent associations between specialty type and agreeing with saying silent prayers or praying with patients. There is some evidence that family practice residency programs emphasize learning about patients’ spiritual beliefs and acquiring skill in spiritual history-taking more so than residency programs in other primary care specialties: Such skills are included in the “Recommended Core Educational Guidelines for Family Practice Residents” published by the American Academy of Family Practice under the topic of “Health Promotion and Disease Prevention,”47 but are not explicitly included in curricula promulgated by internal medicine and pediatrics training organizations.
Two studies of pediatricians have compared faculty and resident attitudes versus experiences with religion and spirituality in the medical encounter.27,28 Those studies suggest that attitudes of residents are different from attitudes of faculty, and suggest a greater level of comfort with spiritual and religious issues among pediatricians than other investigators have found among internists and family practitioners. Siegel and colleagues28 found that 93% of pediatrics faculty and residents would ask about spirituality and religion when discussing life-threatening illness. A strong personal spiritual and religious orientation was associated with believing that spirituality and religiosity and medicine are connected, but was not associated with reports of actions; also, residents were more likely than were faculty to say it is appropriate to pray with patients if asked. Armbruster and colleagues27 surveyed 46 faculty and 44 residents and found that faculty were more likely than were residents to ask new patients about religious affiliation, but residents were more likely than were faculty to be asked to pray during health crises (61% of residents versus 28% of faculty said they were asked to pray “often” or “sometimes”), to believe that spirituality and religion have health relevance, and to perceive pediatrician-initiated prayer as appropriate. We did not find a trend for pediatrics residents to be more likely than other primary care residents to agree with spiritual and religious inquiry or prayer with patients; if anything, pediatricians were much less likely to endorse those activities than were family physicians. The reason for the much higher overall level of agreement with asking about the spiritual and religious beliefs of a dying patient in Siegel and colleagues’ study is unclear. Both our study and theirs used similar questions and surveyed physicians working in large urban children's hospitals.
While training program type was associated with opinions regarding asking patients about their spiritual and religious beliefs, opinions regarding prayer in the clinical encounter were only associated with residents’ tendency to use religious coping strategies in their own lives. An increased tendency to agree with asking patients about their spiritual and religious beliefs among “newer” (lower PGY level) residents may be explained by an increased emphasis on spirituality and religion in medical school training in recent years. Another explanation might be that senior residents are likely to be less thorough history-takers, in general, than are newer residents because senior residents are generally responsible for more patients and have less time to spend with each.
Additionally, agreement with prayer in the clinical encounter may be explained by transference of residents’ personal coping strategies to their patients. Transference could also help explain why higher levels of positive religious coping are associated with believing that it is important to a patient that his or her doctor has strong spiritual beliefs. For the less specific question about whether a physician should play a role in patients’ spiritual and religious lives, general measures of spiritual well-being and organized religious activity replaced the RCOPE subscales in multivariable analyses as significantly associated variables. As in a previous study of physicians’ attitudes regarding spiritual and religious behavior in patient encounters,29 rates of favoring silent prayer and praying aloud with patients were significantly lower than rates of favoring spiritual and religious inquiry, and residents’ agreement with each activity increased as the gravity of the patient's clinical situation increased.
It is interesting to note that although 90% of the residents surveyed in our study agreed that physicians should be aware of patients’ spiritual or religious beliefs, less than 40% agreed that they should ask about beliefs during a routine office visit, and less than 80% agreed with asking about beliefs even when a patient is near death. It is unclear how physicians expect to become aware of patients’ beliefs if they do not ask about them, but it is possible that residents and other physicians would be more comfortable obtaining this information from a written intake form than obtaining it verbally from patients. Alternatively, it is possible that residents would be comfortable asking about spiritual and religious beliefs if they knew how to address it quickly during routine history-taking; Puchalski and colleagues12 have developed a four-question instrument for such purposes.
