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Another Useless NCCAM-Funded Study

Sometimes I read an article in a medical journal that makes me say, “Well, duh! I could have told you that without a study.” Sometimes I read collected data that make me ask, “So what?” Sometimes I read an article that makes me wonder what kind of pogo stick they used to jump from their data to their conclusions. Sometimes I read a study that is so poorly conceived that you couldn’t hope to get any useful information from it. Sometimes I read a study that reminds me of class projects or term papers where you just thought of something easy to do to fill the squares to get credit. Sometimes I read a study funded by the NCCAM that makes me very angry that they wasted my tax dollars. Sometimes all these things coincide in one article.

“Ophthalmology Patients’ Religious and Spiritual Beliefs: An Opportunity to Build Trust in the Patient-Physician Relationship” is such an article. A questionnaire was anonymously filled out by 124 consecutive return patients in one ophthalmologist’s practice. It asked about their religious and spiritual beliefs and their understanding and level of concern about their eye condition.

Results:
    • 76.6% Christian
    • 82.3% reported that prayer was important or very important to their sense of well-being
    • 45.2% reported weekly attendance at religious service
    • More patients had positive interpretations of God’s role in illness than negative interpretations

They concluded,

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.

Why did they do this study? We already have demographic information about religious beliefs and practices; what could be gained by studying one more small sample? Could anyone be surprised to learn that most of these patients were Christians, that most found prayer helpful, that many attended religious services, and that more of them agreed with “God can help me with my illness” than “God caused this illness to punish me”?

Why study ophthalmology patients? Was there any special reason? Of course not. This was a sample of convenience. All patients were from one doctor’s practice. The doctor was a subspecialist in medical retinal diseases. There were more female patients than males, and the age range was markedly skewed towards older age groups. We aren’t told anything about their socioeconomic status. In short, this was a nonrepresentative sample of the population. It wasn’t even representative of the average ophthalmologist’s patients.

Some of the statements pushed my “Well, duh!” button:

    • “Most patients reported awareness of their diagnosis.”
    • “Patients who reported poor vision…were significantly more likely to report worry about their eye problem… compared with patients who reported fair or good vision.”
    • “Christians reported more frequent religious service attendance… than individuals… reporting Jewish and agnostic beliefs.” [What, you mean agnostics aren’t regular church-goers?]
    • Since there were few non-Christians in this sample, “This could produce biased results that are not representative of these non-Christian groups.”

They admitted that this particular ophthalmologist was known to have an interest in religious and spiritual concerns; in fact, he has an MA in theology. Patients who knew that might have been subtly influenced to give answers more favorable to religion. The data was all from self-reports – how do we know they really attended church or prayed as much as they reported? How much can we trust the results when some items were left blank and 6.5% of the sample didn’t even report their sex?

Even assuming the results were valid, what do they mean? The authors say “The consistency of these results across medical patient samples implies that R/S beliefs often can be a resource for patients in coping with adverse health problems and negative life events,” but

    • Since there were already consistent results across other medical patient samples, that just points out how unnecessary the present study was.
    • Consistency only shows that information about beliefs is consistent; it says nothing about whether those beliefs are a resource.
    • It goes without saying that beliefs can be a resource for some patients. So what?

They recommend asking all patients:

    • Do you consider yourself spiritual or religious?
    • How important are these beliefs to you and do they influence how you care for yourself?
    • Do you belong to a spiritual community?
    • How might health care providers best address any needs in this area?

Their subtitle is “An Opportunity to Build Trust in the Physician-Patient Relationship.” They have established that patients have beliefs; they have done nothing to show that asking about those beliefs builds trust. They suggest that obtaining a routine religious/spiritual history may “assist in the healing process, especially when a cure is not possible.” That’s just speculation unsupported by any data.

They want us to know the patient as a whole person including his religious beliefs. OK. Good clinicians have always been holistic practitioners. We treat people, not diseases. We want to know what kind of person we’re treating and how social/financial/family and other concerns might impact on health care. But why emphasize religious beliefs? Why not ask about the patient’s beliefs about alternative medicine, ability to afford medication, attitudes that might affect compliance? Why not ask about his music preferences, favorite sports team, grandchildren, politics? Many nominally religious people are really apatheists; they don’t think about religion very often or care about it very much. Some patients are far more involved with and passionate about non-religious concerns; the authors have not made a case that knowing about a patient’s religion is any more important than knowing about other aspects of a patient’s life.

They say

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.

I find this insulting. Every good clinician honors the patient’s efforts to cope with illness; every good clinician manages patients effectively and has a compassionate response to the personal experience of disease. Most good clinicians accomplish that without specifically asking patients about religion; the authors have not shown that engaging in a religious discussion improves the physician/patient relationship.

