Is there a place for religion in the exam room?

As part of a family medicine rotation, we recently discussed the importance of bringing spirituality into the hospital. The conversation was led by Stanford Hospital’s chaplain, Dr. Bruce Feldstein, an ER doctor in a former life. We began with definitions of spirituality, discussed personal experiences surrounding a spiritual moment, and concluded with how to take a “spiritual history,” a series of questions that explore patients’ spiritual or religious beliefs.

We even got a practice script that we took turns reading aloud. It went something like, “We have been discussing your support systems. In the past, what sustains you in difficult times? … What are your sources of hope, strength, comfort and peace? … What is your faith and belief? … How would you like me as your doctor to address these issues with you?”

Saying the words aloud made me realize how uncomfortable I was broaching this topic with my patients. I had always thought, and I’m not sure why I had this notion, that doctors were not supposed to talk about religion with patients. Much like other polarizing topics such as politics, religion seemed to be a taboo topic that made interactions between doctors and patients more unprofessional.

It could either go really well and strengthen the doctor-patient bond, or it could go really badly and push the patient further away from his provider. I think of this from a patient’s perspective. Would I feel comfortable discussing my faith with my doctor of a different religion? I would fear that I may color the doctor’s opinion of me due to certain prejudices he may hold, which somehow could affect my medical care. I’ve also never seen a doctor discuss religion with a patient, so I would worry that the doctor would think I am wasting his time.

And what if my doctor were atheist? What would I say to him? How could he possibly understand how and why I am turning to my religion to sustain me through this hospital visit?

I think my takeaway from this class is that the decision to discuss religion depends on what cues I get from my patients. If my patient brings up religion in our discussions, seems comfortable mentioning spirituality with me, or seems to talk about faith and religion with his family when considering medical decisions, then yes, I may explore this topic (though to be honest, I’m not quite sure what it will add to discuss religious topics with me versus with a spiritual figure like a pastor or a chaplain). But if the patient requests it, I will engage. Personally, I still will not actively ask about religious preferences if the patient does not bring the issue up.

For now, religion will remain mostly off limits for me in the workplace.

Joyce Ho is a medical student who blogs at Tea with MD.  She can be reached on Twitter @TeawithMD.

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  • guest

    I wouldn’t want my doctor asking about my religion. That’s not necessary. I’m glad mine don’t do that.

  • Suzi Q 38

    I was getting ready to have surgery to remove a tumor suspected to be cancer and needed to be removed.
    The anesthesiologist came in and introduced himself to my husband and I. He asked us if I wanted to pray with him before the surgery.
    I was surprised that he brought this up, but grateful for his kind words and good wishes.
    We ended up holding hands and praying for about 3 minutes.
    Even though I didn’t think praying was his business, I appreciated his gesture of kindness.

    • Lisa

      I had my first hip replacement at a Catholic hospital. When I checked in they asked me if I wanted to see a priest. I told them no, I didn’t. Well, they sent one around anyhow. He was a nice enough person, but we had nothing to talk about other than the lousy hospital food.

      If one of my doctors asked me if I wanted to pray with them before surgery, I think I’d be worried. Along the lines of is there something they aren’t telling me….

  • Joe

    Be very careful with that. Class or no class, there are some who will want you failed/fired for taking your religious beliefs seriously. And/or will be even more outraged when you try to defend yourself.

    http://www.kevinmd.com/blog/2012/11/religion-patients-practice-medicine.html

    Not trying to discourage you. I’m just saying to be very aware of who your superiors are.

    • Allie

      It definitely cuts both ways, particularly in OB clerkships. Two attendings in my clerkship were to a disturbing degree inappropriate in how they handled women who might be considering abortion due to religious beliefs (a specialist in MFM who seemed to be doing it so she could tell women facing severe fetal abnormalities not to kill their babies). I saw a patient who was considering abortion and was carefully nonjudgmental and accepting of her choice. I was basically told to go back in and “ask her more questions to see if she really knew exactly what she was doing” even though we were not going to be involved in any way in providing her the care she was considering seeking. I refused to participate in woman shaming as part of my medical training. Fortunately, my resident accepted my view and protected me.

  • MedStu

    When I was in the hospital recovering from surgery, a chaplain came around to pray with me, and didn’t give me much choice in the matter– honestly, it made me uncomfortable, as I am not particularly religious in general, and came from a different faith background from the chaplain as well.

    However, we are taught to ask about spirituality in the support systems part of the social history, and I think it can be approached tactfully, after first asking an open ended question about whom the patient gets support from. If you need to follow up: “Are you a spiritual or religious person at all?” If yes, ask “Is that a community you turn to in times of stress?” If no, ask out other communities in the patient’s life that they turn to.

    • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

      I agree. Some of the comments above are about unwanted chaplain visits or invitations to pray, very different (and much more invasive) than simply being asked in an open-ended way about the topic. Statistics show that physicians, on average, are less religious than their patients, so neglecting to ask about this potentially central aspect of life is a type of blind-spot. Some patients will be glad you asked, others will shrug or feel a bit uncomfortable. As you wrote, a sensitive doctor shapes the next part of the interview accordingly — and a really sensitive doctor takes note of what topics are comfortable or uncomfortable for their patient, and learns something about the patient’s personality that way. We treat people, not organ systems.

    • guest

      I don’t want that kind of information in my medical record. I would politely decline to answer any of those questions. I would prefer they focus on my upper respiratory infection or whatever I’m there for. No need to delve into whether I’m religious or not.

  • querywoman

    I’ll take prayer, but some people don’t want it, and we have total freedom of religon in the US.
    I’m Christian, but I’ll be glad to accept prayer from adherents of other religions.
    Because most of my immediate family is gone, I list my minister as my contact and my church tends to me, so it’s obvious with me.

  • Patient Kit

    As a patient, I’m not sure how I feel about this. What I do know is that I can’t explain my spirituality by answering a few quick questions with very brief answers. So, there is this to consider before asking me about my spirituality: It would take some time for me to answer that question.

  • penguin50

    I’m curious about what physicians hope or expect to learn by asking what religion a patient might follow. Brief, pro forma inquiries may yield the name of a religion, but that doesn’t really tell you much, does it? If someone said they belonged to a church, would that mean that you assume they have bountiful social support, and so you therefore would not put them in touch with a social worker when you otherwise might have? (Note: some churches are filled with loving, supportive souls, and others are populated by backbiting, petty individuals, like any other group—you cannot assume anything about the level of genuine support a person might have from their church or synagogue, etc.)

    I just don’t understand what you are trying to ferret out, beyond a few practical things like the Jehovah Witness objection to blood transfusions. Do you assume certain things about certain religions? I feel like in the absence of a concrete explanation of why you are asking, I would merely be subjecting myself to whatever random thoughts or unnamed prejudices you might have about various religions.

    I’ve been asked about religion in a medical context only on hospital admission forms; it led to visits from a chaplain with a very different belief system and who seemed to have little to say to someone who did not share his outlook and vocabulary.

    I have studied religious traditions extensively at the graduate level and could discuss my thoughts about them for weeks with a doctor. Trust me—you don’t want that. Why would you even get me started?

    • MedStu

      You don’t assume that religion is a source of support, you ask if it is, the same way you might ask if a patient’s family lives nearby and if they are close with their family. It’s not about ferreting out anything, just learning whom your patients turn to in times of need.

    • guest

      Part of treating the patient holistically involves badgering them upon hospital admission with a bunch of busybody questions. Someone apparently thought it would be a great idea, so now it’s another box on the EMR that has to get checked. Patients particularly like it when they are asked these endless questions after spending hours in the ER. The data probably ends up in some bar graph presented at some meeting.

    • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

      Thanks for asking. For starters, I want to make clear that filling in a blank on an admission form, inviting unwarranted assumptions about church support, or receiving surprise visits from chaplains are all very far from what I meant. Also, if you are in an ER or urgent-care clinic for a minor, specific complaint and will never see that doctor again, the issue is likely irrelevant and even bizarre.

      The original poster is a medical student learning how to do a basic get-to-know-your-patient interview. My assumption is that she is not training to do assembly-line or vending-machine medicine, but to build real doctor-patient relationships that in many cases may last years or even decades. I guess I was picturing primary care, although this applies in many specialties as well. In that context religion or spirituality may be centrally important to the patient, completely irrelevant, or something in-between. Usually the only way to find out is to ask an inoffensive open-ended question and see what happens. In your case, “I’ve given it much thought, and it’s complicated” would be a fine response, if you felt like saying that. It would probably go no further.

      Why is it important to ask? For one thing, it usually builds rapport. Several commenters here seem to prefer “listen to my chest and lemme out of here” medical care, but that’s not what most people claim to want. They want to be treated as a whole person, not a collection of symptoms on a checklist. You in particular should well know how religion or spirituality can feel like “knowing the real me inside.” Second, the conversation is often fairly pragmatic. While some folks can discuss their theological views for weeks, most people reply that they’re a lapsed Catholic, active in their Episcopalian choir, or attend their synagogue every week. This is no more fraught than asking about regular exercise, yet in a later time of crisis can be very supportive when, yes, the right chaplain is summoned to the bedside, or their church is recognized as a true source of support (if it is).

