Editor’s Note: A shorter version of this article was released in the spring 2015 edition of Today’s Christian Doctor.

---

About 25 years ago, while sharing an early morning cup of coffee with my dear friend and practice partner, family physician John Hartman, MD, he asked, “Walt, how come we don’t bring our faith to work with us more often?”

It was a question the Lord used to convict me of the fact that although my personal relationship with God was the primary and most important relationship in my life, more often than not I tended to leave Him at the door when entering the hospital or medical office.

Over several years, John and I prayed about and explored ways in which we might incorporate a number of spiritual interventions into our practice, including, but not limited to, faith flags, faith stories, faith prescriptions, praying for and with patients, spiritual consults and referrals and incorporating a spiritual assessment.

The fruit we experienced eventually led to my working with William C. Peel, ThM, and CMDA to develop the Saline Solution[1] in the mid-1990s and, more recently, Grace Prescriptions.[2] Feedback from tens of thousands of attendees from these conferences and small-group curricula from around the world indicate that these interventions have revolutionized their witness for Christ and their satisfaction with practice. In the first part of this two-part article, we’re going to explore the basics of spiritual assessment in clinical care.

Are spiritual assessments important?

The value of religiousness and/or spirituality (R/S) to patients and health professionals is underscored by lay polls, medical research, undergraduate curricula, recommendations of professional organizations, government regulations and clinical practice guidelines.

The most recent data from Gallup indicate 86 percent of adults in the United States believe in God and that 78 percent consider religion either very important (56 percent) or important (22 percent).[3]

Similarly, more than 80 percent of physicians identify themselves as Protestant, Catholic or Jewish; 79 percent identify themselves as very or somewhat strong in their beliefs;[4] and 78 percent feel somewhat or extremely close to God.[5] Another informal survey of physicians revealed that 99 percent believe religious beliefs can heal and 75 percent believe others’ prayers can promote healing.[6]

Studies demonstrate that up to 94 percent of hospitalized patients believe spiritual health is as important as physical health,[7] 40 percent of patients use faith to cope with illness[8] and 25 percent of patients use prayer for healing each year.[9]

According to Duke University psychiatrist Harold Koenig, MD, “Nearly 90% of medical schools (and many nursing schools) in the U.S. include something about (religion or spirituality) in their curricula and this is also true to a lesser extent in the UK and Brazil. Thus, spirituality and health is increasingly being addressed in medical and nursing training programs as part of quality patient care.”[10]

Numerous health professional organizations call for greater sensitivity and training concerning the management of religious and spiritual issues in the assessment and treatment of patients.[11] For example, the Joint Commission, whose certification is a requirement for organizations receiving government payment (i.e., Medicare and Medicaid), now requires a spiritual assessment for patients cared for in hospitals or nursing homes or by a home health agency.[12]^,[13]

Guidelines from the Institute for Clinical Systems Improvement state that addressing spirituality “may help in creating comprehensive treatment plans for those with chronic pain,”[14] and guidelines from the National Consensus Project for Quality Palliative Care state that “spirituality is a core component of palliative care.”[15]

Also, the Institute of Medicine recommends, “Physicians and other clinicians must do a better job of caring for patients with advanced illness who are approaching death … (and) should pay more attention to these patients’ social, emotional and spiritual needs.” They propose that a “core component of end-of-life care” includes “frequent assessment of the patient’s emotional, social and spiritual wellbeing” and “attention to the patient’s spiritual needs.”[16]

Health professionals who don’t take a spiritual history are often surprised to learn how frequently spirituality affects their patient encounters and how open their patients are to their inquiry. For example, one study of 456 outpatients at six academic medical centers found that in the ambulatory setting, 33 percent wanted their physician to inquire about religious beliefs and 19 percent wanted their physician to pray with them. However, when dying, this increased to 70 percent who would want their care providers to know their beliefs and 50 percent would want their health professional to pray with them.[17]

Another hospital study showed that 77 percent of inpatients felt that physicians should consider their spiritual needs and 48 percent wanted their physician to pray with them.[18] Other studies have also found that hospitalized or terminally ill patients are much more likely to welcome a spiritual assessment.[19]

In another large national survey, 83 percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77 percent), serious medical conditions (74 percent) and loss of loved ones (70 percent). Among those who wanted to discuss spirituality, the most important reason for discussion was a desire for physician-patient understanding (87 percent). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67 percent), give medical advice (66 percent) and change medical treatment (62 percent).[20]

