Here’s one tool for taking a spiritual assessment, developed by doctor named, Puchalski:

F – faith, belief, meaning: Do you consider yourself spiritual or religious? Do you have beliefs that help you cope with stress? What gives your life meaning?
I – importance, influence: What importance does faith have in your life? Do you have specific beliefs that might influence your healthcare decisions?
C – community: Are you part of a religious community? Is this a source of support?
A – address/action in care: How should the healthcare provider address these issues?

I have never done a spiritual assessment in a clinical situation, nor do I ever plan to. In general, whenever I make bold or controversial statements, I try to provide some argument. The position, however, that discussions of religion/spirituality have no place within the context of the doctor-patient relationship, I consider to be neither bold nor controversial. Doctors get paid the big bucks to provide treatment and to help patients make medical decisions. Could someone’s faith influence their medical decision making? Sure. So what? Is there ever a situation in which I would counsel a patient differently, treat them differently or recommend different treatment based on their spiritual religious beliefs? Absolutely not. Never. In no situation is it ever necessary or even preferable to know what a patient’s religion is, indeed whether or not they have religion/spirituality in their lives at all, in order to provide effective medical care.
Eliciting a patients preference with regard their medical treatment, on the other hand, is often of critical importance. But there’s no need for your doctor to know what’s influencing those preferences. Your preferences are your preferences and where they come from is between you and you and, perhaps, God.

Oh, well…so much for not providing an argument.

<ul>

• <DM>Guest post by Sysy Morales at Diabetes Mine on the top 10 things women want their partners to know about their diabetes.</DM>
• <!>Henry Stern from InsureBlog gives us the story of man who takes the idea of patient empowerment a bit too far.</!>
• <ouch>Ryan Dubosar, who blogs at ACP Internist runs with this theme, mentioning the same case in his post about self surgery.</ouch>
• <chest pain>Ryan also blogs at ACP Hospitalist and, in this post, examines the connection between chest pain and the liklihood of acute MI.</chest pain>
• <ALCL>Can breast implants cause cancer? Ramona Bates from Suture for a Living gives us more information on a clinical entity known as anaplastic large cell lymphoma.</ALCL>
• <med news>Jessie Gruman gives us a post on how the revenue model for online news undermines our ability to make good choices about our health care. She posts regularly on the What It Takes blog at the Prepared Patient Forum website</med news>
• <brca 1>Amy Berman, who blogs at The John A Hartford Foundation Blog, gives us the fifth post in her series on living with stage IV breast cancer.</brca 1>
• <brca 2>Breast cancer survivor Beth Gainer gives us a post this week on the psychological burden of her illness Her blog is called Calling the Shots.</brca 2>
• <htn>Dr. Charles looks at the pitfalls of evaluating blood pressure in an office setting.</htn>
• <heat>Dr. Paul S. Auerbach has a post on this past week’s unprecedented heat wave over at Healthline.</heat>
• <portal>Steve Wilkins of Mind the Gap gives us his take on patient portals.</portal>
• <psych>Finally, Will Meek gives us a very interesting post on the clinical issue of believing that something is fundamentally wrong with oneself. He blogs at www.willmeekphd.com.</psych>

</ul>

<i>Next week’s Grand Rounds will be hosted by Dr. Deb.</i>

Thanks for visiting!

Analysts agree that a failure of both parties to reach an agreement by the August 2 deadline, the date that Dr. Logan is scheduled to host Marshall and Lacey Claremont for dinner, would be disastrous.  Lacey Claremont, who has been following the standoff closely, had this to say, “I just don’t know what they’re thinking!  Do they expect us to eat off the kitchen floor?”  While it has been proposed that Dr. Logan simply take his wife and his in-laws out to dinner on August 2, it is widely believed that an inability to provide a home cooked meal would seriously damage his credibility with the Claremont family requiring him to buy more expensive Christmas and birthday gifts for the next 5 to 10 years and also to visit the Claremont’s in Alburqurque, NM more frequently than the previously stipulated once every 8 months.  “It would amount to a giant tax hike on the Logan household,” Dr. Logan was heard saying the other day, “And neither Mrs. Logan nor I are willing to going to accept that.

