Published online January 2, 2007
PEDIATRICS Vol. 119 No. 1 January 2007, pp. e117-e123 (doi:10.1542/peds.2006-0642)
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ARTICLE

Pediatrician Characteristics Associated With Attention to Spirituality and Religion in Clinical Practice

Daniel H. Grossoehme, BCC, MDiva, Judith R. Ragsdale, MDivb, Christine L. McHenry, MD, MATSc, Celia Thurston, DMind, Thomas DeWitt, MDc and Larry VandeCreek, BCC, DMine

a Department of Pastoral Care, Children's Hospital Medical Center, Akron, Ohio
b Departments of Pastoral Care
c Community and General Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
d Spiritual Care Services, Children's Hospital of Michigan, Detroit, Michigan
e Consultant, Bozeman, Montana


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The literature suggests that a majority of pediatricians believe that spirituality and religion are relevant in clinical practice, but only a minority gives them attention. This project explored this disparity by relating personal/professional characteristics of pediatricians to the frequency with which they give attention to spirituality and religion.

METHODS. Pediatricians (N = 737) associated with 3 academic Midwestern pediatric hospitals responded to a survey that requested information concerning the frequency with which they (1) talked with patients/families about their spiritual and religious concerns and (2) participated with them in spiritual or religious practices (eg, prayer). The associations between these data and 10 personal and professional characteristics were examined.

RESULTS. The results demonstrated the disparity, and the analysis identified 9 pediatrician characteristics that were significantly associated with more frequently talking with patients/families about their spiritual and religious concerns. The characteristics included increased age; a Christian religious heritage; self-description as religious; self-description as spiritual; the importance of one's own spirituality and religion in clinical practice; the belief that the spirituality and religion of patients/families are relevant in clinical practice; formal instruction concerning the role of spirituality and religion in health care; relative comfort asking about beliefs; and relative comfort asking about practices. All of these characteristics except pediatrician age were also significantly associated with the increased frequency of participation in spiritual and religious practices with patients/families.

CONCLUSIONS. Attention to spiritual and religious concerns and practices are associated with a web of personal and professional pediatrician characteristics. Some characteristics pertain to the physician's personal investment in spirituality and religion in their own lives, and others include being uncomfortable with spiritual and religious concerns and practices. These associations shed light on the disparity between acknowledged spirituality and religion relevancy and inattention to it in clinical practice.

Key Words: pediatricians • pediatric practice • spirituality • religion

Abbreviations: SR—spiritual and religious/spirituality and religion

The pediatric literature contains few research studies concerning how the physicians' spirituality and religion (SR) are related to the clinical care they deliver. As Feudtner et al note, "[t]he literature on the spiritual care of sick children consists mostly of case studies, reviews of theories regarding spiritual development, suggested methods, and editorial opinion."1

Research concerning the physicians' own SR and their relationship to clinical care is important for at least 3 reasons. First, studies2,3 have documented that many patients/families want physicians to ask about their beliefs and practices. For example, MacLean et al4 reported that two thirds of primary care patients believe that physicians should be aware of their SR beliefs. From the physician perspective, Luckhaupt et al5 concluded that approximately half of primary care residents feel that they should play a role in their patients' SR lives. Writing from a pediatric perspective, Barnes et al pointed out that "[i]n every clinical encounter, a child's and family's spirituality and religious life will interact with that of the clinician."6(p901)

Second, the physicians' SR often enter into their clinical practice when they face medical situations that contain ethical/moral considerations such as physician-assisted suicide/euthanasia7,8,9 and sexuality concerns including contraception and abortion.10

Third, a clearer understanding of physician SR characteristics is important because physicians from religious minorities report increased harassment. Muslim, non–mainstream Christian, and Jewish physicians have reported a higher prevalence of harassment in their medical settings than those from majority religious groups.11,12 The relationship of physician SR characteristics to clinical practice, therefore, deserves continuing attention.

Three studies have examined the SR of pediatricians and their relationship to clinical practice. Siegel et al13 surveyed pediatric faculty and residents (N = 165) and found that 90% believed that faith played at least some role in healing. Attention to SR in clinical practice was associated with a strong personal SR orientation. They reported a discrepancy, however, between the attitude among pediatricians that they can appropriately initiate SR discussions with patients/families (35%) and the behavior of actually doing so (19%). In response to 6 clinical scenarios ranging from life-threatening to routine, most respondents (96%) reported that death situations warranted SR attention. In less serious cases, those with stronger SR orientations were more likely to initiate discussions than peers with weaker investment in SR.

