Moral Controversy and Working with Colleagues with a Shared Ethical/Moral Outlook: A National Survey of US Primary Care Physicians.

OBJECTIVES: This study assesses physicians' attitudes on the importance of working with colleagues who share the same ethical or moral outlook regarding morally controversial healthcare practices and examines the association of physicians' religious and spiritual characteristics with these attitudes. METHODS: We conducted a secondary data analysis of a 2009 national survey that was administered to a stratified random sample of 1504 US primary care physicians (PCPs). In that dataset, physicians were asked: "For you personally, how important is it to work with colleagues who share your ethical/moral outlook regarding morally controversial health care practices?" We examined associations between physicians' religious/spiritual characteristics and their attitudes toward having a shared ethical/moral outlook with colleagues. RESULTS: Among eligible respondents, the response rate was 63% (896/1427). Overall, 69% of PCPs indicated that working with colleagues who share their ethical/moral outlook regarding morally controversial healthcare practices was either very important (23%) or somewhat important (46%). Physicians who were more religious were more likely than nonreligious physicians to report that a shared ethical/moral outlook was somewhat/very important to them (P < 0.001 for all measures of religiosity, including religious affiliation, attendance at religious services, intrinsic religiosity, and importance of religion as well as spirituality). Physicians with a high sense of calling were more likely than those with a low sense of calling to report a high importance of having a shared ethical/moral outlook with colleagues regarding morally controversial healthcare practices (multivariate odds ratio 2.5, 95% confidence interval 1.5-4.1). CONCLUSIONS: In this national study of PCPs, physicians who identified as religious, spiritual, or having a high sense of calling were found to place a stronger emphasis on the importance of shared ethical/moral outlook with work colleagues regarding morally controversial healthcare practices. Moral controversy in health care may pose a particular challenge for physicians with lower commitments to theological pluralism.

Predictors of Empathic Compassion: Do Spirituality, Religion, and Calling Matter?

OBJECTIVE: To determine whether physician spirituality, religion, and sense of calling toward medicine are predictors of self-reported empathic compassion. METHODS: We sampled 2000 practicing US physicians from all specialties and used self-reported measures of general and clinical empathic compassion taken from previous studies. Independent variables were single-item measures of calling, spirituality, and religiosity (importance of religion). RESULTS: The survey response rate was 64.5% (1289/2000). Physicians with a strong sense of calling were more likely to report higher general empathic compassion (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.26-3.15) and higher clinical empathic compassion (OR 3.33, 95% CI 2.07-5.36). Similarly, physicians who considered themselves spiritual were more likely to report higher general empathic compassion (OR 2.76, 95% CI 1.69-4.50) and higher clinical empathic compassion (OR 2.32, 95% CI 1.38-3.90). We did not find an association between religiosity and measures of physicians' empathic compassion. CONCLUSIONS: This national study of practicing US physicians from various specialties found that spirituality (not religiousness) and the identification of medicine as a calling are associated with physicians' empathic compassion. Further study is needed to understand how spirituality and calling are linked to prosocial behaviors among physicians that may be enhancing their clinical empathy and promoting compassionate patient care.

Physicians' Religious Characteristics and Their Perceptions of the Psychological Impact of Patient Prayer and Beliefs at the End of Life: A National Survey.

BACKGROUND:: Physicians who are more religious or spiritual may report more positive perceptions regarding the link between religious beliefs/practices and patients' psychological well-being. METHODS:: We conducted a secondary data analysis of a 2010 national survey of US physicians from various specialties (n = 1156). Respondents answered whether the following patient behaviors had a positive or negative effect on the psychological well-being of patients at the end of life: (1) praying frequently, (2) believing in divine judgment, and (3) expecting a miraculous healing. We also asked respondents how comfortable they are talking with patients about death. RESULTS:: Eighty-five percent of physicians believed that patients' prayer has a positive psychological impact, 51% thought that patients' belief in divine judgment has a positive psychological impact, and only 17% of physicians thought the same with patients' expectation of a miraculous healing. Opinions varied based on physicians' religious and spiritual characteristics. Furthermore, 52% of US physicians appear to feel very comfortable discussing death with patients, although end-of-life specialists, Hindu physicians, and spiritual physicians were more likely to report feeling very comfortable discussing death (adjusted odds ratio range: 1.82-3.00). CONCLUSION:: US physicians hold divided perceptions of the psychological impact of patients' religious beliefs/practices at the end of life, although they more are likely to believe that frequent prayer has a positive psychological impact for patients. Formal training in spiritual care may significantly improve the number of religion/spirituality conversations with patients at the end of life and help doctors understand and engage patients' religious practices and beliefs.

