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Ophthalmology Patients' Religious and Spiritual BeliefsAn Opportunity to Build Trust in the Patient-Physician Relationship
Gina Magyar-Russell, PhD;
Patricia Fosarelli, MD, DMin;
Holly Taylor, PhD, MPH;
Daniel Finkelstein, MD, MA in Theology
Arch Ophthalmol. 2008;126(9):1262-1265.
ABSTRACT
Objective To assess the prevalence of religion and spirituality as a component of ophthalmology patients' value systems.
Methods A brief questionnaire distributed to 124 consecutive patients was self-administered by the patient and was collected without identifier so that participants could be assured that answers would not affect their care. The main outcome measure was the prevalence of religious and spiritual beliefs and behaviors in ophthalmology patients.
Results The sample was predominantly Christian (76.6%). Of the participants, 82.3% reported that prayer was important (69.4% "very important" and 12.9% "moderately important") to their sense of well-being, and 45.2% reported weekly attendance at religious services. The prevalence of positive religious and spiritual interpretations of God's role in illness was higher than that of negative religious appraisals of God's role in illness.
Conclusions The prevalence and importance of religious and spiritual beliefs in this sample of ophthalmology patients suggests that, like other medical patient populations, religion and spirituality are significant, and often positive, components of patients' value systems. Attention to religion and spirituality is one aspect of acknowledging and respecting a patient's value system and of establishing a relationship that promotes trust for making joint therapeutic decisions.
INTRODUCTION
Ethical medical practice includes physician behavior, beyond technical competence, that promotes healing and optimizes the patient's welfare.1 A growing body of literature draws attention to the importance of physician behaviors that acknowledge the patient's status as a whole person, beyond the person's disease.2 The physician who respects the patient as a person with dignity must acknowledge the patient's value system to establish a relationship that permits conversations that nourish trust for joint therapeutic decision making.3 For many patients, religion and spirituality (R/S) is important to their value system4 and may represent a unique source of motivation and coping with life events,5 including the experience of personal illness (illness refers to the response of a patient to a disease).2 The physician who knows little about a patient's family status, occupation, and R/S beliefs may provide inadequate therapeutic guidance despite being technically competent. For this article, we define R/S as the highly individualized search for a sense of connectedness with the sacred.6 Knowing a patient as a whole person, including his or her R/S beliefs, may allow a physician to aid better in the adjustment, coping, and healing process in the face of disease.7
To begin an investigation of the role of R/S as a component of ophthalmology patients' value systems, we asked consecutive returning ophthalmology patients about their R/S beliefs and practices, their sources of social support, and their personal assessment of the severity of their eye disease.
METHODS
A 14-item survey (Figure) approved by the Johns Hopkins internal review board and compliant with Health Insurance Portability and Accountability Act regulations was given to consecutive patients before their scheduled appointment and was self-administered by the patient. One hundred twenty-four returning patients of an ophthalmologist with a subspecialty interest in medical retina disease (D.F.) consented orally, and by virtue of completing the questionnaire, to participate in the study. Fewer than 5% of patients approached declined participation. Surveys were anonymously collected in a "drop box," without identifier, so that participants could be assured that their answers would not affect their care. Half of the questions related directly to the patient's R/S beliefs, with the other 7 questions assessing demographic variables and the patient's understanding of, and level of concern regarding, their ocular condition. Survey responses were analyzed using descriptive analyses, Pearson product moment correlations, independent-samples t tests, and nonparametric statistics.
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Figure. Survey given to 124 ophthalmology patients.
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RESULTS
Sample demographic characteristics and R/S beliefs and practices are given in Table 1. Most patients reported awareness of their diagnosis, with 59.7% being seen for vision problems related to diabetes mellitus, 14.7% for vein occlusions, and the remaining 25.6% for a variety of conditions, such as macular degeneration, sickle cell anemia, and refractive error. Of the patients, 61.3% reported that the vision in at least 1 eye was good, 33.1% stated that vision was poor in at least 1 eye, and 6.7% reported that vision was poor in both eyes; 59.7% reported being "moderately" (33.1%) or "very" (26.6%) worried about their eye problem. Of the patients, 85.5% reported that should their vision worsen, they would be likely to receive help from relatives; 41.9% reported that help would be likely from neighbors, 28.2% from their religious communities, and 10.5% from coworkers (participants were instructed to check all sources of help that might apply to them).
