God in five minutes or less

First of all, I wouldn't know what I'm doing, but mostly I don't have enough time!
--A typical doctor's reasons for not addressing a patient's spiritual concerns.

Some 77% of patients want their physicians to address their spiritual concerns, but only a tiny fraction of doctors actually do, according to one study clinical psychologist Jean Kristeller cited at this week's Spirituality in Health Care Education conference.

To me, this kind of statistic is the most convincing kind of empirical evidence for integrating spiritual care into the health care system as well as making it a part of the way doctors and other medical personnel are trained. In contrast, trying to measure (in a scientific way) whether spiritual care (and/or prayer) actually improves people's health -- as critics of spirituality in medicine like Columbia University's Richard Sloan have pointed out -- has turned out to be extremely difficult.

But the patient's desire for this kind of treatment from their physicians should be enough of a reason to demand that doctors do do this (not to mention the fact that there are probably benefits that are not so easily measured with the tools of science). And, as Kristeller points out, the fact that some 10% of patients are uncomfortable with their doctors inquiring about this, is hardly reason enough to deprive the overwhelming majority who do. And since when do we say it is ok for doctors to avoid certain subjects with their patients because it makes the patient uncomfortable? Many people are uncomfortable being asked about their sexual history, but such questions are part of any standard medical history taking.

But that is not to say that the discomfort that some people may feel in being asked about their spirituality is not something that should be treated seriously. It also doesn't mean that physicians' concerns about their time shouldn't be taken seriously.

So, is it possible to train physicians to ask about spiritual concerns in a way that minimizes patient discomfort and that doesn't take a lot of time?

Kristeller says, yes. In an article she co-wrote with professor Leonard Hummel, she describes an interview script that she came up with for doctors to guide themselves through an effective spiritual interview that only takes five to six minutes (thus the title of this blog entry!). The script was used as part of their Oncologist Assisted Spirituality Intervention Study (OASIS). [The article can be found in the recent book Spiritual Transformation and Healing: Anthropological, Theological, Neuroscientific, and Clinical Perspectives]

Here is what the script looks like:

• 1) Introducing the issue in a neutral manner
• "When dealing with a serious illness, many people draw on spiritual or religious beliefs to help cope. It would be helpful for me to know how you feel about this." (emphasis, mine)
  
• 2) Four paths to inquiring further, based on how the patient responds:
• a) If the patient says they definitely have been helped to cope by their spirituality (a "postive-active" response) -- then the doctor responds, "What have you found most helpful about your beliefs since your illness." (emphasis, mine)
• b) If the patient gives a more "neutral-receptive" response -- "How might you draw on your faith or spiritual beliefs to help you?"
• c) A "spiritually distressed" response (such as anger or guilt) -- "Many people feel that way . . . what might help you come to terms with this?"
• d) A "defensive/rejecting" response -- "It sounds like you're uncomfortable . . . What I'm really interested in is how you are coping. Can you tell me about that?"
• This strikes me as an important part of the script for the doctor. It addresses the doctor's fear that he or she might offend the patient by bringing this up and gives them a graceful way out of that discomfort.
  
• 3) Continue to explore further (based on the response in 2, above)
• 4) Ask about the patient's ways of finding meaning and hope.
• 5) Ask about the patient's resources/support system -- " do you have anyone you can talk to about these concerns?"
• 6) Offer assistance where appropriate.
• Refer to support group, and/or chaplain, etc. (Or even to a book to read.)
  
• It seems to me this is another particularly important part of this script from the perspective of the doctor. It addresses the doctor's fear that they may get stuck talking with this patient for a long period of time (that is, it gives them an 'out').
  
• 7) Conclude -- "Thanks for talking with me about this. May I ask you about it, again?"
  

