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Pediatrician Beliefs About Spirituality and Religion in Medicine: Associations With Clinical Practice

Christy A. Armbruster, MD^*,, John T. Chibnall, PhD and Sarah Legett, MD^*,

^* Departments of Pediatrics
Psychiatry, Saint Louis University School of Medicine, St Louis, Missouri
SSM Cardinal Glennon Children’s Hospital, St Louis, Missouri

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	ABSTRACT

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Objectives. Identify pediatrician (faculty and resident) beliefs about spirituality and religion (SR) in medicine and the relationship of those beliefs to SR behavior and experiences in clinical practice.

Methods. A self-report questionnaire was administered to full-time pediatric faculty (N = 65) and residents (N = 56) of an urban children’s hospital affiliated with a school of medicine. The response rate was 70.8% among faculty (n = 46) and 78.6% among residents (n = 44). Respondents indicated the extent of their SR inquiry and the frequency of their SR experiences (requests by patients or families to discuss SR or pray), routinely and during health crisis, and rated 19 belief statements about SR in pediatrics.

Results. Few pediatricians routinely ask about SR issues. Faculty were more likely than residents to ask about religious affiliation, whereas residents were more likely to be asked to pray during health crises, to believe that SR has health relevance, and to perceive pediatrician-initiated prayer as appropriate. Composite scores indicated that physicians who did not expect negative patient reactions to SR inquiry and prayer, who believed more strongly that SR is relevant to pediatric outcomes, and who felt more capable with SR inquiry were more likely to engage in SR inquiry and to experience SR requests.

Conclusions. Pediatrician beliefs with respect to health relevance of SR, patient reactions to SR inquiry, and physician capabilities regarding SR in the clinic are strongly related to their clinical practice concerning SR inquiry and experiences. Correction of physician misperceptions about SR issues and incorporation of religious sensitivity into physician training may remove barriers to both patient and physician SR inquiry.

Key Words: pediatrics • religion in medicine • physician’s role • attitude of health personnel • internship and residency • medical education

Abbreviations: SR, "spiritual and religious" or "spirituality and religion" • SD, standard deviation

	INTRODUCTION

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There is a bounteous literature on the role of spirituality and religion (SR) in the practice of clinical medicine.¹ Research has documented positive relationships between religious behavior and health,^2–8 and the majority of patients seem to want their physicians to be able to address the SR aspects of the illness experience.^9–11 Although many physicians accept the idea that patient religiousness or spirituality can positively affect health, most do not initiate SR inquiry with patients.^12–15 Numerous reasons have been offered for this discrepancy, including physician discomfort with psychosocial, emotional, or palliative approaches; lack of time; fear of the perception of proselytizing; lack of training; and confusion over the applicability of SR concepts within the patient encounter (eg, "prescribing" SR behavior is different from "prescribing" good health habits, such as smoking cessation, exercise, proper diet).^{12,13,16–18} For addressing physician discomfort with SR issues, training models that provide education and exposure regarding the interaction of patient SR orientation with the illness experience have been offered.¹⁹

By comparison, there are few data about the beliefs and clinical practices of pediatricians regarding SR inquiry. Historically, the primary focus in pediatrics has been on parental religious objections to medical care for children, and a substantial literature exists on this topic.²⁰ A related issue is the potentially negative characteristics of some forms of SR, including authoritarianism and punitiveness, and the psychological responses to these characteristics, including feelings of guilt or unworthiness. In the current study, however, the emphasis was on the potentially positive, affirming, and/or explanatory role of SR in the illness experience. Although the potentially negative effects of SR should not be dismissed, recent research has hypothesized that SR may positively mediate health and wellness through several mechanisms, including respect for the body (eg, avoidance of tobacco, drugs, risky sexual activity); the social support provided by an SR community; and the psychoneuroimmunological effects of prayer, worship, meditation, and ritual.² In addition, the life philosophy engendered by SR traditions (eg, feelings of optimism, love, hope, and solicitude) and the explanatory role of SR in providing meaning during existential crises (especially those prompted by loss of health and life) may have relevance to illness outcomes.² Overall, research on the prevalence of and recovery from physical and mental illness is more supportive of the positive role of SR in health than on its negative potential,^1–8 although it must be recognized that 1) some researchers have raised questions about the validity of this interpretation¹⁷ and 2) these studies have not been done with pediatric populations.