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Table 1. Demographic Characteristics and Religious/Spiritual Beliefs and Practices of 124 Ophthalmology Patients
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Two questions, with multiple yes/no items within each question, inquired about patients' beliefs regarding the role of God in illness (participants were instructed to check all responses that applied to their beliefs) (Table 2). When participants were asked if they would like to discuss any role they believed God played in their eye problem with someone (survey item 11), 23.4% responded that they would like to discuss this with their ophthalmologist (D.F.), 20.2% with "family," 17.7% with "no one," 10.5% with a "neighbor or friend," 8.9% with "clergy," 4.8% with "other," and 0.8% with the "[ophthalmology] technician" (13.7% did not respond to this question).
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Table 2. Results of Survey Questions Assessing the Relation of God to Illness
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Patients who reported poor vision in 1 or both eyes were significantly more likely to report worry about their eye problem (t = –2.9, P  .01) and to believe that "illness is a mystery" (t = –2.5, P .05) compared with patients who reported fair or good vision in 1 or both eyes. These 2 groups of participants (poor vision in 1 or both eyes vs fair or good vision in 1 or both eyes) did not differ on R/S questions regarding the role of God in their illness, the meaning of illness in reference to their belief in God, their frequency of prayer, and how often they attend religious services. Participants also did not differ in their responses to R/S questions based on their age or self-reported eye diagnosis.
Using nonparametric statistics to control for unequal sample sizes, individuals who reported poor vision in both eyes displayed a trend toward believing that "God causes illness" compared with all other survey participants (z = –1.9, P .10). Age was significantly and positively related to reporting poor vision in at least 1 eye (r = 0.19, P .05) but was unrelated to worry about eye condition. Faith tradition was associated with different responses to some of the R/S questions. Christians were more likely to believe that God can influence cure ( 2 = 10.8, P .05) than were Jewish and agnostic participants, and there was a trend toward Christians believing that God gives strength to be "at peace" with illness (2 = 6.9, P .10) compared with Jewish and agnostic participants. Christians also reported more frequent R/S service attendance (2 = 23.6, P .01), and they rated prayer as more important than individuals reporting Jewish and agnostic belief systems (2 = 32.8, P .01).
COMMENT
This initial inquiry about the prevalence and importance of R/S beliefs in this sample of ophthalmology patients suggests that, as in other medical patient populations, R/S is a significant component of patients' value systems.8-10 Also consistent with other patient samples, the prevalence and mean ratings of "negative" religious appraisals of disease and illness (eg, God causes illness and "illness is a punishment") are much lower than more "positive" R/S interpretations of health problems (eg, "God gives me strength so that I am ‘at peace’ with my illness" and "illness is a way to make one stronger") (Table 2).8, 11-12 The consistency of these results across medical patient samples4 implies that R/S beliefs often can be a resource for patients in coping with adverse health problems and negative life events.5-6,8, 13
The data obtained from this questionnaire suggest that patients' expressions of R/S should be assessed and acknowledged by their ophthalmologist. Attention to R/S is one aspect of respecting the status of the patient as a whole person.7 By appreciating a patient's value system, the physician may progress beyond treatment of pathologic features of a disease and honor the patient's efforts to cope with his or her illness. A physician can then provide more effective management, which includes a compassionate response to the personal experience of disease.
Recent studies14-15 of physician attitudes toward R/S in clinical practice suggest that although many physicians believe that it is appropriate to discuss R/S if the patient broaches the topic, there is a general lack of physician comfort in raising R/S issues with patients. Reasons for not raising these topics with patients include lack of time, lack of training in obtaining an R/S history, concern about projecting physicians' beliefs onto patients, and uncertainty about the manner in which the physician should address R/S issues raised by patients.14-18 Studies18-19 that have investigated patient preferences, however, emphasize that patients often want a conversation with their physician regarding R/S, including physician expression of genuine interest in, and reinforcement of, patients' R/S efforts to cope with health problems.