But, unfortunately, Dr. Logan and his wife are no closer to a compromise than they were 3 weeks ago.  At press time, Dr. Logan is believed to be out shopping for a round table which would expand to seat 6 people.  Mrs. Logan dismissed this as political posturing saying, “If he thinks that particle board s@&! from Ikea is what we’re going to seat our guests around for the next 20 years, he can forget it!”

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What did they find?  Physicians were significantly more likely to choose the option which carries a higher mortality rate but a lower risk of complications for themselves than they were when making a recommendation to thier patient.  Why was this the case?  The authors point to cognitive bias.  They suggest that the biases of “betrayl aversion” (an exagerated feeling of harm caused by an action designed to prevent harm) and “omission” (the added regret of harm caused by a treatment when compared with the same degree of harm caused by a withholding of treatment) are more at work when doctors are choosing for themselves than they are when choosing for patients. 

The idea that we make better decisions for others than we do for ourselves and our loved one is entirely plausible.  Indeed there is other research to suggest that this is the case.  It is a big part of the reason why doctors shouldn’t operate on friends and loved ones, deliver their babies or, in my view, even prescribe them medications.  This is why I am disturbed by what I believe to be the prevailing view in medicine today – namely that we, as Dr. Wes recommends, “Treat every patient like our mother.”  I will elaborate.

In the ideal situation, medical decision are based on good evidence, reflect the patient’s beliefs and values and are ethically permissible to the physician.  For this to happen a good doctor needs to a) dispassionately weigh the evidence including all attending risks and benefits of any possible intervention and b) establish a relationship with his or her patient which promotes the expression of autonomy.  Treating patients as we would ourselves or someone who is close to us (i.e. with kindness, respect and empathy) is clearly necessary for the latter of these goals.  But, as the above study demonstrates, it is likely detrimental to the former.

Many commentators worry that the rigorous nature of medical training beats the empathy out of young doctors – that medical students loose their idealism during the third year of medical school, become jaded and cynical.  This may be true, but is the wrong question to ask.  I would argue that being caring and empathic are qualities which are necessary in order to effectively perform one’s function as a physician, but are not goals to be achieved for their own sake.  Just as it helps us develop a rapport with patients and establish an effective therapeutic relationship, empathy impairs our ability to rationally weigh evidence and make decisions free of cognitive bias.  Treating every patient like your mother should not be seen as an ideal to strive for.  Rather, it should be seen as a first step which providers must then overcome in order to provide the best possible care.

He was interrupted by the frantic call of a nurse from down the hall. “Dr. Logan, chi can bree!” Dr. Logan slowly put down his pen, for, while he didn’t understand what the Filipina nurse on the post partum floor was trying to tell him, he had the sense that it was of some urgency. Again came the nurse’s cry, bordering on hysteria this time, “Dr. Logan! Come kweek, chi can bree!” Turning the words over and over, upside down and sideways in his mind, James Logan made his way over to Post-Partum. Slowly at first, then more quickly as meaning began to take shape in these strange syllables. He arrived at the patient’s room to find her awake, sitting up in bed and taking quick, shallow breaths. The look on her face was one he recognized well, as he frequently would see it on his fellow interns – panic.

The next several hours were a blur. James’s chief resident, Jen, came by to help out with the lady who “couldn’t breathe.” It took about twenty minutes for everyone to reassure themselves that the patient was just having an anxiety attack. Shaken but relieved, James got to the business of rounding on his eighteen patients, a task that would have exhausted him on the best of days. Today, crying babies and new moms’ discourteous taking of showers before he’d had a chance to examine them sapped the last few ounces of his strength. There were still notes and orders to write before he would be allowed to leave. While he contemplated these things, Jen popped by the nursing station where James was buried under a pile of charts with a friendly reminder. “Did you ever get to that delivery note?” He hadn’t. The look on his face must have indicated to Jen the need for quick, empathetic intervention.

“Yeah,” she said. “I know it sucks. I was an intern once too.” She smiled encouragingly. “Hey, I’ve got a joke for you! An OBGYN resident walks into a bar.” James waited.

