Medical Students' Reflections on Discussing a Patient's Religious Issue
Cindy Schmidt, PhD, Director of Scholarly Activity and Faculty Development and Assistant Professor, Kansas City University of Medicine and Biosciences
Most patients in the U.S. use their religion and spirituality in the face of illness and pain. (1-4) Religious beliefs can provide meaning and hope, or can fuel damnation beliefs and feelings of despair. Other aspects of religiosity and spirituality can similarly contribute to, or help ameliorate, illness and pain. Whether sources of healing or not, whether strongly religious or not, most U.S. patients want their physicians to ask them about it. (5) Despite this longing for integrated care, very few physicians talk with their patients about their religious and spiritual needs. (6-9)
In order to explore this gap, 231 medical students met with a Standardized Patient experiencing a religious issue. His/her daughter was engaged to someone who was not Orthodox Jewish, like the family, and continued to avoid talking to him about converting. In this scenario, the patient became very upset after receiving a text from her daughter, and his/her religious issue became the focused topic for the encounter. After the encounter, students wrote narrative reflections to questions about how/if their own religion and/or spirituality impacted the discussion and also how they felt during the patient encounter.
We used a content analytic approach to qualitatively analyze themes in their reflections, beginning with a list of a priori codes generated from previous research and a once-through reading of the students’ comments. (10-11) Family medicine residents coded the reflection comments, creating new themes and sub-themes. We began with individual coding before refining and re-refining the coding categories as the coders met as dyads and then as an ensemble of four. We used triangulation of analysts and engaged in reflexivity discussions, in addition to employing two observers to listen for implicit bias during the coding discussions and negotiations.
Some of the medical students described how their own religion helped them connect better with their patient, either due to the similarity in belief (e.g., same religion) or similarity in religious needs (e.g., Muslim student also needed particular food and proximity to religious institution). Other students noted how not sharing the same beliefs or traditions negatively impacted the discussion (e.g., student felt distant from the patient). There was also concern about “crossing a line into an area a patient considers off limits.”
Overall, 41% of students said their own religion contributed positively to their patient encounter, even when they indicated they were not Orthodox Jewish (26%). Among the uncomfortable students (11%), many of them indicated their discomfort was due to not being religious themselves, to lacking knowledge of Orthodox Judaism, and to the overall awkwardness and sensitivity of discussing religion.
Qualitative analyses generate hypotheses, and we propose the following: Do students become uncomfortable because they feel uninformed about religious diversity? Among students who become uncomfortable, have they had negative previous experiences with discussing religion? Would a discussion of boundaries and integrating religious and spiritual needs into medical care impact discomfort?
References
1. Koenig HG, King DE, Carlson VB. Handbook of Religion and Health. 2nd ed. Oxford, UK: Oxford University Press; 2012.
2. Alcorn SR, Balboni MJ, Prigerson HG, et al. “If God wanted me yesterday, I wouldn’t be here today”: religious and spiritual themes in patients’ experiences of advanced cancer. J Palliat Med. 2010;13:581-588. doi.org/10.1089/jpm.2009.0343.
3. Park CL. Spirituality and meaning making in cancer survivorship. In: Markman K, Proulx T, Lindberg M, ed. The Psychology of Meaning. Washington DC: American Psychological Association; 2013:257-277.
4. Preau M, Bouhnik AD, Le Corollar Soriano AG. Two years after cancer diagnosis, what is the relationship between health-related quality of life, coping strategies and spirituality? Psychol Health Med. 2013;18:275-386. doi.org/10.1080/13548506.2012.736622.
5. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen, J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med. 1999;159:1803-1806.
6. Best M, Butow P, Olver I, Do patients want doctors to talk about spirituality? A systematic literature review. Pat Educ Couns. 2015;98:1320-1328. doi.org/10.1016/j.pec.2015.04.017.
7. Franzen AB. Influence of physicians’ beliefs on propensity to include religion/spirituality in patient interactions. J Rel Health. 2018;57:1581-1597. doi.org/10.1007/s10943-018-0638-7.
8. Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163:2751-2756. doi.org/10.1001/archinte.163.22.2751. 9. Ernecoff NC, Curlin FA, Buddadhumaruk P, White DB. Health care professionals’ responses to religious or spiritual statements by surrogate decision makers during goals-of-care discussions. JAMA Intern. Med. 2015;175:1662-1669. doi.org/10.1001/jamainternmed.2015.4124.
10. Schmidt CA, Patterson MA, Ellis AM, Nauta HN. Religious and spiritual assessment: A standardized patient curriculum intervention. Clin Sim Nurs. 2017;4:314-320. doi.org/10.1016/j.ecns.2017.05.007.
