Oct 28 2008
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.
• 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
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.
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.
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