Overall, I really like this script (and think it might even have application -- in a modified form -- for chaplaincy volunteers and students), but I have some criticisms and concerns:

• It is both belief and coping centered
• Belief -- This strikes me as a typically Christian assumption (that the essence of religion or spirituality is about belief; that is, that it is something that involves primarily thoughts). Yet, practices (including rituals) can be a much more important defining factor of many faith traditions and spiritualities. Ultimately, the defining factor in spirituality is about meaning, and meaning can come from many things other than a pattern of beliefs, including membership in a community and a set of rituals (see my blog entry on the definition of spirituality ).
  
• Coping -- It is kind of maddening to a person (such as myself!) to see a thousands-year old system of faith (that one has devoted one's life to) reduced to a coping mechanism (as if it was the same thing as taking a pill!!). I don't worship God because God helps me cope -- I worship God because of my awe for God and my sense of submission to God's rule and commandments. It is something Holy to me, not a (mere) coping mechanism! And this, too, is what I seek to bring to patients -- something Holy, and not just a substitute for a pill!
• It does not well address spiritual distress (2c)
• A patient in spiritual distress is very often not at all ready to start talking about coping mechanisms (which is essentially what questions 4 and 5 are about). The pastoral care way to deal with a person in spiritual distress is -- ala Henri Nouwen's classic, The Wounded Healer -- to "deepen their pain." That is, to (before moving on to coping) help the patient explore the reasons for their pain/distress, and to heal by helping the patient feel less alone in their suffering.
  
• Granted, deepening the pain is probably beyond the scope of the physician (who, unlike a trained chaplain, is not an expert at this kind of difficult spiritual exploration). It is also a task probably beyond the limits of the five-seven minute goal of the OASIS scripted interview. Thus, this is a good place to refer to a chaplain (or perhaps a social worker and/or therapist) and perhaps the OASIS script should be modified to reflect this.
• The script does not directly address the key issue of hope.

Another concern is about properly training the doctors who do this. Kristeller says the doctors in the OASIS study were trained for two to three hours. She also points out that there is also an underlying assumption that the doctors involved are capable in basic (patient-centered) counseling techniques (although, it seems most medical school curriculums now have at least some basic counseling training in them).

But I have some concern that the script might actually be counterproductive in terms of good counseling techniques being used. As Fred Lee, a health care consultant (and author of fIf Disney Ran Your Hospital: 9 ½ Things You Would Do Differently) says, compassion means going beyond what you say. Focusing on what you say -- as a script does by its nature! -- means that you don't move beyond courtesy. But, certainly, in an encounter where a doctor is asking about a patient's spiritual concerns you, of course, want to move beyond courtesy to compassion. Lee -- whose work has become very influential at our hospital -- says that compassion is about what you feel. And the enemy of compassion is judging the patient. [It should be said, as well, that the OASIS script properly used is not meant to be stuck to word-for-word.]

All this also makes me curious about the focus on doctors. Could a script like this be used by nurses, or even admissions clerks. Or is there something about the doctor -- with all the authority that role bestows on him or her -- asking about these questions that is particularly healing?

Speaking of healing, Kristeller and Hummel note (pg. 276) that what they found to be healing about the OASIS approach for patients was not "prayer with patients, nor altering their treatment, nor even referral for spiritual counseling [but, rather] simply asking them a series of questions about their spiritual and religious resources." (emphasis, mine)

That is, it was the physician listening to the patient that helped! A book I would highly recommend for doctors (or chaplains and other educators of doctors) who are interested in improving their listening skills is Barry Bub's Communication Skills that Heal. Bub's book isn't packed with the statistics and careful research that Kristeller's work is. Rather, it is a a practical guide written by a doctor for doctors. But like Kristeller, he maintains that a mere five minutes or so is enough to help a patient feel profoundly listened to by the physician.

Bub also addresses a vital issue that I haven't seen from Kristeller -- how this might be healing for the physician as well. That is, it might help reawaken in the overstressed, burned out, jaded doctor the very idealism -- I want to help people! -- that might have been the very thing that brought him or her into medicine in the first place. [If you're interested in hearing more from Bub without buying his book he is featured in the "Healing Healthcare" podcast you can find on this page.]

