Today's Christian Doctor - Summer 2001

The physician-patient relationship is the cornerstone of medical practice, an essential ingredient in the restoration and maintenance of health. As a researcher, clinician and teacher, I have spent much of my career studying, implementing and modeling the healing effects of the physician-patient relationship, seeking to maximize its benefits in the care of patients. My first research studies at Yale University addressed patients' perceptions of physician performance, in which I documented that patients ultimately cherish "TLC"-time, listening and caring.^1-3 Patients desire and welcome treatment by doctors who show the willingness to listen to their concerns and the heart to care for them as individuals.

More recently, I have been interested in the healing effects of the "patient-God relationship," most notably the impact of faith, spirituality and religious commitment upon health. I have discovered that patients with strong faith commitments experience enhanced physical and mental health, including reduced rates of drug and alcohol addiction and mental illness, and improvements in the quality of life, life expectancy and recovery from medical and surgical illness.⁴

Perhaps now we should begin to consider a higher order of healing relationship: the physician-patient-God relationship. In doing so, I would like to begin by separately examining the three permutations of this trinity: the physician-patient relationship, the patient-God relationship and the physician-God relationship. Then, I will sketch an outline of their integration: the physician-patient-God relationship. I will propose the latter relationship as the desired model for helping humans to heal.

The Physician-Patient Relationship

A 60-year-old woman came to my office with hypertension, diabetes, arthritis, gastrointestinal reflux disorder and depression. After completing my examination, I reasoned that all of her problems would be aided by weight loss and I vigorously encouraged her to pursue this. Upon her return visit three weeks later, I was pleased and surprised by her 15-pound weight loss, and the consequent clinical improvement in all of her diseases. I asked her to tell me "the secret" of her success, after admitting to her that few patients were as successful as she had been. She burst into tears, and said words that a young physician would never forget: "It's because you cared for me! That's why I lost the weight!"

Francis Peabody, in his immortal essay many years ago, wrote, "the secret in the care of the patient is to care for the patient."⁵ I proposed some years ago that the secret of patient care is to love the patient, unconditionally.⁶ But how on earth can we "love" all of our patients? What about the alcoholics, the drug abusers, the homeless, the AIDS patients, the  non-compliant patients? Of course, there is no possible way "on earth" that we can love all of our patients. As Jesus said to His disciples,  "With man this is impossible, but not with God; all things are possible with God" (Mark 10:27). Therefore, the question is: How can we partner with God to implement and embody "these things"?

First and foremost, physicians must seek and embrace faith, "being sure of what we hope for and certain of what we do not see" (Hebrews 11:1). Faith that "all things are possible" is a gift from God and the physician should fervently pray for and welcome this gift.

Second, we can conduct a rigorous assessment and monitoring of our attitudes and values. I believe that the most important physician characteristics that foster healing relationships with patients are acceptance, affability and availability. All patients, like us, are "made in the image of God" (Genesis 1:27) and yet, each is fundamentally different from us, with unique ideas, traits and lifestyles that may challenge or even repel us. One of the most shocking aspects of Jesus' ministry to His contemporaries was His willingness to reach out and touch members of even the most forsaken and ostracized elements of society-tax collectors, prostitutes, adulterers, lepers, Samaritans. He recognized and embraced the dignity of each individual and demonstrated that all are worthy of our careful attention, our caring concern and our enduring respect. We must "walk as Jesus did" (1 John 2:6) with compassion and cheerfulness. This, too, requires faith and prayer.

Third, we can create a healing environment in our practices that will help to establish and maintain rapport. Perhaps the most important aspect of the environment is our use of time. When we are perpetually late, we demonstrate by our actions that we believe that our time is inherently more valuable than our patients' time and thereby fail to demonstrate respect for them. When we rush through the visit or fail to return patients' phone calls promptly, we demonstrate by our actions that their concerns are unimportant to us.

The most important moments in the meeting between a doctor and patient are the greeting, the opening of the interview, handling of emotional moments and the closing. In the greeting, you should communicate warmth and welcome, as if you are welcoming someone into your home. In fact, I generally open the interview with a warm handshake, attentive eye contact, a smile and nod of my head and one hearty word: "Welcome!" Rapport is further maintained through listening (without interrupting) to your patients' principal concerns, allowing them to tell their own story, and mirroring their characteristic words, expressions and body language. If a patient prefers to describe herself as being "tired," says firmly that "I'm not 'depressed,'" and she speaks slowly and quietly with few gestures, tell her, using a similar tone of voice and body movements that your goal is to help her become less tired.

