American College of Physicians: Internal Medicine — Doctors for Adults ®

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How housestaff blend spirituality and science

From the December 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Christine Wiebe

  • Previously published ethics case studies are available online.
  • For additional ethics resources, visit the College's Center for Ethics and Professionalism

When resident Michael Goldrich, MD, learned he was scheduled to do a vasectomy during his surgical rotation, he faced an unusual dilemma: As an orthodox Jew, he is forbidden from performing such procedures. After consulting his rabbi, he asked to be excused from the surgery. The attendings initially were reticent, he recalls, but they eventually found a replacement for him.

Similar dilemmas for primary care practitioners might arise over such moral dilemmas as whether or not to refer patients for abortions or about advising families about discontinuing life support. For example, one hospital physician decided he could not disconnect a patient's ventilation according to the family's wishes, recalls David Schiedermayer, FACP, associate professor of medicine at the Medical College of Wisconsin. The physician contacted the hospital ethics committee, which asked another physician to perform the task, he says.

In such situations, residents should be allowed to take a stand, even step aside for another physician, says Father James F. Bresnahan, PhD, professor and co-director of the medical ethics and humanities program at Northwestern University Medical School. "For me there is no doubt that physicians need to be people of conviction," he says.

Resolving such moral dilemmas is not easy, however. For example, Dr. Goldrich, a sixth-year resident in otolaryngology at the Manhattan Eye, Ear and Throat Hospital, is struggling with the issue of plastic surgery, an important component of his specialty. Even though his religion grants special dispensation during residency, he still feels conflicted doing procedures he knows his religion forbids once he's in private practice. "I'm still conflicted internally about some of the procedures I have to do," he says, explaining that Judaism restricts surgery that is strictly for aesthetics. He talks regularly with a rabbi who specializes in medical issues as he tries to sort out the dilemmas.

Peace of mind

More commonly, however, residents experience subtle tensions over how to integrate spiritual beliefs with the scientific practice of medicine. Unfortunately, some physicians say, religion is largely ignored in medical training, even though patients and residents could benefit by bringing the topic to the fore.

Residents at the University of Iowa Hospitals and Clinics in Iowa City frequently work with critically or terminally ill patients and are called upon to counsel patients' families, says Clayton Cowl, ACP Associate, a fellow in pulmonary critical care. To do that, "It's important to understand your own beliefs," he says. However, some residents have not yet reached that point. "If you do not have your own spiritual beliefs together, it makes it much more difficult and uncomfortable," he says. "Often we get so busy that we don't even think about the difficult issues we're experiencing."

In fact, medical students and residents could complete their entire training without hearing any mention of religion unless they encounter a professor, attending or mentor who introduces the topic. "It's something I bring up regularly with medical students at some point in their training," says John Clarke, FACP, associate professor of medicine at Northwestern University Medical School.

Most of his students experience at least one patient death during rotations at the VA hospital, he says. "They recognize they're encountering eternal issues that don't always lend themselves to the limits of our scientific knowledge," Dr. Clarke says. He tells them that the Bible helps him deal with many questions, and encourages them to "return to the faith of their fathers" to search for their own answers.

Although some students show no interest in pursuing the subject, about half have been very open to the idea, Dr. Clarke says. In fact, several students have thanked him for raising the issue because they thought being a doctor and having faith were mutually exclusive, he says.

Medicine is an extremely demanding job with a high emotional price tag, Dr. Clarke says, and medical training is an important time for students and trainees to sort out their spiritual beliefs and to acknowledge their own vulnerabilities. "They need to consider what their lifestyle is going to be like and what their everyday defenses are going to be," he says. Religion, he says, offers an opportunity to grow while confronting life and death issues.

Treating the whole patient

Beyond the personal benefits residents can derive from examining their own spirituality, some educators believe patient care also can be enhanced by addressing patients' religious beliefs.

"We practice as if people's faith has nothing to do with how we treat them," says Dr. Schiedermayer, FACP. "It's like ignoring that they're married or if they have a job."

Dr. Schiedermayer, who is also a member of ACP's Ethics and Human Rights Committee, believes that attempts to separate religion and state have made people afraid to talk about religion, assuming it is something that interferes with doctor-patient relations. "[Patients] don't leave their faith at the door," he says. "If you choose not to ask [about their faith], you're sending a powerful message."

He suggests addressing the issue while discussing a patient's social history, with a question like, "Do you have a particular faith tradition?" Such a question would flow naturally from others about habits such as smoking and drinking. The information would not necessarily affect the patient's care, but it might become important depending on the course of treatment, he says.

Dr. Schiedermayer, who wrote "Putting the Soul Back in Medicine," regularly addresses this issue with students and residents. He says it is regrettable that some widely distributed history and physical forms do not include a spot for recording religious affiliations. He recognizes that some physicians are afraid they will insult patients by raising the question, but, he argues, "If we can ask about anal sex, we can certainly ask if that's a Bible on their bedstand."

Probably the most common approach is referring patients to their own clergy or to the hospital chaplain, says Scott Solcher, ACP Member, a renal fellow at the University of Kansas Medical Center in Kansas City. Although that is an accepted practice, particularly for terminally ill patients, residents are not explicitly taught what to do, he says.

In fact, residents are largely left to make their own personal judgments about whether and how to broach the subject of religion, Dr. Solcher says. "Maybe we should do more outreach," he suggests, "but it's hard to do unless everyone has the same beliefs."

Of course, many physicians avoid the subject of religion because they are concerned about offending patients' beliefs. In fact, some medical faculty believe religion has no place in medical training, says Dr. Schiedermayer.

Unfortunately, he says, the fear of offending patients often prevents physicians from making potentially meaningful relationships. Many patients seek spiritual contact with their physician, he says, even if they do not articulate it. For instance, he tries to acknowledge religious holidays his patients celebrate.

A fine line

At the same time, almost everyone agrees there is a fine line between appropriate professional contacts and inappropriate proselytizing. "It would be selfish of the person who's found something good not to share it," Dr. Schiedermayer says. "However, it would be cruel to impose it on someone." He acknowledges that the line might be grayer in a physician-patient relationship because of the power imbalance, but he insists it is no different from other issues that physicians have to approach delicately.

"I do discourage residents from overtly proselytizing," Dr. Schiedermayer says. "I think that is over the line." In the past 10 years, he adds, he has encountered only one case where a resident overstepped that boundary.

The key, educators say, is for residents to be sensitive to the patient's needs, and to respond appropriately. Although that may be a sensitive area, they say, residents generally are responsive and understand that not everyone shares their views.

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

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