This possibility of healing through listening is also very much touched on by what Kristeller and Hummel (derisively?) describe as the "theoretical musings of Rita Charon (2004) about the importance of narrative and empathy in the practice of medicine." (pg. 276)

There was another fascinating speaker at the conference -- professor Elizabeth R. Mackenzie -- who spoke in detail about her own use of narrative. I hope to write more about what she spoke about in the coming days.

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A final question I want to touch on is how chaplains fit into all of this. There is some anxiety among chaplains about physicians (and psychologists, social workers, nurses, etc.) getting involved in spirituality in medicine. I think there are two foci for this anxiety:

• 1) They're taking our jobs!
• 2) They're doing it all wrong!

It's the second of these anxieties that I think is most worthy of reflection, and I think it comes to the heart of one of Columbia University professor Richard Sloan's objections to doctors being involved in spirituality (see, this article). Sloan is concerned that a doctor might not properly understand the coercive nature of the authority built into his or her role. That authority -- he says -- is proper when the doctor is recommending a medical treatment ("you must take this pill if you want to live!"), but not when matters of belief or religion are involved (as we, as a nation, believe in freedom of religion).

In clinical pastoral education, of course, we are very concerned with helping chaplains understand how they carry this kind of authority and how that impacts the spiritual care they do with patients. Anybody who has been involved in this part of the pastoral education process knows how very hard it is to come to well understand the authority one carries and how that might intimidate or coerce a patient; it is hard for me to believe that such an understanding can be met in the kind of short training session OASIS uses.

I am especially concerned because of the spiritual work I have seen some doctors and psychologists doing in health care settings. Sometimes there seems to be a very poor awareness of how the caregiver's own belief systems are being imposed on the patient. Either that, or the caregiver is just not giving enough value to the importance of the discipline of keeping one's own religious values under control in an interfaith and/or secular setting.

In clinical pastoral education we work very hard to train future chaplains and clergy to be aware of these issues. We know how much damage can be done to folks -- especially the kind of folks who have been wounded by their clergy (by sexual abuse or less onerous coercive and inappropriate behaviors) when they were children or otherwise vulnerable -- by imposing your belief structures on them. We know how important it is to allow people to voice anger at God or religion. It is painful to us to see people engaging in spiritual caregiving without the kind of training we have undergone in being sensitive to these issues.

Getting back to the first anxiety ("they're taking our jobs!"), the evidence seems to indicate that this fear is misplaced, at least with doctors. The OASIS study data said that 85% of the doctors in the study felt that a chaplain was the ideal person to be involved regarding a patient's spiritual concerns.

And, a study mentioned at the conference by the chief chaplain from the Hershey Medical center, Paul Derrickson, that one of the main effects of making medical students aware of the work of the chaplain was to dramatically increase the number of times they made referrals to chaplains when they working with patients.

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I think, having now written and reflected on all this at some length that what I would ideally like to see done with something like the OASIS survey is to have chaplaincy integrated into it from the git-go. That is, it's perfectly fine to have a doctor use a tool/interview like this as a form of making a spiritual assessment (and, as chaplains well know and as the OASIS data supports, the spiritual interview/assessment in and of itself has a healing effect on most people). But at defined points in the interview script, there should be triggers to make the interviewer consider referring the patient to a chaplain. In particular, any patient in spiritual distress should be talking to a chaplain.

For many oncology practices, however, this may not be practical at the present time. Chaplaincy (and chaplains) tend to be hospital based. But most cancer care is outpatient these days. This opens up the question for the world of chaplains of how we might be able to become more involved -- and how we might be able to fund that involvement -- in the outpatient care of cancer patients.

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[6/18/07 -- Another method for a physcian to take a "spiritual history" is Christina Puchalski's FICA. Here is an article, in which she cites FICA.]