At certain times in the interview "emotional windows" may open, particularly if the physician has already demonstrated a capacity and willingness to listen. A patient may say "I've been having a difficult time" and her voice may trail off, followed by a tear in her eye. This is not the time to continue a biomedical approach. Instead, using an open-ended question (e.g., "What's been going on?" or "Tell me more") and giving the patient time and space to show emotion will demonstrate caring and strengthen the physician-patient relationship.

At the close of the interview, the physician should review the principal findings and the plan of action, including specific notation of the next point of contact (e.g., phone call or letter regarding findings of diagnostic tests, scheduling of a follow-up visit). As in the greeting, it is also important to touch the patient (hearty handshake with perhaps a touch of the upper arm), maintain eye contact and convey warmth (e.g., "I look forward to watching you get better"). In certain instances, if patients have already demonstrated an openness to a more spiritual approach, a "benediction" is appropriate (e.g., "God bless you!" or "Blessings!") or an actual time of prayer with the patient can occur.

The Patient-God Relationship

Numerous research studies indicate that patients who show evidence of a strong religious commitment are mentally and physically healthier than those who are without such beliefs and practices.^4,7 One study has estimated that the average person who attends worship more than once per week lives seven years longer than one who never attends worship.⁸

Why does having religious faith and participating in religious rituals enhance mental and physical health? Religious commitment appears to convey its benefits through a variety of mechanisms. It appears that persons who actively live out their commitment are more likely to take medications and to follow physicians' advice and less likely to engage in unhealthy practices, such as smoking, alcohol and drug abuse, sexual promiscuity and risk-taking behavior. Furthermore, those who attend worship regularly are more likely to engage in social activities and to seek social support in times of need. Persons who are isolated from others (including unmarried men, widowers,  loners) are more likely to suffer adverse health events than those who join and participate in groups. Persons who volunteer are more likely to enjoy good health, and much of the volunteer work in this country is done under the auspices of organized religion.

Persons of faith accept and embrace the transcendent dimension of life, thereby providing hope and solace in moments of crisis. They report receiving aid from clergy and from religious rituals, which offer meaning, purpose and connection in times of turmoil. Finally, scientific studies have begun to demonstrate the healing effects of prayer and intercessory ministry itself.¹¹ These findings should not come as a surprise to believers, who can be comforted that everyone who seeks God through Holy Scripture receives God's blessings (Revelation 1:3). After all, as the apostle Peter writes, "(God's) divine power has given us everything we need for life and godliness through our knowledge of him who called us by his own glory and goodness" (2 Peter 1:3).

The Physician-God Relationship

Physicians are often reluctant to explore and share their feelings and beliefs or to examine their own role and impact on the healing process. This reticence is generally hardened during medical training, which is replete with harrowing and overwhelming experiences (e.g., dissecting a cadaver, resuscitating victims of trauma). While physicians, like patients, are in need of the coping skills and health benefits that accompany authentic religious experience and practice, some (albeit not all) studies indicate that health professionals, particularly mental health practitioners, are less likely to be religious and thereby to receive and enjoy those skills and benefits.^4,10 Nonetheless, whether they are religious or not, physicians and other health professionals are God's appointed agents of healing and should strive to maximize their skills and capacities as healers.

Christian physicians have the wonderful opportunity and advantage of having Jesus, the Great Physician, as their exemplar in the care of the sick. Much of Christ's ministry (approximately one quarter of the Gospels) related to healing. The principles He lived by are useful ones for all physicians to examine and espouse. His clarion call to the disciples is the same message that all of us need to hear today: "Follow me!"

State licensing boards require physicians to spend time in continuing medical education to maintain and upgrade their clinical skills. What about continuing spiritual education? In the midst of His busy and exhausting ministry, Jesus always took time to worship (Mark 1:21-2, John 11:41-42) and to spend time with His Father in prayer (Mark 1:35, Luke 6:12). How important and useful might it be for physicians to spend as much time reading the Bible as reading the New England Journal of Medicine? Or, spending as much time in prayer or on spiritual retreats as attending medical meetings? Of course, one should never neglect one for the other. Physicians are never called to forsake or forget their clinical tasks and abilities. Far from it! Doctors are charged to combine compassion with competence, prayer with professionalism. Yet, we need not, indeed must not, forsake our spiritual lives in the process of caring for others, for our ability to care for others' needs depends upon our ability to care for our own needs, including our spirituality.⁹

Jesus recognized and acknowledged the role of religious rituals and authorities in helping patients to re-enter society after their illness (Luke 17:14, John 9:7). Physicians are not called to be religious professionals; the roles of physician and priest are, indeed, separate. Instead, we are called to establish healing partnerships and closer relationships with clergy to help effect healing for individuals within our caring network.