Demographic and Practice Characteristics of Physicians Who Care for Medically Underserved People: A National Survey.

OBJECTIVES: Few national studies have examined the influence of role models as a potential predictor for caring for medically underserved (MUS) patients. This study tested associations between previous physician role model exposure and caring for MUS populations, as well as examines the practice environments of these physicians. METHODS: Between October and December 2011, we mailed a confidential questionnaire to a representative sample of 2000 US physicians from various specialties. The primary criterion variable was "Is your patient population considered medically underserved?" We assessed demographic and other personal characteristics (calling, spirituality, and reporting a familial role model). We also asked about their practice characteristics, including a validated measure that assessed whether their work environment was considered chaotic/hectic or calm. RESULTS: The survey response rate was 64.5% (1289/2000). Female physicians and African American physicians were more likely to report working in MUS settings (multivariate odds ratio [OR] 1.32, confidence interval [CI] 1.00-1.76 and OR 2.65, CI 1.28-5.46, respectively). Physicians with high spirituality (OR 1.69, CI 1.02-2.79) and who reported familial role model exposure (OR 1.91, CI 1.11-3.30) also were associated with working with MUS populations. Physicians who worked in academic medical centers (OR 1.93, CI 1.45-2.56) and in chaotic work environments (OR 3.25, CI 1.64-6.44) also were more likely to report working with MUS patients. CONCLUSIONS: Familial role models may be influencing physicians to work with MUS patients, but the quality of their current work environments raises concerns about the long-term retention of physicians in MUS settings.

Project on the Good Physician: Further Evidence for the Validity of a Moral Intuitionist Model of Virtuous Caring.

THEORY: In the Project on the Good Physician, the authors propose a moral intuitionist model of virtuous caring that places the virtues of Mindfulness, Empathic Compassion, and Generosity at the heart of medical character education. HYPOTHESES: Hypothesis 1a: The virtues of Mindfulness, Empathic Compassion, and Generosity will be positively associated with one another (convergent validity). Hypothesis 1b: The virtues of Mindfulness and Empathic Compassion will explain variance in the action-related virtue of Generosity beyond that predicted by Big Five personality traits alone (discriminant validity). Hypothesis 1c: Virtuous students will experience greater well-being ("flourishing"), as measured by four indices of well-being: life meaning, life satisfaction, vocational identity, and vocational calling (predictive validity). Hypothesis 1d: Students who self-report higher levels of the virtues will be nominated by their peers for the Gold Humanism Award (predictive validity). Hypothesis 2a-2c: Neuroticism and Burnout will be positively associated with each other and inversely associated with measures of virtue and well-being. METHOD: The authors used data from a 2011 nationally representative sample of U.S. medical students (n = 499) in which medical virtues (Mindfulness, Empathic Compassion, and Generosity) were measured using scales adapted from existing instruments with validity evidence. RESULTS: Supporting the predictive validity of the model, virtuous students were recognized by their peers to be exemplary doctors, and they were more likely to have higher ratings on measures of student well-being. Supporting the discriminant validity of the model, virtues predicted prosocial behavior (Generosity) more than personality traits alone, and students higher in the virtue of Mindfulness were less likely to be high in Neuroticism and Burnout. CONCLUSIONS: Data from this descriptive-correlational study offered additional support for the validity of the moral intuitionist model of virtuous caring. Applied to medical character education, medical school programs should consider designing educational experiences that intentionally emphasize the cultivation of virtue.

Physicians' Opinions on Engaging Patients' Religious and Spiritual Concerns: A National Survey.