In a smaller study (N = 90), Armbruster et al14 reported that a majority of pediatric faculty and residents in 1 training program believed that SR have health implications, strengthen the therapeutic relationship, and provide support for patients/families. They found, however, that only 7 percent of faculty and none of the residents routinely performed a spiritual history with new patients, a frequency that rose to 33% for faculty and 30% for residents when life-threatening illness had occurred.

Brooks and Chibnall15 reported the same disparity in a study of Salt Lake City pediatricians. Having interviewed a random sample of 61 pediatricians, they summarized their findings by making 2 points. First, most of the pediatricians believed that religion could have a positive role in patient care. Second, most pediatricians did not discuss the religious concerns of their patients/families.

The disparity identified in these reports suggests the need for additional investigation. Seeking to engage a larger sample, we hypothesized that results would demonstrate the same disparity and that clinical attention to SR concerns and practices of patients/families would be significantly associated with personal and professional characteristics of pediatricians. These results could clarify, within the limits of a cross-sectional study design, a web of associations related to this disparity and suggest additional research.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Participants
We surveyed all pediatricians in 3 academic Midwestern pediatric hospitals including residents, interns, and community pediatricians with medical staff privileges. The institutional review board of each hospital approved the study. The aggregate response rate was 58% (737 of 1275).

Instrument
We designed a questionnaire that requested information on 10 selected personal or professional characteristics that were possibly associated with giving attention to SR in clinical practice (Table 1). Two dependent-variable questions asked, "How often do you talk with patients/families about their SR concerns?" and "How often do you participate in SR practices with patients/families (eg, prayer, chanting, meditation?)" (Table 2).


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  		TABLE 1 Pediatrician Personal/Professional Characteristics

 

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  		TABLE 2 Frequency of Talking With Patients/Family Members About Their SR Concerns and Participating With Them in SR Practices

 
Procedure and Analysis Process
Hospital staff members received a cover letter, the survey, and a return envelope. After 2 weeks, a postcard thanked responders and encouraged nonresponders. After 2 additional weeks, nonresponders received a revised cover letter, the survey, and a return envelope. Pearson's {chi}2 statistic was used to determine statistical significance (P ≤ .01).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Personal and professional characteristics of the sample are described in Table 1. As the results in Tables 1 and 2 indicate, the disparity between relevancy and attention to SR in clinical practice identified in the previous studies is again evident. In this study, 73% agreed that their own SR were important in their delivery of care, and 76% indicated that the SR of their patients/families were relevant to their practice (Table 1). However, 51% never or rarely talked with patients/families about SR concerns (Table 2). Ten percent frequently or always gave attention to these concerns. In addition, 89% never or rarely participated with patients/families in SR practices (ie, prayer).

Several pediatrician characteristics were associated with providing attention to SR concerns and practices. Examination of the relationship to pediatrician gender suggested no significant relationships. Respondent age, however (clustered in the survey into the 4 decades displayed in Table 1), demonstrated a significant relationship (Table 3). The youngest respondents (25–35 years) talked less frequently about SR concerns than older pediatricians. No significant association was found between age and participating in SR practices with patients/families.


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  		TABLE 3 Pediatrician Characteristics Significantly Associated With the Frequency of Talking With Patients/Families About Their SR Concerns

 
Most respondents reported a Christian heritage (72%). When compared with those from other religious heritages, those with a Christian heritage talked more frequently with patients/families about SR concerns (Table 3); they also participated more frequently with patients/families in SR practices (Table 4).


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  		TABLE 4 Pediatrician Characteristics Significantly Associated With the Frequency of Participating With Patients/Families in Their SR Practices

 
Respondents who identified themselves as religious (72%) talked more frequently with patients/families about SR concerns than their nonreligious peers. This pattern continued in regards to the frequency with which they participated with patients/families in SR practices.

Pediatricians who self-identified as spiritual persons (83%) more frequently talked with patients/families about SR concerns than those who denied being spiritual. Participation in SR practices with patients/families reflected the same trend; respondents who described themselves as spiritual were involved more frequently.