Some patients may appreciate their doctor asking them about spiritual matters; others may be offended. If the doctor doesn’t share the patient’s beliefs, it might tend to undermine trust rather than build it. This can be a rather delicate area that good clinicians have always managed to navigate judiciously. I don’t think they have made a case for routinely asking every patient about religion.

A more appropriate subtitle might have been “An Opportunistic Exercise to Build CVs and Promote Religious Belief.” This goes on the NCCAM’s scorecard as one more instance of wasting our tax dollars on studies that should never have been funded. That list is long and is steadily getting longer.

Posted in: Faith Healing & Spirituality, Science and Medicine

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25 thoughts on “Another Useless NCCAM-Funded Study

  1. Peter Lipson says:

    Like most clinicians, I ask about religion only if the patient has made it clear to me that this is important to them, and it is somehow clinically relevant.

    The quickest way to lose a patient’s confidence is to bring up religion or politics unsolicited.

    Great piece! (Lousy paper)

  2. David Gorski says:

    There is currently a movement in medicine to insist that being religious is inherently healthier than being non-religious. Some of its more extreme adherents insist that a clinical history is not complete without a “spiritual” history. One advocate of this point of view, Walter Larimore, has even gone so far as to declare that excluding God from a consultation should be grounds for malpractice. I kid you not. Such physicians go beyond even that and advocate recommending (i.e., prescribing) “religious activity” to patients. A couple of years ago, Richard P. Sloan published an excellent book entitled Blind Faith: The Unholy Alliance of Religion and Medicine that documents these sorts of abuses. The “Cliff Notes” version is an article he published here:

    http://www.latimes.com/news/opinion/la-oe-sloan2dec02,0,4668000.story

    My perspective is that this sort of activity is a grave abuse of the trust and power patients accord to their physicians. It is in essence a religious freedom and patient autonomy issue. Physicians have no business abusing their position to proselytize. After all, how would a Jewish patient feel about a Catholic physician proselytizing, or vice-versa? What about an atheist patient being told that he should pray if he wants to get better?

    But there’s a more dire implication. If a physician believes that religion is healthier than non-religion, how long before he starts wondering if one religion is healthier than another and that patients should engage in that religion over others? Not long, I’ll warrant.

    None of this is to say that chaplains shouldn’t be allowed in hospitals or anything like that. Patients derive solace from their religion. Nor do I necessarily see it as wrong if physicians engage in prayer with their patients if physician and patient already share the same religious background so that there is no disconnect. What I do have a serious problem with is physicians claiming that religion (excuse me, “spirituality,” a word whose use fools no one) is essential to health and that physicians should in essence meddle in the religious life of their patients.

  3. TheProbe says:

    NCCAM does serve a useful purpose. When a Altie whines that no one will fund Dr. Weirdo’s study because of X, Y & Z, I point out that there are funds a-waiting at NCCAM, but, Dr. Weirdo did not apply because it would be bad for business, since negative results must be published.

    Note that some of the real quacks, Hulda Clark, Stan Burzynski, et al, always claim that they are conducting “research” but, strangely, not applying for the big bucks at NCCAM. Customer/patient supported research.

  4. medstudt says:

    As a reader of this blog, I have the impression that NCCAM funds a lot of sloppy and unnecessary work. Is there any systematic review of NCCAM-funded studies, perhaps comparing their quality to studies funded by another NIH branch? Given the current tight funding environment, a review detailing wasteful research spending could mobilize shruggies.

  5. Fifi says:

    I wonder how many people lied to their doctors about how often they pray and go to church? I mean, it’s common for patients to lie (or fib a little bit to make themselves look “good”) about their other habits like diet and exercise.

  6. Skip says:

    I’m a first year Med Student and nothing made me sadder than to go on a 4 hour shadowing assignment with a Family Practice doctor who brought up: Political Comments, Sexist remarks, explained his role as a liaison between ‘western and eastern medicine’ and took pride in going to get certified in Acupuncture to provide more complete care for his patients.

    There are so many doctors out there who may read this article and think it’s the bee’s knees. Rather than defend the role of the scientist, doctors are embracing the role of the quack. I know I am not alone in my class in feeling this way, but I do not believe we are the majority.

    -Skip

    *Disclaimer, I’m allowed one post per day with horrible grammar… and that is this one.