11. Schmidt CA, Nauta L, Patterson MA, Ellis AM. Medical students’ (dis)comfort with assessing religious and spiritual needs. J Rel Health. 2019;58(1):246-258. doi.org/10.1007/s10943-018-0714-z.
In order to explore this gap, 231 medical students met with a Standardized Patient experiencing a religious issue. His/her daughter was engaged to someone who was not Orthodox Jewish, like the family, and continued to avoid talking to him about converting. In this scenario, the patient became very upset after receiving a text from her daughter, and his/her religious issue became the focused topic for the encounter. After the encounter, students wrote narrative reflections to questions about how/if their own religion and/or spirituality impacted the discussion and also how they felt during the patient encounter.
We used a content analytic approach to qualitatively analyze themes in their reflections, beginning with a list of a priori codes generated from previous research and a once-through reading of the students’ comments. (10-11) Family medicine residents coded the reflection comments, creating new themes and sub-themes. We began with individual coding before refining and re-refining the coding categories as the coders met as dyads and then as an ensemble of four. We used triangulation of analysts and engaged in reflexivity discussions, in addition to employing two observers to listen for implicit bias during the coding discussions and negotiations.
Some of the medical students described how their own religion helped them connect better with their patient, either due to the similarity in belief (e.g., same religion) or similarity in religious needs (e.g., Muslim student also needed particular food and proximity to religious institution). Other students noted how not sharing the same beliefs or traditions negatively impacted the discussion (e.g., student felt distant from the patient). There was also concern about “crossing a line into an area a patient considers off limits.”
Overall, 41% of students said their own religion contributed positively to their patient encounter, even when they indicated they were not Orthodox Jewish (26%). Among the uncomfortable students (11%), many of them indicated their discomfort was due to not being religious themselves, to lacking knowledge of Orthodox Judaism, and to the overall awkwardness and sensitivity of discussing religion.
Qualitative analyses generate hypotheses, and we propose the following: Do students become uncomfortable because they feel uninformed about religious diversity? Among students who become uncomfortable, have they had negative previous experiences with discussing religion? Would a discussion of boundaries and integrating religious and spiritual needs into medical care impact discomfort?
References
1. Koenig HG, King DE, Carlson VB. Handbook of Religion and Health. 2nd ed. Oxford, UK: Oxford University Press; 2012.
2. Alcorn SR, Balboni MJ, Prigerson HG, et al. “If God wanted me yesterday, I wouldn’t be here today”: religious and spiritual themes in patients’ experiences of advanced cancer. J Palliat Med. 2010;13:581-588. doi.org/10.1089/jpm.2009.0343.
3. Park CL. Spirituality and meaning making in cancer survivorship. In: Markman K, Proulx T, Lindberg M, ed. The Psychology of Meaning. Washington DC: American Psychological Association; 2013:257-277.
4. Preau M, Bouhnik AD, Le Corollar Soriano AG. Two years after cancer diagnosis, what is the relationship between health-related quality of life, coping strategies and spirituality? Psychol Health Med. 2013;18:275-386. doi.org/10.1080/13548506.2012.736622.
5. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen, J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med. 1999;159:1803-1806.
6. Best M, Butow P, Olver I, Do patients want doctors to talk about spirituality? A systematic literature review. Pat Educ Couns. 2015;98:1320-1328. doi.org/10.1016/j.pec.2015.04.017.
7. Franzen AB. Influence of physicians’ beliefs on propensity to include religion/spirituality in patient interactions. J Rel Health. 2018;57:1581-1597. doi.org/10.1007/s10943-018-0638-7.
8. Monroe MH, Bynum D, Susi B, et al. Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med. 2003;163:2751-2756. doi.org/10.1001/archinte.163.22.2751. 9. Ernecoff NC, Curlin FA, Buddadhumaruk P, White DB. Health care professionals’ responses to religious or spiritual statements by surrogate decision makers during goals-of-care discussions. JAMA Intern. Med. 2015;175:1662-1669. doi.org/10.1001/jamainternmed.2015.4124.
10. Schmidt CA, Patterson MA, Ellis AM, Nauta HN. Religious and spiritual assessment: A standardized patient curriculum intervention. Clin Sim Nurs. 2017;4:314-320. doi.org/10.1016/j.ecns.2017.05.007.
11. Schmidt CA, Nauta L, Patterson MA, Ellis AM. Medical students’ (dis)comfort with assessing religious and spiritual needs. J Rel Health. 2019;58(1):246-258. doi.org/10.1007/s10943-018-0714-z.