Jesus did not "need" anyone to help Him in His ministry, and yet He surrounded Himself with 12 intimate friends who walked and worked alongside Him, sharing His mission. In particular moments of exaltation and despair (the Transfiguration, the Garden of Gethsemane), His three closest friends (Peter, James and John) accompanied Him. Physicians are too often "Lone Rangers" who spend much of their time isolated from everyone except their staff and patients. Loneliness can lead to depression, and even precipitate alcohol and drug abuse or sexual promiscuity. Fellowship with other believers, particularly faithful physicians, can help ease the burdens of practicing spiritually sensitive medicine.

Finally, Jesus often established a personal relationship with  individuals who came to Him for healing and He demonstrated compassion and respect for all. Mother Teresa was once asked how she was able to carry the enormous burdens of her ministry to the sick and dying in Calcutta and around the world. She answered simply, "I see the face of Christ in everyone I meet," echoing Jesus' parable of the Sheep and the Goats: "'When did we see you sick or in prison and go to visit you?' "...(W)hatever you did for one of the least of these brothers of mine, you did for me." (Matthew 25:39-40). When we can truly see the face of Christ in all of our patients and colleagues, we will radiate the love of God and enhance healing for our patients and for ourselves.

The Physician-Patient-God Relationship

In light of these thoughts, should physicians encourage religious activities? We do encourage proper diet, exercise and sleep and we ask patients to take all the pills we prescribe. Should we prescribe prayer? Or, does that turn religion into merely "a pill"-a means to an end of producing greater health? Is religion thereby subordinate to the "higher good" of good health? Do you smell the whiff of idolatry?

Our commitment to God should not be dependent on what health benefits it can produce for us. Although our bodies are "the temple of the Holy Spirit" (1 Corinthians 6:19) and "physical training is of some value" (1 Timothy 4:8), God is far more interested in our level of faith and godliness than in our cholesterol level or body mass index. Furthermore, physicians should never say or imply that patients must (or even should) participate in religious rituals to remain healthy. While faith and religious practice can be an important contributor to good health, many individuals with no religious activity at all may still be entirely "healthy" from the medical point of view.

Imposing one's own religious beliefs on a patient is "bad medicine" as well as "bad religion." Nonetheless, based on current scientific data, it is ethically defensible to mention religious activity as a potential source of health benefits for those who are open to such participation, as long as such encouragement does not cross the line into coercion.

What about eternal health-the Christian's insurance policy that, as one of my patients liked to say, is "out of this world"? Should physicians present the heavenly benefits of accepting Christ as Savior? Christian physicians must "always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But we should do this with gentleness and respect" (1 Peter 3:15). However, as Christian physicians, we must also submit ourselves ". . . for the Lord's sake to every authority instituted among men" (1 Peter 2:13). Medicine is one such authority. I am a diplomate of the American Board of Internal (not "Eternal") Medicine.

My role as a healer is given to me by God, but my medical degree and my authority to practice internal medicine is given to me by Caesar, and I must "give to Caesar what is Caesar's and give to God what is God's" (Matthew 22:21).  What is Caesar's is a fundamental reliance upon the scientific method of healing and to objectively verifiable and accepted standards of practice that allow me to practice the best medicine I can "on earth." Medical practitioners are rightfully called by the state to practice internal medicine and to spurn any type of  "eternal medicine" that itself bypasses or rejects legitimate medical care. What is God's is love: the Great Commandment, to love our patients as ourselves, realizing that all healing emanates from God, the Great Physician. Love bridges the gap between "conventional" medical care and spiritually sensitive care, internal and eternal medicine. Love opens doors for healing and healing open doors for the Gospel, as the ministry of Jesus Himself illustrates so clearly.

Physicians who wish to practice spiritually sensitive care can begin by taking a spiritual history in all patients, generally during the initial visit. I listen closely for "God talk," spontaneous references to religious beliefs and practices in ordinary conversation (e.g., "I've been on my knees a lot throughout this illness," "The Good Lord must be watching out for me"). At such moments, I offer an open-ended question that facilitates further exploration (e.g., "Tell me more about your beliefs"). If no "God talk" occurs, one can ask some broad questions during the "Social History" component of history taking. After asking about hobbies and interests, I generally ask patients about any involvement in community or volunteer activities. Then, I ask them if they are involved in any spiritual or religious activities. If the answer is no, I ask them whether they were ever involved a lot with these types of activities in order to determine whether or not there has been any form of spiritual trauma that needs to be addressed. If yes, I ask patients whether their religious and spiritual activities are important to them and how these activities influence their beliefs or practices regarding health matters. Finally, I ask them whether they would want me as their physician to engage in these types of discussions with them. By saying "yes," the patient has granted permission to the physician to discuss and address salient religious and spiritual concerns as part of regular medical care.