Another review noted, “In general, the public appears to view and value spirituality as a central factor of life when facing illness and desires healthcare professionals to inquire about beliefs that are important to them;”[21] while another added, “Most patients desire to be offered basic spiritual care by their clinicians,” and, “censure our professions for ignoring their spiritual needs.”[22] Another review concluded, “The majority of patients would not be offended by gentle, open inquiry about their spiritual beliefs by physicians. Many patients want their spiritual needs addressed by their physician directly or by referral to a pastoral professional.”[23]

This patient need only seems to be growing. One recent review found that “studies have shown that (up to) 90% of patients (depending on the setting) want physicians to address their spiritual needs,” and emphasizes that “the ability to identify and address patient spiritual needs has become an important clinical competency.”[24]

Why aren’t more health professionals doing spiritual assessments?

Nevertheless, most ambulatory and hospitalized patients report that no health professional has ever discussed spiritual or religious beliefs with them,[25]^,[26] even though 85 to 90 percent of physicians felt they should be aware of patient spiritual orientation.[27]^,[28] In fact, our most recent national data (now about 10 years old) reveals that only 9 percent of patients have ever had a health professional inquire about their R/S beliefs.[29]

So why do health professionals ignore this “important core competency” of quality patient care? When asked to identify barriers to the spiritual assessment, family physicians in Missouri pointed to a lack of time (71 percent), lack of experience taking spiritual histories (59 percent) and difficulty identifying patients who wanted to discuss spiritual issues (56 percent).[30]

In my anecdotal experience teaching spiritual interventions to health professionals over the last 20 years, I have seen the same concerns expressed time and time again. In fact, CMDA’s Saline Solution[31]and Grace Prescriptions[32] conferences and small-group studies were designed specifically to address these apprehensions.

Yet, one review on spiritual assessment concluded:

Assessing and integrating patient spirituality into the health care encounter can build trust and rapport, broadening the physician-patient relationship and increasing its effectiveness. Practical outcomes may include improved adherence to physician-recommended lifestyle changes or compliance with therapeutic recommendations. Additionally, the assessment may help patients recognize spiritual or emotional challenges that are affecting their physical and mental health. Addressing spiritual issues may let them tap into an effective source of healing or coping.

Furthermore, as Koenig points out, in difficult situations (problems that cause suffering, such as incurable disease, chronic pain, grief, domestic violence and broken relationships), providing comfort to patients can increase professional satisfaction and prevent burnout.[33]

From the perspective of the health professional, a spiritual assessment, included routinely in the patient’s social history, provides “yet another way to understand and support patients in their experience of health and illness.”[34]

How do I do a spiritual assessment?

Before you get started, I must share this caution from Stephen Post, PhD: “Professional problems can occur when well-meaning healthcare professionals ‘faith-push’ a patient opposed to discussing religion.” However, on the other side of the coin, “rather than ignoring faith completely with all patients, most of whom want to discuss it, we can explore which of our patients are interested and who are not.”[35]

Simply put, a spiritual assessment can help us do this with each patient we see. We can potentially gain the following from a spiritual assessment:

• The patient’s religious background,
• The role that religious or spiritual beliefs or practices play in coping with illness (or causing distress),
• Beliefs that may influence or conflict with decisions about medical care,
• The patient’s level of participation in a spiritual community and whether the community is supportive, and
• Any spiritual needs that might be present.[36]

The Joint Commission writes:[37]

Spiritual assessment should, at a minimum, determine the patient’s denomination, beliefs and what spiritual practices are important to the patient … This information would assist in determining the impact of spirituality, if any, on the care/services being provided and will identify if any further assessment is needed.

Several fairly-easy-to-use mnemonics have been designed to help health professionals conduct a spiritual assessment including, but by no means limited to, the SWBS,[38] SIBS,[39] SIWB,[40] HOPE,[41]FICA,[42] SPIRITual,[43] FAITH,[44] CSI MEMO,[45] ACP/ASIM[46] and the Open/Invite[47] tools. Since the mid-1990s, in CMDA’s Saline Solution, we’ve taught the “GOD” spiritual assessment:

• G = God:
  • May I ask your faith background? Do you have a spiritual or faith preference? Is God, spirituality, religion or spiritual faith important to you now, or has it been in the past?
• O = Others:
  • Do you now meet with others in religious or spiritual community, or have you in the past? If so, how often? How do you integrate with your faith community?
• D = Do:
  • What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Or, is there anything I can do to encourage your faith? May I pray with or for you?