LIMITATIONS AND FUTURE DIRECTIONS
The results of this study should be viewed as a starting point toward gaining a better understanding of the role R/S plays in the value systems, perceptions, and medical decision making of ophthalmology patients. Despite using nonparametric statistics to control for discrepancies in sample size, there were few non-Christian participants in this sample. This could produce biased results that are not representative of these non-Christian groups. Moreover, the specific questions that were asked of participants could be questions more consistent with Christian belief systems and, therefore, less relevant to non-Christians. In future studies with ophthalmology patients, it will be imperative to include standardized measures of R/S that have been validated with individuals from various faith traditions and belief systems.20 In addition, it will be important to link questions assessing R/S appraisals of illness directly to the patient's ocular condition to gain a more complete understanding of how patients may use their R/S beliefs to cope and make medical decisions within the context of vision problems. The present sample may be more R/S than other ophthalmology patient samples because of the attending physician's (D.F.) recognized interest in the physician-patient relationship, including R/S concerns. Although most patients are referred to this physician for their particular eye disease, it is important to consider his interest in R/S concerns as a possible confounding factor, so that R/S should continue to be studied in other ophthalmology patient samples.
Future studies should also continue to explore efforts to equip physicians with the tools they need to feel comfortable addressing R/S in patient encounters. Deciphering the most efficacious format for assisting the physician with this knowledge base and skill acquisition is important given the demands on physician time. Finally, research has demonstrated that most patients want the opportunity to share their R/S beliefs with their physician19, 21; however, whether such conversations have an effect on improved disease management is a question that remains open for empirical inquiry.
CONCLUSIONS AND RECOMMENDATIONS
These data from ophthalmology patients support a more holistic approach to patient care, including a brief patient-physician discussion of R/S. One method of overcoming some of the physician-reported barriers to inquiring about R/S18 may be further education and training. Many institutions have begun to provide formal training to medical students and residents and to offer continuing education courses to improve physician abilities and confidence in R/S assessment.22-23 Brief assessment could include the 4 questions suggested by the task force of the American College of Physicians19, 24-25: (1) Do you consider yourself spiritual or religious? (2) How important are these beliefs to you and do they influence how you care for yourself? (3) Do you belong to a spiritual community? (4) How might health care providers best address any needs in this area?
Although it may be unrealistic to suggest that all physicians in all settings ask these questions of all their patients, it seems reasonable that many physicians can ask these questions of many of their patients, perhaps during separate visits as a relationship develops. Asking these questions does not imply that the physician must have a firm background in theology or a personal R/S belief system. In addition, if a patient indicates that R/S is not a significant factor in his or her medical care, the physician can explore other coping mechanisms that are important for the patient. When a patient responds to these questions with a specific religious or theological concern, or an R/S belief that may run counter to recommended medical care, the issue should be explored further with the patient, the patient's minister or clergy person, or both.26 In such instances, the physician may also want to obtain consultation from an appropriate professional chaplain. Survey research18-19 demonstrates that most patients who respond to these questions asked by their physician will simply appreciate their physician's consideration of their values and may develop a greater sense of rapport with their physician.
Obtaining a brief R/S history, when it becomes a routine part of developing a relationship between the patient and the physician, may become more comfortable for the physician with time, add to an understanding of the patient's value system, provide the patient with a greater sense of trust in the physician, and assist in the healing process, especially when a cure is not possible.
AUTHOR INFORMATION
Correspondence: Daniel Finkelstein, MD, MA in Theology, Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 N Wolfe St, Maumenee 729, Baltimore, MD 21287-9227 (df{at}jhmi.edu).
Submitted for Publication: December 20, 2007; final revision received February 28, 2008; accepted February 29, 2008.
Author Contributions: Drs Magyar-Russell and Finkelstein had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This study was supported by grant R21# NS048593 from the National Institutes of Health National Center for Complementary and Alternative Medicine (Dr Magyar-Russell).
Additional Contributions: Kenneth I. Pargament, PhD, provided helpful comments on an earlier version of the manuscript.
Author Affiliations: Department of Psychiatry (Dr Magyar-Russell) and Wilmer Eye Institute (Dr Finkelstein), Johns Hopkins School of Medicine; Johns Hopkins Center for Mind-Body Research (Drs Magyar-Russell and Finkelstein); The Ecumenical Institute of Theology, St Mary's Seminary and University (Dr Fosarelli); Bloomberg School of Public Health, The Johns Hopkins University (Dr Taylor); and Johns Hopkins Berman Institute of Bioethics (Drs Taylor and Finkelstein), Baltimore, Maryland.
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