  7. Calli Arcale says:

    Regarding lying about one’s religious attendance, I think Fifi is right that people tend to exaggerate it — one way or the other, depending on their religious perspective and probably also depending on how they perceive the investigators’ religious perspective. In general, though, I think such surveys tend to reflect people’s ideals rather than their reality. They *can* be useful for gauging trends, but the figures for actual attendance will undoubtedly not be consistent with reality.

    There is currently a movement in medicine to insist that being religious is inherently healthier than being non-religious.

    I think this movement has always existed, throughout human society. It’s not so much a new movement as a resurgence of a very old one. Skepticism and scientific thinking are relatively new concepts to the West, only taking hold in the mainstream since the Enlightenment. They form the basis of our gigantic leaps in scientific understanding over the past few centuries. It’s human nature, I suppose, but your post, Dr Gorski, is a serious wake-up call that all scientifically-minded folks need to be on guard against it. That’s scary stuff you’re talking about. I mean, I consider myself religious, insofar as I go to church regularly, pray to God, and believe fervently in Jesus Christ. But it’s terrifying, on so many levels, to think of a doctor believing this is so significant to my physical health that it would be malpractice not to bring it up. Heck, it’s even in direct conflict with my faith!

    I do not understand why so many people want to return to the bad old days. I can only conclude it is because they don’t really understand how dangerous this sort of thinking (or rather, non-thinking) is.

  8. delaneypa says:

    At Georgetown Medical School where I trained (a Jesuit institute), we were encouraged to pry into all aspects of our patients lives…their health, their financial circumstances, employment status, their beliefs, their religion, etc. all to be “holistic”. When I did that, people basically got annoyed, and with good reason.

    Physicians take care of medical problems, in the context of the other aspects of a patient’s life. A physician is not a minister, not a financial advisor, not a lawyer, not a marriage counselor. Unfortunately, some physicians unwittingly assume that their expertise in one field makes them experts in others.

  9. If a doctor were to ask me about my religious faith (or lack thereof) as a precursor to suggesting I attend church to help me feel better, I would be polite to him in the office and afterwards drop him like a hot rock and seek another doctor.

    “How might health care providers best address any needs in this area?”, the article queried. It is not the job of healthcare providers to address needs in that area, nor should it be.

  10. Fifi says:

    What I find most deliciously ironic about this is that one of the accusastions often leveled against doctors and scientists by the pseudoscientific and religious anti-science crowd is that they think or feel that doctors and/or scientists consider themselves to be (or want to usurp the role of) “priests” or that science based medicine is a “religion”.

  11. Danio says:

    Nor do I necessarily see it as wrong if physicians engage in prayer with their patients if physician and patient already share the same religious background so that there is no disconnect.

    I’m interested in how you would set the ground rules for this, or if the AMA has an official–or unofficial–position on praying with patients. There is a practicing Ophthalmologist in my city who routinely asks every patient to pray with him before he performs LASIK, etc. He is unconcerned with the religious beliefs of the patients in question, as evidenced by his request to share a pre-op prayer with a friend of mine who is an atheist Jew. She agreed, mostly because she didn’t want to ‘throw him off his game’ by refusing, and her procedure was extremely successful. It troubles me that her response might not be all that uncommon–that other patients with different beliefs might feel pressured to comply with his request only because he is moments away from applying a laser to their eyeballs, and they fear that a rejection of his request could lead to complications with the procedure.

  12. Joe says:

    I read this early today, I have finally recovered (somewhat). I tried to find out how much money these people got for this “research” with no luck. It shouldn’t cost more than a few cents since they only used 124 pieces of paper to poll the subjects.

    On top of that, there are four(!!) authors for the publication. How many theologians does it take to screw in a lightbulb? (I know, they screw in a bed.)

    Is that a “journal” that has no reputation to uphold? It seems to be an AMA publication. We get bad articles in Am Chemical Soc publications; but, Dang …

  13. Fifi says:

    It does, however, put a whole new slant on my eye doctor checking my “vision” and asking if I “see the light”! Perhaps this is some kind of new age thing where they think opthamologists ARE priests because they take care of “vision”.

  14. David Gorski says:

    I’m interested in how you would set the ground rules for this, or if the AMA has an official–or unofficial–position on praying with patients. There is a practicing Ophthalmologist in my city who routinely asks every patient to pray with him before he performs LASIK, etc. He is unconcerned with the religious beliefs of the patients in question, as evidenced by his request to share a pre-op prayer with a friend of mine who is an atheist Jew. She agreed, mostly because she didn’t want to ‘throw him off his game’ by refusing, and her procedure was extremely successful.