However, each of these spiritual assessment tools, including mine, fail to inquire about a critical item involving spiritual health: any religious struggles the patient may be having. A robust literature shows religious struggles can predict mortality, as there is an inverse association between faith and morbidity and mortality of various types.[48] In Part 2 of this article, I’ll review that literature with you and show you a new tool I’m using in my practice to address this factor.

Conclusion
George Washington Crile, Jr. was the son of a famous surgeon who was a founding partner of the Cleveland Clinic. After graduating from Yale and earning his MD from Harvard Medical School in 1933 (summa cum laude and first in his class), he returned to the Cleveland Clinic and became the head of general surgery.[49] In his book Cancer and Common Sense he wrote, “No physician, sleepless and worried about a patient, can return to the hospital in the midnight hours without feeling the importance of his faith. … No physician entering the hospital in these quiet hours can help feeling that the medical institution of which he is part is in essence religious, that it is built on trust. No physician can fail to be proud that he is part of his patient’s faith.”[50]

Sir William Osler, one of the four founding professors of Johns Hopkins Hospital and frequently described as the “Father of Modern Medicine,” [51] wrote “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.”[52]

Psychotherapist Arthur Kornhaber, MD, reflected, “To exclude God from a medical consultation is a form of malpractice. … Spirituality is wonder, joy, and shouldn’t be left in the clinical closet.”[53]

You can experience that driving force of faith when you apply these principles of spiritual assessment in your practice of healthcare, thereby allowing you to minister to your patients in ways you never imagined possible, while also increasing personal and professional satisfaction. One doctor recently shared with me, “Ministering in my practice has allowed God to bear fruit in and through me in new and wonderful ways. I can’t wait to see what He’s going to do in and through me each day. My practice and I have been transformed.”

Are you ready to be transformed? Visit www.cmda.org/graceprescriptions to start learning how to share your faith in your practice.

Look for Part 2 of Dr. Larimore’s article in the fall 2015 edition of Today’s Christian Doctor.

Bibliography

[1] Larimore, W, Peel, WC. The Saline Solution: Sharing Christ in a Busy Practice. Christian Medical & Dental Associations. Bristol, TN. 2000.

[2] Larimore W, Peel WC. Grace Prescriptions. Christian Medical and Dental Associations. Bristol, TN. 2014. See: http://bit.ly/1yAtR1L. Accessed November 21, 2014.

[3] Gallup, Inc. Religion. http://www.gallup.com/poll/1690/Religion.aspx?version=print. Accessed November 21, 2014.

[4] King DE, Sobal J, Haggerty J III, Dent M, Patton D. Experiences and attitudes about faith healing among family physicians. J Fam Pract. 1992;35(2):158–162.

[5] Daaleman TP, Frey B. Spiritual and religious beliefs and practices of family physicians: a national survey. J Fam Pract. 1999;48(2):98–104.

[6] Larimore WL. Providing Basic Spiritual Care for Patients: Should It Be the Exclusive Domain of Pastoral Professionals? Am Fam Physician. 2001(Jan 1);63(1):36-41.

[7] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[8] Koenig HG. Religious attitudes and practices of hospitalized medically ill older adults. Int J Geriatr Psychiatry. 1998;13(4):213–224.

[9] Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4):246–252.

[10] Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012;Article ID 278730.

[11] Puchalski, CM. Taking a Spiritual History: FICA. Spirituality and Medicine Connection. 1999:3:1.

[12] Koenig, HG. Spirituality in Patient Care. Why, How, When, and What. 2^nd Ed. Templeton Press. West Conshohocken, PA. 2007:188–227.

[13] Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The Joint Commission. Oakbrook Terrace, IL. 2010. (This document mentions spirituality throughout, but see especially pp. 15, 21-22, 27, and 85. See: http://bit.ly/1vx3NXAand http://bit.ly/1r668Cj. Accessed November 21, 2014).

[14] Institute for Clinical Systems Improvement. Assessment and management of chronic pain. Institute for Clinical Systems Improvement. Bloomington, MN. 2011.

[15] National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 2nd ed. National Consensus Project for Quality Palliative Care. Pittsburgh, PA. 2009.

[16] Graham J. IOM Report Calls for Transformation of End-of-Life Care. JAMA. 2014;312(18):1845-1847.

[17] MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med. 2003;18(1):38–43.

[18] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[19] MacLean CD, Susi B, Phifer N, et al. Ibid.