“Where’s the punch line?”

“That is the punch line! When does an OBGYN resident ever have time to go to a bar?” She laughed, slung her purse over her shoulder and made her way to the parking garage.

Fighting back tears, James reopened the 3-ring binder chart, tore out the old, unfinished note and began anew. “Late entry secondary to patient care. On August 16, patient H.P. delivered a viable…” But, he had forgotten the details. The official record of the delivery of H.P.’s baby whatever-it-was would be one of historical fiction.

Most of you reading this won’t understand what it’s like for a non-coffee drinker like myself.  Coffee is so pervasive in our society, soon it will be coming out of our faucets!  I replay the following scene at least a few times every week.

Colleague #1: Hey, I’m going to the cafeteria to get some coffee, anyone want some?”
Colleague #2: Sure, I’ll join you.
Colleague #3,4,5…17: Us too!
(Everyone turns to me)
Colleagues 1-17 (simultaneously): James?
Me:  No, no thanks.  No coffee for me.
Colleague #1: You sure?
Me: Yes, I’m sure.
Colleagues 1-17: (exchange confused looks and murmur to each other)  Really?
Me:  Yes!  Yes, I’m absolutely sure.  Please, read my lips…no coffee for me. Really!

Coffee is everywhere in our society.  Every morning, someone in my vicinity is either brewing it or buying it or grinding it, or french pressing it…and I am constantly having to refuse offers of coffee.  Pretty soon, I’m going to start wearing a sign on my head that reads, “To you generous offer of coffee, I politely decline,” and save everyone the trouble. 

I do actually drink it sometimes.  Just not first thing in the morning.  It makes me nauseous, jittery and have to pee when I start the day with it.  But, back to my original point, couldn’t the ‘thank you’s’ for the various research projects I have so selflessly contributed to be a gift card from some other, non-coffee specializing establishment?  Why not an iTunes gift card, or a coupon for a free lap dance at Club Ecstasy?  (Not that I’ve ever been there…just sayin’)  Or better yet, the gift could simply be a syringe filled with dopamine that I could inject directly into my brain.  That would be cool.

With regard to gun ownership, my opinion is even less meaningful than for wearing of bicycle helmets.  I’ve never held a gun in my life, let alone fired one.  I haven’t the faintest clue about proper gun safety, nor do I intend to learn.  Just as I wouldn’t presume to ask a pilot whether he follows all proper safety procedures and inspections before take-off, or whether a scuba diver properly checks out his gear before diving, I have no business asking about gun ownership.  Sure, the AAP is fond of quoting the higher incidence of gun-related deaths among gun-owners (hence, my personal decision not to own one).  Similarly, I could quote the higher rate of airplane related deaths among those who fly vs those who don’t.  Or the higher incidence of scuba diving related accidents among those who scuba dive vs those who don’t.  The list goes on.  My point is, that these are personal, life-style decisions.  They’re not medical decisions and, as such, my opinion is really irrelevant.

All that being said, a bill which holds doctors criminally accountable for discussing guns during a patient visit, as Florida law HB 155 does, is simply outrageous.  Mona Mangat argues that this type of legislation places us at the top of a “slippery slope” at the bottom of which it may become illegal to ask patients about smoking.  I would go even further and say that we’re already well on our way down the slope with this legislation, the issue is no longer slippery.  One can have a rational, academic discussion about which types of behaviors and decisions doctors should and should not be asking their patients about.  But to make a particular line of questioning illegal is an unprecedented step which clearly undermines doctors’ ability to establish trust with their patients.  The issue is not, as some have argued, that this law prevents doctors from their duty to identify a particular risk to patient safety.  Whether or not doctors have a duty to ask about gun ownership as a patient safety concern is a matter of opinion (I’ve expressed mine very strongly above).  The issue here is that making any topic of discussion with your patients illegal, in addition to being a likely 1st amendment violation, represents an attack on the heretofore highly protected and privileged doctor-patient relationship.  As Virginia Hood, president of The American College of Physicians put it,  ”This issue is much bigger than guns, it is about whether the government or any other body should be allowed to tell physicians what they can and can’t discuss with their patients.”