Next, physicians can encourage attendance at worship, including small group participation and volunteer activities, regular prayer and study of Scripture. In addition to pharmacotherapy, I often practice "bibliotherapy"-the offering of specific Bible passages to facilitate an individual's growth and healing. For example, I might encourage patients with certain conditions to read particular passages (e.g., for anxious persons: John 14:1-4 and Matthew 5:25-34; for depression: Philippians 4:4-8; for fatigue: Isaiah 40:28-31 and Matthew  11:28-30, and for grief: Psalm 30:5, Romans 8:18-39 and Revelation 21:1-4).

In addition, I particularly encourage patients to study the prayers of Jesus Himself, including the Lord's Prayer (Matthew 6:9-13) and His prayer in the Garden of Gethsemane (Mark 14:36), in which the Lord faced His own pain, suffering and mortality with great poignancy.

In this prayer, I find four key elements that serve as guiding principles for incorporating religious practices into regular medical care:

1. "Abba, Father...."  God is our father and loves us personally and intimately as a father would;
2. Everything is possible for you...." Here is a succinct definition of faith: believing the invisible, the impossible;
3. Take this cup from me...." Some wonder why we should even bother with prayer, as God knows our own thoughts before we think them. Why should we pray? Jesus, as our great Teacher and Model in all aspects of life prayed regularly and fervently. We, too, should pray;
4. Finally, "Yet not what I will, but what you will." Prayer is ultimately not about "getting what we want." Prayer is not "outcome-based medicine." Instead, prayer is a process, a continual sharpening of the soul, an ongoing endeavor to train us to be more fully and completely within God's will.

We know that healing is God's will (Matthew 8:2-3) and that healing is a natural part of God's order as exemplified by the ongoing activity of our immune system. The place and timing of "supernatural" healing, on the other hand, is up to God and not to us. All individuals who follow Jesus will eventually receive ultimate healing after death (1 Corinthians 15:50-57, Revelation 21:1-4); some, but not all, receive unexpected, supernatural healings on earth. All whom Jesus touched were healed and He often credited their faith as being instrumental to their healing (Matthew 15:28, Mark 5:34, 10:46-52), but clearly not everyone alive in Jesus' time was healed; further, all supernatural healings on earth are temporary. Remember that even Lazarus, who was raised from the dead, eventually died again.

By strengthening the physician-patient-God relationship, physicians and patients find themselves as fellow supplicants under the umbrella of God's mercy, power and grace. Patients can place their patience and trust in God, not just in their physician. Physicians need not "play God" anymore-they can let God be God while they remain physicians. The healing hand of God can touch both patients and physicians, as they join together to confront the dilemma of disease, the mysteries of medicine and the hope of healing.

References:
^1. Matthews DA, Feinstein AR. A 'review of systems' for the personal aspects of medical care. Am J Med Sci 1988;295:159-171.
^2. Matthews DA, Feinstein AR. A new instrument for patients' ratings of physician performance in the hospital setting. J Gen Intern Med 1989;4:14-22.
^3. Matthews DA, Suchman AL, Branch WT. Making  connexions: enhancing the therapeutic potential of  patient-clinician relationships. Ann Intern Med  1993;118:973-977.
^4. Matthews DA, Clark C. The Faith Factor: Proof of the Healing Power of Prayer. New York: Viking; 1998.
^5. Peabody FW. The care of the patient.  JAMA 1927;88:877-82 .
^6. Matthews DA. The "L" word. Physician 1992; 4(4):24.
^7. Koenig HG. The Healing Power of Faith. New York: Simon and Schuster, 1999.
^8. Hummer RA, Rogers RG, Nam CB, Ellison CG. Religious involvement and U.S. adult mortality. Demography 1999;36(2):273-85.
^9. Sulmasy DP. The Healer's Calling: A Spirituality for Physicians and Other Health Care Professionals. Mahwah, NJ: Paulist Press,  1997.
^10. King DE. Faith, Spirituality and Medicine: Towards the Making of the Healing Practitioner.
Binghamton, NY: Haworth Pastoral Press, 2000.
^11. Matthews DA, Marlowe SM, MacNutt FS. Effects of  intercessory prayer on patients with rheumatoid  arthritis. South Med J 2000;93(12):1177-86 (see summary at right).