      The bottom line is that doctors can be faulted either way. As medicine becomes more and more impersonal, it feels strange to have to defend traditional whole person concern. If patients want to be treated like parts on an assembly line, it will be very easy to get that in the coming years. Personally, I’d hate it.

      • guest

        I don’t think anyone is arguing for assembly line medicine. I have great rapport with my primary phsyciain (as with other physicians I’ve seen over the years) without them knowing my religious affiliation. It’s possible to ask what suppoort systems a patient has without asking if they have a particual religious affiliation; that is what I would prefer. Not sure why that’s problematic.

      • EmilyAnon

        Instead of asking ‘what *is* your religious affiliation?’ which might make the patient feel trapped to reveal something they regard as personal, you could just ask ‘would you like me to list a religious affiliation?’

      • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

        This thread has been a real eye-opener for me. Rather than post more long comments here, I wrote a piece for my own blog:
        http://blog.stevenreidbordmd.com/?p=881

        Check it out if you’re so inclined.

  • guest

    Actually, they asked this of patients upon admission at a hospital where I once worked. It did say “Baptist” or whatever in the patient’s medical record. I’ve also seen chaplains make notes in the patient’s medical record, too. All in the name of “holistic” care, the patient of course having no earthly idea what they thought was shared in confidence with the chaplain was ending up in their medical record. No thanks. Blue Cross and the xray technician and everyone else have no need to know what religion the patient is unless the patient chose to share it. Luckily so far I have not been asked about my religion by a doctor, and I would prefer to keep it that way.

  • Suzi Q 38

    “……..Unless the doctor knows for sure that a) you are religious b) you are of the same religion, it’s not the doctor’s place. What is the doctor started a prayer to a flying spaghetti monster or decided to sacrifice a few roosters to a Sun God?”

    I agree that it was somewhat unusual.

    So what.

    What he asked me to do was not so “alien,” “Sun God,”
    or “flying spaghetti monster” to me.

    No, I didn’t feel that his gesture of prayer was a symbol of what he thought his abilities were.

    Yes, I could have chosen to be offended, but I wasn’t, plain and simple.

    Everyone is different.

  • Jennifer G

    Honestly, not only would I refuse to answer, I might walk out.

  • Dave

    I’m afraid I have to disagree and I hope that you will at least try talking about it with some of your patients in the future. Sure, the questions you listed may feel awkward and unnatural for you, but they are just starting points from which you can generate your own that feel more comfortable. Personally, I ask about religion if the patient uses verbiage which suggests he or she is a person of faith, or if the situation otherwise calls for it. I’m pretty well-versed in the major world religions, but when patients have identified as something else it often leads to great conversations when I ask them to tell me about it.

  • DoubtfulGuest

    MedStu, I’d like to add something to the general discussion about this topic, even though I have no problem with what you’re saying. Doctors, please use caution when asking about a patient’s social supports. Anyone could go through periods in our lives in which our support is less than optimal. It’s often temporary and no reflection on us as people.

    It’s very hard for doctors to be objective about this and still diagnose and treat the patient correctly. They can over-interpret things, like a patient’s romantic relationship that became long-distance for employment reasons, is assumed to be the cause of any symptoms the patient might report (i.e. due to loneliness or attention-seeking). Or the patient is assumed to have a personality disorder if not close to their family, when in fact it’s quite common in abusive family situations for the person to be kept isolated from everyone else.

    Doctors can feel overwhelmed by pity, or even genuine empathy, while harboring fears that a patient with sub-optimal support is going to be excessively needy. That isn’t necessarily warranted. Patients still have whatever disease they come in with, they still need care regardless of what else is going on, and they may have reasonable expectations of you even if their background isn’t the greatest.

    • EmilyAnon

      Doubtful, what important points. I never thought that a doctor might judge you on those issues.

      • DoubtfulGuest

        Thanks, Emily. Have a good weekend.

  • buzzkillerjsmith

    Does NFL football count as a religion? How about PAC 12 football?

  • FEDUP MD

    FYI, there are groups that regularly come around and put those in waiting rooms, then teplace them when you take them away. Short of doing a daily sweep it is hard to eliminate them. We are in the South and it’s a huge pain because we come from a variety of traditions, including Jewish, Hindu, and humanist, and it really doesn’t represent us at all.

  • Thomas D Guastavino

    “For now, religion will remain mostly off limits for me in the workplace”
    I guess religion can now be disregarded as part of “culturally competent” care.