Our study had several limitations. One was the large number of variables, both independent and dependent, that we analyzed which may have yielded spurious findings. Second, we modified measures of spiritual well-being and religious coping strategies that were developed for use in patients with chronic disease, and used them in a group of participants who (we presumed) did not have chronic disease. Furthermore, although 73% of our respondents were Christian, comments written in the margins of the questionnaires suggested that some respondents were uncomfortable with the perceived Christian slant to our study instruments. Perhaps other types of spiritual and religious practices, such as referral to a chaplain, would be more acceptable to residents than would be saying a silent prayer or praying with a patient.
In the survey questionnaire we used, we did not differentiate between patient-requested prayer and physician-initiated prayer, a potentially important distinction, as physician-led prayer has been discouraged by some because of the risk of potential coercion or proselytizing.9,14 In their survey of physicians, the RSME Study Group included questions starting with the preface “If the patient requests” (e.g., “If a patient requests, an MD should say a silent prayer for the patient” or “If a patient requests, an MD should pray with the patient”), and found that physicians were more likely to endorse prayer if asked, but 23% of physicians still disagreed with praying with a patient near death even at the patient's request, perhaps because of ethical conflicts that physicians have regarding praying with people with spiritual backgrounds different from their own or from not being comfortable with that level of intimacy with a patient. Nevertheless, with a 2001 poll showing that approximately 50% of respondents would like their doctor to pray with them during times of illness,48 some physicians and medical educators would likely support training about praying with patients so that physicians can at least respond to requests sensitively and respect patients’ needs without compromising their own values and beliefs.
Although univariate analyses suggested some trends for black residents to endorse some activities more than did nonblack residents, we did not have enough black residents in our sample size to stratify by black race in multivariable analyses. Instead, blacks were classified with Asians as “nonwhites,” even though Asians appeared to respond more like whites in univariate analyses. Although univariate analyses also suggested differences between Protestant, Catholic, Jewish, other religious, and secularist residents in responses to several outcome statements, the small numbers of non-Christians in our sample prohibited us from stratifying religious affiliation in multivariable analyses beyond dichotomization into Christian and non-Christian. The trend for Jews to more closely resemble secularists than Christians in univariate analyses is consistent with recent studies demonstrating that religious affiliation is less predictive of strong beliefs in the areas we studied for Jews than it is for Catholics or Protestants.35,36 In addition, the small number of family medicine residents surveyed (no. = 27; 12% of total sample) limits the generalizability of our findings of differences between family medicine residents and other residents. Finally, our study was limited to house officers at one medical center in the midwestern United States, and our results may not be applicable to trainees at other centers in other parts of the country. It is encouraging, however, that we found results similar to those obtained by the RSME Study Group conducted at medical centers in the southeastern and northeastern United States.
Our study also had several important strengths. We were able to collect data from a large number of house officers and had a response rate of 92%. Internal medicine, pediatrics, family medicine, and internal medicine/pediatrics trainees represent the breadth of primary care residents and their beliefs have not been directly compared previously. We used three different instruments to measure resident spirituality and religiosity in order to examine different facets of spirituality and religion and their relationships with attitudes concerning spiritual and religious activities in the patient encounter. To our knowledge, ours is the first study to look for an association between religious coping among physicians versus attitudes regarding spiritual and religious activities in the physician–patient encounter.
In conclusion, approximately half of primary care residents in our study believed that they should play a role in their patients’ spiritual and religious lives. Spiritual and religious coping patterns and training program type—specifically family medicine (versus other primary care program types)—appear to have been important factors in residents’ attitudes about incorporating spirituality and religion in clinical encounters. Further studies are needed to examine other ways in which primary care residents feel they could or should play a role in the spiritual and religious lives of their patients.
The authors are grateful to Kenneth Pargament, PhD, of Bowling Green State University, for helping to adapt the Brief RCOPE. The authors are also grateful to the anonymous reviewers who provided valuable comments on an earlier version of this manuscript. This project was supported by the National Center for Complementary and Alternative Medicine (grants R01 AT001147 and K24 AT001676), and Health Services Research and Development, U.S. Department of Veterans Affairs (grant # ECI 01–195). Dr. Yi is supported by a National Institute of Child Health and Human Development Career Development Award (grant # 1K23HD046690-01A1). Dr. Mrus is a recipient of a Career Development Award (grant # RCD 01011–2) from the Veterans Affairs Health Services Research and Development Service.
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