CONTEXT: There has been a sustained debate in the medical literature over whether physicians should engage with patients' religious and spiritual concerns. OBJECTIVES: This study explores what physicians believe about the relative importance and appropriateness of engaging with patients' spiritual concerns and physicians' choices of interventions. METHODS: In 2010, a questionnaire was mailed to 2016 U.S. physicians with survey items querying about the relative importance of addressing patients' spiritual concerns at the end of life and the appropriateness of interventions in addressing those concerns. The survey also contained an experimental vignette to assess physicians' willingness, if asked by patients, to participate in prayer. RESULTS: Adjusted response rate was 62% (1156/1878). The majority of physicians (65%) believe that it is essential to good practice for physicians to address patients' spiritual concerns at the end of life. Physicians who were more religious were more likely to believe that spiritual care is essential to good medical practice (odds ratio: 2.76, 95% CI 1.12-6.81) and believe that it is appropriate to always encourage patients to talk to a chaplain (odds ratio: 5.71, 95% CI: 2.28-14.3). A majority of the physicians (55%) stated that, if asked, they would join the family and patient in prayer. Physicians' willingness to join ranged from 67% when there was concordance between the physician's and the patient's religious affiliation to 51% when there was discordance. CONCLUSION: The majority of U.S. physicians endorse a limited role in the provision of spiritual care, although opinions varied based on physicians' religious characteristics.

Religion, sense of calling, and the practice of medicine: findings from a national survey of primary care physicians and psychiatrists.

OBJECTIVES: A sense of calling is a concept with religious and theological roots; however, it is unclear whether contemporary physicians in the United States still embrace this concept in their practice of medicine. This study assesses the association between religious characteristics and endorsing a sense of calling among practicing primary care physicians (PCPs) and psychiatrists. METHODS: In 2009, we surveyed a stratified random sample of 2016 PCPs and psychiatrists in the United States. Physicians were asked whether they agreed with the statement, "For me, the practice of medicine is a calling." Primary predictors included demographic and self-reported religious characteristics, (eg, attendance, affiliation, importance of religion, intrinsic religiosity) and spirituality. RESULTS: Among eligible respondents, the response rate was 63% (896/1427) for PCPs and 64% (312/487) for psychiatrists. A total of 40% of PCPs and 42% of psychiatrists endorsed a strong sense of calling. PCPs and psychiatrists who were more spiritual and/or religious as assessed by all four measures were more likely to report a strong sense of calling in the practice of medicine. Nearly half of Muslim (46%) and Catholic (45%) PCPs and the majority of evangelical Protestant PCPs (60%) report a strong sense of calling in their practice, and PCPs with these affiliations were more likely to endorse a strong sense of calling than those with no affiliation (26%, bivariate P < 0.001). We found similar trends for psychiatrists. CONCLUSIONS: In this national study of PCPs and psychiatrists, we found that PCPs who considered themselves religious were more likely to report a strong sense of calling in the practice of medicine. Although this cross-sectional study cannot be used to make definitive causal inferences between religion and developing a strong sense of calling, PCPs who considered themselves religious are more likely to embrace the concept of calling in their practice of medicine.

Limits and responsibilities of physicians addressing spiritual suffering in terminally ill patients.

CONTEXT: Many patients experience spiritual suffering that complicates their physical suffering at the end of life. It remains unclear what physicians' perceived responsibilities are for responding to patients' spiritual suffering. OBJECTIVES: To investigate U.S. physician opinions about the impact patients' unresolved spiritual struggles have on their physical pain, physicians' responsibilities for treating patients' spiritual suffering compared with patients' physical pain, and the number of patients in the past 12 months whose suffering the physician was unable to relieve to an acceptable point. METHODS: The study was based on a mailed survey to 2016 practicing U.S. physicians from clinical specialties that care for significant numbers of dying patients. RESULTS: Of 1878 eligible physicians, 1156 (62%) responded. Most physicians agreed that patients with unresolved spiritual struggles tend to have worse physical pain (81%) and that physicians should seek to relieve patients' spiritual suffering just as much as patients' physical pain (88%). Compared with physicians who strongly disagreed that physicians should seek to relieve patients' spiritual suffering just as much as patients' physical pain, those who strongly agreed were less likely to report being unable to relieve patients' suffering to a point the physician found acceptable (27% vs. 54% reported three or more such patients in the previous 12 months, adjusted odds ratio [95% CI] = 0.3 [0.1, 0.8]). CONCLUSION: Most physicians believe that spiritual suffering tends to intensify physical pain and that physicians should seek to relieve such suffering. Physicians who believe they should address spiritual suffering just as much as physical pain report more success in relieving patient's suffering.