A survey item questioned whether the pediatrician's own personal SR were important in their practice of medicine. Those who affirmed the importance (73%), when compared with those who denied such importance, talked more frequently with patients/families about concerns. They also participated more frequently with them in SR practices.

Another item inquired whether they regarded patient/family SR as relevant to their practice of medicine. When compared with those who denied relevancy, those who responded positively (76%) more frequently talked about SR concerns and more frequently participated in SR practices with patients/families.

A minority of pediatricians reported at least some formal instruction concerning the role of SR in health care (13%), and they talked more frequently with patients/families about SR concerns and participated with them in their SR practices. Respondent age was significantly associated with this training ({chi}2: 23.81; P = .001). Among those who reported this training, 46% were 25 to 35 years old, compared with 10% in the ≥55-year age group.

The final 2 questionnaire items concerned pediatrician comfort levels when talking with patients/families about SR concerns and participating with them in SR practices. Results demonstrated highly significant relationships, because those who reported more comfort inquired about SR concerns and participated in SR practices more frequently.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The disparity between acknowledged relevancy and lack of attention found in the previous studies is again documented here. A majority of pediatricians (76%) agreed that patient/family SR were relevant to their practice, but 51% of the respondents never or rarely talked with them about these concerns; only 10% did so frequently or always. Siegel et al13 report that 19% stated that they at least sometimes inquired about SR. Armbruster et al14 report the frequency with which pediatricians inquire about SR in routine and crisis situations. When health crises arose, 56% inquired about faith-group affiliation, and 35% obtained a spiritual history.

These results suggest that variations in the frequency of attention to SR concerns are associated with 9 personal and professional characteristics of pediatricians. Those who more frequently engaged patient/family SR concerns are characterized as older pediatricians from Christian heritages who describe themselves as religious and/or spiritual, who believe that their SR and those of patients/families are relevant to clinical practice, who report at least some formal instruction concerning SR in health care, and who are more comfortable in such interactions. Conversely, younger pediatricians who did not report Christian heritages, who thought of themselves as irreligious or nonspiritual, who believed that SR are unimportant and irrelevant to clinical practice, and reported no formal instruction in the role of SR in health care tended not to give attention to SR concerns or practices. They also reported being uncomfortable asking about SR concerns or participating in SR practices. These results confirm and extend the results of previous studies. As the Siegel et al13 results suggest, pediatricians with a strong sense of their own SR tend to engage these concerns of patients/families.

These results suggest that pediatricians rarely participate in SR practices with patients/families; 89% indicated that they never or rarely did so. The Siegel et al,13 Armbruster et al,14 and Brooks and Chibnall15 studies reported no results concerning such participation. Monroe et al,16 however, surveyed internal medicine and family practice faculty and residents concerning circumstances in which they believed they should pray with patients. The sequence of items varied the clinical setting (routine office visit, a hospitalized patient, and a patient near death) and the physician's level of involvement (saying a silent prayer for the patient, praying with the patient). The item sequence also gathered data concerning the physicians' initiative by repeating items with the preface, "If the patient requests... ." The odds ratio of praying with patients in each clinical setting significantly increased with physicians' greater investment in SR and the patients' more serious medical condition. Although our results suggest that participation in SR practices with patients seldom takes place, the results reported by Monroe et al suggest that such involvements, similar to talking with patients/families about SR, are related to clinical context, the physician's investment in SR, and the role of patient request.

Some authors17,18 have pointed out that physicians are poorly trained to respond to patient/family SR concerns, thereby suggesting that additional training can reduce the disparity between perceived SR relevancy and clinical attention. The results of our study suggest that the role of additional training may be limited, because attention to SR in clinical practice is deeply intertwined with the personal SR life of the individual pediatrician. It will be difficult to address this personal motivation, or lack thereof, for giving attention to SR in the context of training. The results suggest that the pediatricians who are most likely to engage in additional training are those who already value and provide SR attention. The remaining pediatricians do not believe that SR are relevant, which would limit their interest in training.