    That’s exactly the problem, isn’t it? I think it’s a matter of history. What I mean is if patient and physician are in the same congregation and had thus prayed together before, then I don’t see anything wrong with the physician asking to pray with the patient. After all, patient and doctor are the same religion and have prayed together before. Other than that, though, I’m hard-pressed to come up with an example where it’s ethically acceptable for a physician to ask his or her patient to pray with him, especially before a procedure.

  15. Harriet Hall says:

    To put the prayer request into perspective, what would happen if the physician asked the patient to participate in a ceremony to sacrifice a goat? :-)

  16. Danio says:

    I’m hard-pressed to come up with an example where it’s ethically acceptable for a physician to ask his or her patient to pray with him, especially before a procedure.

    I agree–and I fear that unethical behaviors such as this go unchallenged more often than not, either because of the inherent inequities of the doctor-patient relationship or because of the degree to which many patients would tend to be ‘shruggies’ in theses circumstances–especially if the treatment had a positive outcome. I wonder how many patients would feel as sanguine if the surgeon asked permission to throw the I Ching, or consult astrology charts before proceeding with the treatment? Are there any MDs out there willing to test their patients’ tolerance of random superstitious pre-op behaviors? I’ll be we could put together a cracking NCCAM proposal!

    Fifi, do you suppose ophthalmology residents are now being taught that the eyes literally are the windows to the soul?

  17. Danio says:

    Sorry, Harriet, I didn’t see your comment before I posted mine. I did try to select…er…non-invasive practices in my example that would be perhaps more comparable to the innocuous, passive nature of praying.

    I suppose that much also depends on the nature of the prayer itself. A petition of “Heavenly Father, I ask You to steady my hand as I do Your work and save this faithful servant’s sight” might evoke a somewhat different patient response from “Hail Satan, allow me to restore this man’s sight, so that he might better work Your will upon the earth”

  18. Fifi says:

    What I want to know is whether I can claim religious oppression if my doctor refuses to perform satanic rituals or tries to pray over me if I happen to be a satanist? (Since, obviously, being a satanist any prayers to a god would be the equivalent of cursing me.)

  19. wertys says:

    I’m SSOOOOO glad I’m not an American taxpayer….

  20. borealys says:

    I can imagine situations where questions about religious beliefs and involvement would be relevant. In dealing with mental health issues and stress-related illnesses, for instance, it would be helpful to know about a person’s community involvement and support network. So long as it’s treated as just one aspect of community life, I’m fine with questions about religion from my GP (not that she ever has asked, but I’d be fine with it if she did). But an ophthalmologist?? I’d be looking for a new eye doc the very next day.

  21. Prometheus says:

    I read the study (it may take me years to get over that) and I have to admit that my reaction to the data they collected (as opposed to their conclusions) was:

    So what?

    The patients were about what you’d expect in a retinal specialist’s office in a major metropolitan area of the US: older, Chtistian, moderately religiously observant.

    Their conclusions, however, ranged from the fatally obvious (doctors should be sensitive to their patients’ religious beliefs) to the “where did that come from?” (that asking about a patient’s religious beliefs builds trust).

    Apart from the personal issue I might have about my physician (or other “health care provider”) asking about my religious views, I can’t see where their data supported most of their conclusions.

    For example: just because someone thinks that prayer is “moderately important” or even “very important” does not mean that they want to pray with their physician. Nor does it mean that they want their physician asking them about their religious beliefs or practices.

    I have to wonder how many of these patients simply filled out the questionaire with the answers they thought the doctor wanted to hear (or the answers they thought they should give).

    It’s a meaningless study that – worst of all – was designed so badly that it was guaranteed to give meaningless results. Even the most rudimentary review of the study design should have revealed that it had no hope of finding anything useful.

    If that’s the kind of scrutiny that the NCCAM gives to its grant applications, I’ve got to find a way to “spin” my research into a “CAM” project.

    Prometheus

  22. Fifi says:

    I have a slightly off topic question… Does NCCAM have people appointed to positions of authority by the government? Is it managed and staffed like FEMA is? It kinda sounds like it is so I’ve got to wonder whether people making decisions are political appointed or how they are chosen to be in the positions they’re in since clearly they don’t know what they’re doing (unless what they’re doing is actually something other than the job of giving out money for and guiding research).

  23. The Blind Watchmaker says:

    A relative of mine was recently diagnosed with colon cancer. After getting the news from the gastroenterologist, she went to her internist. She wanted to get a plan of action started.

    During the visit, he said, “Do you believe in God?”. She responded yes (in a Spinoza kind of way). “Good”, he said.

    He then referred her to an oncologist.

    Now I don’t know about you, but such questions not only make most people feel uncomfortable, but in situations like this, it is not the kind of question one would want to be asked. (“Holy crap! I’m doomed!”)

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