[20] McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004(Jul/Aug);2(4):356-361.

[21] Hatch, RL, Burg, MA, Naberhaus, DS, et al. The Spiritual Involvement and Beliefs Scale. Development and testing of a new instrument. J Fam Prac. 1998(Jun);46(6):476-486.

[22] Larimore WL, Parker M, Crowther M. Should clinicians incorporate positive spirituality into their practices? What does the evidence say? (Review) Ann Behav Med. 2002(Feb);24(1):69-73.

[23] McLean, CD, Susi, B, Phifer, N, et al. Patient Preference for Physician Discussion and Practice of Spirituality. Results From a Multicenter Patient Survey. J Gen Int Med. 2003(Jan);18(1):38–43.

[24] Katz PS. Patients and prayer amid medical practice. ACP Internist. 2012(Oct).

[25] King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39(4):349–352.

[26] Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract. 1991;32(2):210–213.

[27] Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163(22):2751–2756.

[28] Luckhaupt SE, Yi MS, Mueller CV, et al. Beliefs of primary care residents regarding spirituality and religion in clinical encounters with patients: a study at a midwestern U.S. teaching institution. Acad Med. 2005;80(6):560–570.

[29] McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004(Jul/Aug);2(4):356-361.

[30] Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians’ attitudes and practices. J Fam Pract. 1999;48(2):105–109.

[31] Larimore, W, Peel, WC. The Saline Solution. Ibid.

[32] Larimore, W, Peel, WC. Grace Prescriptions. Ibid.

[33] Koenig HG. Spirituality in Patient Care: Why, How, When, and What. 2nd ed. Templeton Foundation Press. Philadelphia, PA. 2007:72–89.

[34] Saguil, A, Phelps, K. The Spiritual Assessment. Am Fam Phys. 2012(Sep 15);86(6):546-550.

[35] Post SG. Ethical Aspects of Religion in Healthcare. Mind/Body Medicine: J Clin Behav Med. 1996;2(1):44-48.

[36] Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012. http://bit.ly/1wnA4iP.  Accessed December 13, 2014.

[37] Advancing Effective Communication. Ibid.

[38] Paloutzian RF, Ellison CA. Manual for the Spiritual Well-Being Scale. Life Advance, Inc. Nyack, NY. 1982.

[39] Hatch RL, Burg MA, Naberhaus DS, et al. The Spiritual Involvement and Beliefs Scale. Development and testing of a new instrument. J Fam Pract. 1998;46:476–486.

[40] Daaleman TP, Frey BB. The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research. Ann Fam Med 2004;2:499-503.

[41] Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Phys. 2001;63(1):81–89.

[42] FICA Spiritual Assessment Tool. The George Washington. Institute for Spirituality and Health. Washington, DC. 2014. http://bit.ly/1y07swq. Accessed November 21, 2014.

[43] Maugans, TA. The SPIRITual History. Arch Fam Med. 1996(Jan);5(1):11-16.

[44] King, DE. Spirituality and Medicine. In Mengal, MB, Holleman, WL, Fields, SA (eds). Fundamentals of Clinical Practice: A textbook on the Patient, Doctor, and Society. Springer Publishing. New York, NY. 2002:651-659.

[45] Koenig, HG. An 83-Year-Old Woman With Chronic Illness and Strong Religious Beliefs. JAMA. 2002;288(4):487-493.

[46] Lo B, Quill T, Tulsky J. Discussing palliative care with patients. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Int Med. 1999(May 4);130(9):744-749.

[47] Saguil, A, Phelps, K. The Spiritual Assessment. Am Fam Phys. 2012(Sep 15);86(6):546-550.

[48] Pargament, K, Koenig, HG, Tarakeshwar, N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Int Med. 2001(Aug);161(15):1881-1885.

[49] George Crile, Jr. Wikipedia. 2014. http://bit.ly/1uAlIGL. Accessed December 13, 2014.

[50] Crile, GW. Cancer and Common Sense. Viking Press. New York, NY. 1955. Quoted in: Aronowitz RA. Unnatural History: Breast Cancer and American Society. Cambridge University Press. Cambridge, England. 2007: 190.

[51] William Osler. Wikipedia. 2014. http://bit.ly/1wsfixo. Accessed December 13, 2014.

[52] Osler W. The faith that heals. BMJ. 1910;2:1470–1472.

[53] Woodward K. Talking to God. Newsweek. 1992(Jan 6);119:40.