A spiritual problem? Primary care physicians' and psychiatrists' interpretations of medically unexplained symptoms.

BACKGROUND: Patients commonly present to their physicians with medically unexplained symptoms (MUS), and there is no consensus about how physicians should interpret or treat such symptoms. OBJECTIVE: To examine how variations in physicians' interpretations of MUS are associated with physicians' religious characteristics and with physician specialty (primary care vs. psychiatry). DESIGN AND PARTICIPANTS: A national survey of a stratified random sample of 1,504 primary care physicians and 512 psychiatrists in 2009-2010. MAIN MEASURES: The extent to which physicians believe MUS reflect a root problem that is spiritual in nature or result from conditions that scientific research will eventually explain, and whether such patients would benefit from attention to their relationships, attention to their spiritual life, taking medications, and/or treatment by physicians. KEY RESULTS: Response rate was 63 % (1,208/1,909). More religious/spiritual physicians were more likely to believe that MUS reflect a spiritual problem (55 % for high vs. 24 % for low spirituality; OR = 2.8, 1.7-4.5) and that these patients would benefit from paying attention to their spiritual life (79 % for high vs. 55 % for low spirituality; OR = 3.1, 1.8-5.3). Psychiatrists were more likely to believe that scientific research will one day explain MUS (66 % vs. 52 %; OR = 1.9, 1.4-2.5) and that these symptoms will improve with treatment by a physician (54 % vs. 35 %; OR = 2.4, 1.8-3.3). They were less likely to believe that MUS reflect a spiritual problem (23 % vs. 38 %; OR = 0.5, 0.4-0.8). CONCLUSIONS: Physicians' interpretations of MUS vary widely, depending in part on physicians' religious characteristics and specialty. One in three physicians believes that patients with MUS have root problems that are spiritual in nature. Physicians who are more religious or spiritual are more likely to think of MUS as stemming from spiritual concerns. Psychiatrists are more optimistic that these patients will get better with treatment by physicians.

Physicians' beliefs about faith-based treatments for alcoholism.

OBJECTIVE: The study examined physicians' beliefs about faith-based alcohol treatments vis-à-vis Alcoholics Anonymous, pharmacologic treatment, and residential treatment. METHODS: A survey was mailed to a national sample of U.S. primary care physicians and psychiatrists. It included a brief vignette of a nominally religious 47-year-old man hospitalized for acute alcohol poisoning who requested addiction treatment. Physicians rated the likely effectiveness of three treatment methods: Alcoholics Anonymous, pharmacological therapy by an addiction specialist, and a residential program. Physicians were asked whether they would refer the patient to a faith-based program (beyond Alcoholics Anonymous) and whether an emphasis on spirituality is critical to 12-step program success. RESULTS: The response rate was 896 of 1,427 (63%) for primary care physicians and 312 of 487 (64%) for psychiatrists. Psychiatrists were more likely to rate Alcoholics Anonymous as very effective (64% versus 57% of primary care physicians), more likely to rate residential treatment as very effective (47% versus 38% of primary care physicians), and more likely to rate pharmacologic therapy as very effective (31% versus 22% of primary care physicians). Psychiatrists and primary care physicians were equally likely to consider referring the patient to a faith-based program (71% and 79%) and equally likely to believe that "an emphasis on spirituality is critical to the success of 12-step programs" (81% and 85%). CONCLUSIONS: Psychiatrists were more optimistic than primary care physicians about all three treatments. Physicians in both specialties would refer even nominally religious patients to explicitly faith-based programs (beyond Alcoholics Anonymous). Physicians' enthusiasm for faith-based treatments highlights the need for scientific study of these treatments to determine which elements are most helpful for patients seeking recovery.

An assessment of US physicians' training in religion, spirituality, and medicine.

This study examined US physicians' training in religion and medicine and its association with addressing religious and spiritual issues in clinical encounters. Reports of receiving training were higher for highly spiritual physicians, psychiatrists, and physicians with high numbers of critically ill patients. Discussing religion or spirituality with patients was associated with having received training through a book or CME literature or during Grand Rounds, through one's religious tradition and from other unspecified sources but not with having received such training in medical school.