The results of our study encourage comparisons to other medical specialties in regard to personal SR characteristics and how they interface with their clinical practice. Curlin et al19 described results from a stratified random sample of US physicians and reported that 52% described themselves as religious and spiritual, 4% were religious but not spiritual, and 23% were neither religious nor spiritual. In our study, 72% of pediatricians characterized themselves as religious and 83% as spiritual (Table 1), leaving ~17% who regard themselves as neither religious nor spiritual. This suggests that pediatricians tend to be more personally invested in SR than their peers in other specialties.12,19

Daaleman and Frey20 described results from a random sample of active members of the American Academy of Family Physicians and pointed out that those who practice in rural and suburban areas are significantly more SR than their colleagues in urban areas. Because family physicians and pediatricians produce similar religiosity profiles,12,19 the Daaleman and Frey results imply that rural and suburban pediatricians are even more invested in SR than those in our urban sample.

Curlin et al19 found that 55% of their random sample of US physician believed that their religious beliefs influenced their practice. In our sample of pediatricians, 73% indicated that their own SR are important in their clinical practice. The differences in these percentages suggest that pediatricians, in comparison to their peers, more frequently acknowledge the truth of the claim by Barnes et al6 that the child's and family's SR will interact with those of the clinician in every clinical encounter.

At least 4 limitations must be considered when evaluating our results. First, a custom survey instrument generated the results, and no information is available concerning its validity or reliability. Second, responses came from pediatricians with staff privileges in Midwestern academic centers. They may not accurately represent pediatricians outside the Midwest, those who practice in less urban areas, or in less academic settings. Third, we allowed pediatricians to use their definition of religion and spirituality. We believed that this simplified and thus encouraged participation, but it also likely allowed variation in the definition of these terms for which we cannot account. Fourth, these cross-sectional results cannot be linked to conclusions regarding causality.

Future research should give attention to at least 3 areas of concern. First, the acknowledgment of the relevancy of SR does not automatically mean that pediatricians give attention to it. The decision to give attention to SR is the product of the priority the individual pediatrician attributes to them within the multiple pressures and responsibilities of clinical practice. Siegel et al13 began exploration of this concern by demonstrating that more life-threatening clinical situations (ie, death, dying) merit SR attention. Future research should give additional attention to the process by which pediatricians assign priority to SR in the context of their various clinical responsibilities.

Second, although pediatricians acknowledge SR relevancy, their inattention to them may be related to the practice boundaries they set for themselves. Individual pediatricians establish such boundaries in the context of training, subspecialty characteristics, and personal preferences. They may regard a wide range of specific clinical data as relevant, even important, but choose not to give it direct attention because they believe it falls outside their professional boundaries or within the domain of other health care professionals (eg, nurses). Attention to SR concerns and practices is no exception. Apart from instances in which religious beliefs directly impinge on treatment and practice, pediatricians may believe that routine attention to SR is the responsibility of chaplains.21 Indeed, the Armbruster et al study reports that 42% of their pediatrician sample agreed that "[p]atient/family religious issues are the province of pastoral care, not the pediatrician."14(pe230) Additional research should explore how such perceived boundaries pertain to SR concerns and practices.

Third, many of the associations reported here pertain to the private SR lives of pediatricians themselves. Such characteristics may not be amenable to change in response to present and future scientific evidence regarding the helpfulness of giving attention to SR. What is the role of evidence when practice patterns are deeply embedded in personal beliefs and assumptions concerning SR rather than scientific evidence? For example, suppose evidence emerges that pediatrician attention to SR concerns of patients/families is very helpful. Will this evidence increase SR attention from pediatricians who are not religious, do not regard themselves as spiritual, and who regard SR as irrelevant to their practice? To what extent does research evidence lose its power to convince when it pertains to beliefs and attitudes about SR and its relevancy to clinical practice?


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The results of this study, when considered in the context of previously published reports, can help pediatricians and other health care providers further understand the contexts and complexities associated with engaging SR concerns in clinical practice.


   ACKNOWLEDGMENTS
 
We thank Dykstra Consulting (Chicago, IL) for data entry. Robert Tamer and Judy Bean (Department of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center) provided assistance with analysis.


   FOOTNOTES
 
Accepted Aug 7, 2006.

Address correspondence to Daniel H. Grossoehme, BCC, MDiv, Cincinnati Children's Hospital College, Hill Campus, 5642 Hamilton Ave, Cincinnati, OH 45224. E-mail: daniel.grossoehme{at}cchmc.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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