Despite this burgeoning attention to SR factors in health, the extent to which SR is integrated into pediatric health care is virtually unknown. Only 1 empirical study has considered the topic. In a study of 165 pediatricians and pediatric residents, Siegel et al²¹ found that few inquired about SR with patients but that a majority believed that faith plays a role in patient healing. Furthermore, a slight majority of pediatricians considered themselves spiritually/religiously oriented. This group was more likely than those without a personal SR orientation to pray with patients if asked, to initiate SR dialogue, and to contact an SR professional on behalf of the patient. Furthermore, SR-oriented pediatricians were more likely to believe that patients want to discuss SR issues and that these discussions strengthen the patient–pediatrician relationship. This study, however, looked only at pediatrician personal SR orientation as a mediator of SR behavior and attitudes. Unlike the current study, it did not address potential correlates of clinical approaches to SR, including context-specific beliefs regarding SR in medicine. Previous studies have indicated that beliefs about the risks and benefits of clinical SR inquiry may also be important mediators of SR behavior.^13,14

The primary objectives of the current study were 1) to describe clinical practice with regard to SR in an academic department of pediatrics, including the prevalence of SR inquiry and SR requests by patients/families; 2) to identify pediatrician beliefs about SR in medicine; 3) to compare pediatric faculty and pediatric residents regarding SR beliefs and practices; and 4) to examine whether SR beliefs are predictive of SR practices.

	METHODS

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Note on Definitions
There is dispute regarding the use of the terms "religion" and "spirituality."²² We defined religion as the institutionalized expression of shared beliefs, values, experiences, doctrines, traditions, and faith by a community of like believers, usually involving ritual. Spirituality was defined as belief in and experience of a being or state, not necessarily deistic, that transcends physical reality and provides direction, meaning, and/or affirmation in one’s life. Although there are excellent conceptual arguments for separating the 2 terms, the distinction, in our experience, is cumbersome and often lost in the practical context. Furthermore, spirituality is often a direct outgrowth, in whole or in part, of religion. Thus, we use the abbreviation SR to refer to "spiritual and religious" and "spirituality and religion." A related language issue emerges from the fact that, in the pediatric context, the pediatrician may have more direct interaction with parents or caregivers than with the patient, depending on the patient’s age. Rather than making this distinction throughout (eg, "patient and/or family"), we use the term "patient" to denote the patient–family unit.

Respondents
All full-time physician faculty (N = 65) and residents (N = 56) in the Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Hospital, were asked to participate. The response rate was 70.8% among faculty (n = 46) and 78.6% among residents (n = 44), for a total of 90 respondents. The institutional review board of Saint Louis University approved the study protocol. Participation was voluntary and anonymous.

Materials and Procedure
A questionnaire was mailed to the work address of each potential respondent. The questionnaire was a supplemented version of one used previously.¹³ Completed questionnaires were returned through the mail at no cost to the respondent. Through e-mail and word of mouth, potential respondents were reminded about the questionnaire. Respondents were asked about their clinical practice regarding SR, including inquiry with patients (routinely and during health crises) and experience with patient SR requests (to discuss SR or pray). They were also asked about their beliefs regarding SR in pediatric medicine. (Verbatim questionnaire items are displayed in Tables 1–3 of the Results section.) These questions were adapted from previously published studies and reflected recurrent themes in the literature regarding SR issues and physician beliefs/behavior.^9–15 At the end of the questionnaire, respondents indicated their gender, pediatric specialty, religion and/or religious denomination, and personal levels of religiousness and spirituality. The last 2 variables were rated on 4-point scales (1 = not at all, 2 = slightly, 3 = moderately, 4 = very).²² Because of their high correlation (r = .64; P < .001), the 2 items were summed to create a single index.

	RESULTS

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Sample Characteristics
The faculty respondents were 60.9% male (n = 28) and had been in pediatric practice for a mean of 18.4 years (SD: 8.0). The distribution of gender in the sample was not statistically different from the gender distribution for all faculty (² (1) = 0.3, P > .70). General pediatrics was the most common form of practice among the faculty (43.5%, n = 20), followed by neonatology (10.9%, n = 5), critical care (8.7%, n = 4), emergency (8.7%, n = 4), hematology/oncology (6.5%, n = 3), developmental (4.3%, n = 2), cardiology (4.3%, n = 2), pulmonology (4.3%, n = 2), genetics (2.2%, n = 1), allergy/immunology (2.2%, n = 1), endocrinology (2.2%, n = 1), and gastroenterology (2.2%, n = 1). Of the 40 faculty who supplied data on religious affiliation, the majority were Christian (67.5%, n = 27; including Catholic, 40.0%, n = 16; unspecified Christian, 17.5%, n = 7; and Baptist, Methodist, Presbyterian, and Episcopalian, 2.5% each, n = 1 each), followed by no religious denomination (10.0%, n = 4), Jewish (7.5%, n = 3), Muslim (5.0%, n = 2), Unitarian (5.0%, n = 2), Hindu (2.5%, n = 1), and Buddhist (2.5%, n = 1). The data on religion are comparable to those for the US population as a whole,²³ where 76.5% were identified as Christian, 13.2% as no religious denomination, 1.3% as Jewish, 0.5% as Muslim, 0.4% as Hindu, and 0.5% as Buddhist. However, among the Christian denominations, Catholics were overrepresented in our sample. Approximately one quarter of members of the general population identify themselves as Catholic, whereas 40% of our sample was Catholic. Faculty religiousness had a mean of 2.5 (SD: 0.9), and spirituality had a mean of 2.8 (SD: 0.9). (Because participation was anonymous, the only possible comparison between responders and nonresponders was for gender.)

The resident respondents were 68.2% female (n = 30) and had been in residency for a mean of 1.9 years (SD: 0.9). The gender distribution in the sample was not statistically different from the gender distribution for all residents (² (1) = 0.1, P > .75). Of the 35 residents who supplied data on religious affiliation, the majority were Christian (85.7%, n = 30; including Catholic, 48.6%, n = 17; unspecified Christian, 14.3%, n = 5; Methodist, 6.7%, n = 2; and Baptist, Lutheran, Presbyterian, Episcopalian, Pentecostal, and Latter Day Saints, 2.9% each, n = 1 each), followed by Jewish (5.7%, n = 2), no religious denomination (2.9%, n = 1), Muslim (2.9%, n = 1), and Hindu (2.9%, n = 1). Compared with the general population, the resident sample was predominantly Christian and Catholic, with few residents indicating no religious denomination. Mean resident religiousness was 2.7 (SD: 0.8) and mean spirituality was 3.0 (SD: 0.8).

Descriptive Data
Table 1 displays the responses of the faculty and residents regarding SR inquiry. Fewer than 10% of faculty and none of the residents routinely performed a spiritual history with new patients. Faculty were significantly more likely than residents to say that they routinely inquire about religious affiliation. (This finding may have reflected increased faculty awareness, relative to residents, that religious affiliation is collected on a standardized nursing form for new patients in the facility in question. It is perhaps more notable that less than one quarter of the faculty and <10% of the residents indicated that they knew this information was available.) SR inquiry increased during health crises. Table 2 documents pediatrician experiences with patient SR requests, both routinely and during crisis. Residents were significantly more likely than faculty to report being asked to pray at times of health crisis. Table 3 displays responses to belief items. Residents were more likely than faculty to agree that religious beliefs positively affect health, that religious involvement reduces patient morbidity and mortality, that support of patient religious practices can improve health care outcomes, and that offering to pray with patients is appropriate pediatrician behavior. Faculty were more likely than residents to believe that religious issues are the province of pastoral care.

View larger version (18K): [in this window] [in a new window]   Fig 1. Data analysis model: SR beliefs and clinical practices are first adjusted for pediatrician characteristics; then beliefs are used to predict practices.

	DISCUSSION

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In the only other peer-reviewed study of pediatricians and SR, the findings of Siegel et al²⁰ were similar to those reported here. That study found a prevalence of SR inquiry of 19%, comparable to the 16% found here (regarding inquiry about religious affiliation). Similarly, 65% of the Siegel et al sample believed that faith plays a role in patient healing, whereas 82% of the current sample believed that patient religious beliefs positively affect health. Nearly two thirds (64%) of the Siegel et al sample believed that SR discussions strengthen the clinician–patient relationship, whereas 58% of the current sample believed this. Notable differences between the 2 samples were the result of critical differences in questions. For example, a large majority of the Siegel et al pediatricians (90%) believed that prayer with patients is appropriate if the patient asks. When asked whether pediatrician initiation of prayer with patients was appropriate, only 53% of the current sample thought so. Clearly, the difference between responding to patient requests and initiation of prayer is critical. This is borne out by other data. In a previous study of medical students from the same institution as the current sample, 95% of respondents thought that it was appropriate for physicians to pray with a patient if asked.²⁵ A similar case could be made for questions about pediatrician facilitation of patient SR needs. In the Siegel et al study, 45% of respondents indicated that they do contact spiritual community leaders on behalf of patients. In the current sample, 79% of respondents believed that pediatricians should facilitate contact between patients and religious support services. The difference between belief and actual behavior undoubtedly accounts for the large difference. Notwithstanding differences in questions, the majority of the findings across the 2 studies are comparable. This is true also for comparisons between the current results and qualitative data collected from pediatricians in Salt Lake City, Utah.¹⁴ A majority of pediatricians in both samples supported the idea that patient religious beliefs positively affect health (87% in Utah vs 82% here). In addition, concern over time as a barrier to SR inquiry was very similar (21% in Utah vs 24% here), as was the belief that religious values emerge over time, precluding the need for proactive inquiry (31% in Utah vs 33% here). The strong consistency between the studies is noteworthy given that the studies used different methodologies and the samples were drawn from areas strongly representative of different religious denominations (Latter Day Saints in Utah vs Roman Catholic in the current sample).

Comparisons with other research suggest that pediatricians do not, for the most part, view SR in medicine differently from nonpediatricians. In a survey study similar to the current research, Chibnall and Brooks¹³ asked internal medicine physicians, family physicians, neurologists, and surgeons about their SR beliefs and experiences. In both studies, <10% of physicians reported routine spiritual history taking, and similar proportions performed spiritual histories during health crises (31% overall here vs 30% among nonpediatricians). Also similar were concerns about imposition of beliefs onto patients (11% here vs 15% among nonpediatricians), discomfort with addressing SR (29% vs 30%), and lack of time (24% vs 26%), as were beliefs that religious involvement reduces morbidity/mortality (49% vs 43%), religious issues are the domain of pastoral care (21% vs 26%), attention to religion can improve patient outcomes (60% vs 64%), and religion is important to patients only during health crises (11% vs 8%). The nonpediatrician sample, however, reported twice as much routine inquiry about religious affiliation (32%, highest among internists) than the pediatricians (16%), whereas pediatricians were less concerned about patient resentment of SR inquiry (14% here vs 37% for nonpediatricians, highest among surgeons). Thus, pediatricians seem to have experiences and hold beliefs about SR in medicine that are very similar to physicians in primary care, neurology, and surgery. Moreover, Chibnall and Brooks found that physician discomfort with SR inquiry was inversely correlated with level of proactive SR inquiry in the clinic and that belief about the relevance of SR to health care outcomes was associated with both proactive SR inquiry and patient requests to discuss SR. Both of these findings mirror those reported here.

In addition to demonstrating comparability of results with other studies, the current research speaks indirectly to the place of SR in medical training. Pediatricians in the current sample and elsewhere^12,13 did not feel adequately trained to manage SR issues in the clinic and, perhaps as a result, were uncomfortable with the prospect. In a previous study, physician discomfort with SR was the sole multivariate predictor of SR activity in the clinic.¹³ Although the majority of medical schools in the United States are now incorporating aspects of SR into medical student education,²⁵ the pediatricians in our sample likely predated the current trend toward addressing SR in patient care. There is evidence that the marginalizing of SR in medicine may be inculcated early in training. In a study of first- and second-year medical students, fewer than half thought that training in spiritual history taking and instruction in the basic principles of major world religions was an acceptable use of medical school time.²⁶ Of the minority who supported such training, most believed that it should be voluntary or part of clinical rotations only. Conversely, there are also path analytic data for medical students suggesting that exposure to SR in the curriculum is associated with more positive attitudes toward SR inquiry and behaviors.²⁷ The present data suggest that changes in beliefs about SR may be important to changing SR behavior in the clinic. Physicians, however, must also feel prepared to introduce SR and manage the resulting dynamic. In combination with changing beliefs, incorporating models of SR inquiry into continuing physician education, medical student education, and resident training may be an effective way to address feelings of competence regarding SR.^27–31

A call for SR education may be necessary but not sufficient. A historical analogy exists with respect to training and attention to the "new morbidity" in pediatric care—specifically, social, behavioral, and developmental aspects of pediatric practice. Thus, in 1984, 5 years after a task force report on pediatric education,³² Weinberger and Oski³³ reported no change in emphasis across pediatric training programs regarding experiences with the "new morbidity." Only after the publication of the policy statement on the "new morbidity" by the American Academy of Pediatrics in 1993 did pediatric training programs begin directly and consistently to address social, developmental, and behavioral care as a focus of pediatric practice.^34,35 The present data suggest that medical education and residency training may already be having some impact on pediatrician approaches to SR, given that our residents were slightly more open than faculty in their beliefs regarding SR in the clinic. Nevertheless, the prevalence of spiritual inquiry was very low.

There are several limitations to the present study. Generalizability is an obvious issue. Our sample was drawn from an academic department of pediatrics in an urban location of a Midwestern city. The sample was also predominantly Christian and Catholic. Private practice pediatricians and those with different demographic profiles may respond differently to SR issues. However, the current data are strongly comparable to those collected from nonpediatricians in St Louis and pediatricians in Boston and Salt Lake City. The questionnaire was self-report, which raises the question of the extent to which reported activities and experiences match actual behavior and experiences. This is more of a concern for estimates of SR requests by patients than for reports of SR inquiry. A prospective study would be required to examine the actual behavior of the pediatricians regarding SR issues. A related issue is the nature of the questions themselves. For example, there is an important distinction between what physicians actually do in the clinic and what they believe physicians should do in the clinic. There is always the possibility of a positive response bias with a hypothetically stated value question ("should" questions). In defense of our questions, however, we found substantial variability in responses to most of the belief items (and eliminated the few that lacked variability), indicating that the physicians in our sample were not compelled simply to agree with questions about what pediatricians "should" be doing in an ideal situation. With respect to the data analysis, the requirement of combining the faculty and resident responses for the factor analysis may have missed constructs that underlie the responses of one group but not the other. For example, time factors may be more relevant to residents than faculty. However, the existence of differences in item responses between faculty and residents does not necessarily mean that the relationships (correlations) among the responses would be substantially different in each group. In any event, replication of our factor structure is certainly needed in future research. Finally, because participation was anonymous, it was not possible to compare responders with nonresponders on any variables but gender. Response rates, however, were very high, making the issue of representativeness less of a concern.

Clearly, more research is needed to understand the role of SR in pediatric medicine. Future studies are needed to examine the effect of SR inquiry on patient health outcomes, satisfaction with care, and general well-being during the illness experience. In addition, a finer understanding of the barriers to pediatrician incorporation of SR into clinical practice is needed, including the effect of interventions designed to address those barriers. The current data suggest that pediatrician approaches to SR are in part a function of their beliefs about SR, beliefs acquired and honed as a part of their training. This is not to say that personal insight and introspection regarding the physician’s own spirituality is unimportant with respect to responding to spirituality in patients. Sulmasy³⁶ has argued that personal reflection on one’s own spirituality allows access to the spiritual needs of patients in an inherently "spiritual" discipline. Nevertheless, in combination with the burgeoning evidence for the positive benefits to health and well-being of spiritually sensitive medical care, the present study supports the idea that attitudes, knowledge, and skills regarding patient spirituality are important additions to the physician arsenal, regardless of the particular religious orientation of the clinician. As Kepler³⁷ noted >30 years ago regarding the religious factor in pediatric care, "the association between religion in medicine has been long and intimate.... In the best interest of the whole patient, ... we have an obligation to continue that intrinsic relationship and to use, whenever indicated, the religious factor in the total care of the patient" (p. 130).

	ACKNOWLEDGMENTS

 
This study was supported in part by Department of Community and Family Medicine (Saint Louis University) research funds for the study of religion in medicine.

We thank Dr Nora Porter and Joanne Steinkoetter for assistance with data collection, Dr Paul Duckro and the Department of Community and Family Medicine for generous support, and all of the faculty and residents who completed the questionnaire.

	FOOTNOTES

 
Received for publication Jul 18, 2002; Accepted Nov 12, 2002.

Reprint requests to (C.A.A.) Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Hospital, 1465 S Grand Blvd, St Louis, MO 63104. E-mail: brooksca{at}slu.edu

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