The New Frontier: Religious Diversity in Patient Care: A Family Physician’s

Perspective

Robert C. Like, MD, MS Professor and Director

Center for Healthy Families and Cultural Diversity Department of Family Medicine UMDNJ-Robert Wood

Johnson Medical School© 2013 Center for Healthy Families and Cultural Diversity/UMDNJ-RWJMS

“Man is not destroyed by suffering; he is destroyed by suffering without meaning.”

Victor Frankl. Man’s Search for Meaning. New York: Simon and Schuster, 1984

Existential Issues in Health Care

When patients are ill, they often ask themselves the following questions:

“Why did this happen? Why me? Why now?”

While medicine generally addresses the how of disease (i.e., pathophysiology, diagnosis, and treatment), many patients are also concerned about the why of sickness and suffering, and may seek out support from counselors, clergy, and pastoral care providers to cope with other existential personal, family, and societal life issues.

Question 1

Why is developing religio-cultural competence important for clinical care, hospitals, and other healthcare organizations?

Model Hospital Programs: The Importance of Community Engagement and Partnerships

Lutheran HealthCare

Meridian Health

Clinical Case Vignette

Like RC. A Religious and Ethical Dilemma, in Patients and Doctors: Life-Changing Stories of Healing, Steinmetz D, Borkan J et al. (eds.), Madison, WI: University of Wisconsin Press, 1999, pp. 78-79.

Spiritual Distress

“Spiritual distress and spiritual crisis occur when individuals are unable to find sources of meaning, hope, love, peace, comfort, strength and connection in life or when conflict occurs between their beliefs and what is happening in their life. This distress can have a detrimental effect on physical and mental health. Medical illness and impending death can often trigger spiritual distress in patients and family members.”

Anandarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Physician 2001;63:81-8, 89.

Research into the beneficial influence

of spiritual and religious practice

Stress reduction Recovery from illness Reduction of depression Substance abuse prevention and recovery Prevention of heart disease and hypertension Mitigation of pain Adjustment to disability Recovery from cardiac surgery in the elderly Palliative and end-of-life care

Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Annals of Internal Medicine 2000; 132(7): 578583 http://www.annals.org/cgi/reprint/132/7/578.pdf

Selected Clinical Care and Bioethical Issues

Canadian Medical Association Journal – Religion/Spirituality Resourceshttp://www.cmaj.ca/cgi/collection/religion_spirituality

Cultural Competence: Caring for your Muslim patientshttp://medicaleconomics.modernmedicine.com/memag/Young+Doctors%27+Resource+Center%3A+Practice+Management%3A+Patient+relations/Cultural-Competence-Caring-for-your-Muslim-patient/ArticleStandard/Article/detail/158977?contextCategoryId=8727

Recommendation for Management of Diabetes During Ramadanhttp://care.diabetesjournals.org/cgi/reprint/28/9/2305

Recent Developments in Medical Care of Jehovah’s Witnesseshttp://www.ajwrb.org/wjm/wjm.htm

Joint Commission

Hospitals, Language, and Culture: A Snapshot of the Nation, March 2007http://www.jointcommission.org/assets/1/6/hlc_paper.pdf

One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, April 2008http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals, August 2010http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide, October, 2011 http://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf

National Center for Cultural Competence - Georgetown University

• A Guide to Planning and Implementing Cultural Competence Organizational Self-Assessment

• Cultural Competence Health Practitioner Policy Assessment

• Planning for Cultural and Linguistic Competence in Systems of Care

• Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs

• Sharing a Legacy of Caring: Partnerships between Health Care and Faith-Based Organizations

http://www11.georgetown.edu/research/gucchd/nccc http://nccc.georgetown.edu/documents/faith.pdf

Cultivating Cultural Humility

• A lifelong commitment to self-evaluation and self-critique

• Redressing power imbalances

• Developing mutually beneficial partnerships with communities on behalf of individuals and defined populations

Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.

Cultural Humility: People, Principles & Practices. A film by Vivian Chávez, 2012 http://www.youtube.com/watch?v=SaSHLbS1V4w&feature=relmfu

Question 2

What are best practices and available resources for integrating religio-cultural competence into health professions education and staff diversity training initiatives?

Model Educational Programs: Live and Web-Based Strategies

Maria Fareri Children’s Hospital

Tanenbaum Center for Interreligious Understanding

Teaching about Spirituality and Religion in Medical Education and Clinical Practice

In 1992, “2% of U.S. medical schools offered course work in spirituality.

By 2004, the figure was 67%. Now 100 of the approximately 150 U.S. medical schools offer some variation of spirituality-in-medicine course work.

Booth B. More schools teaching spirituality in medicine. American Medical News, March 20, 2008 http://www.ama-assn.org/amednews/2008/03/10/prsc0310.htm

“Ninety percent (range 84%-90%) of medical schools have courses or content on spirituality and health (S&H), 73% with content in required courses addressing other topics and 7% with a required course dedicated to S&H.” (85% response rate from 122 U.S. Medical Schools)

Koenig HG, et al. Spirituality in medical school curricula: findings from a national survey. Int J Psychiatry Med 2010; 40(4):398-398.

The John Templeton Foundation (http://www.templeton.org) has been a major source of funding for many of these spirituality in medicine curricula.

Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and

Ethics. Annals of Internal Medicine 2000; 132(7): 578583http://www.annals.org/cgi/reprint/132/7/578.pdf

• What are the potential risks/benefits of mixing religion and medicine/faith and science? • What is the clinical relevance of spirituality, religion, faith, and prayer?• What role does spirituality and religion play in your own personal and professional life?• Should physicians discuss spiritual issues with patients? Do patients want us to?• Is it ever appropriate to try to encourage or discourage religious beliefs for the “benefit” of the patient?• What should be the professional boundaries between physicians and chaplains, who can be clergy or nonclergy lay persons with clinical pastoral education?

Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and

Ethics. Annals of Internal Medicine 2000; 132(7): 578583http://www.annals.org/cgi/reprint/132/7/578.pdf

• Should an appreciation of spirituality be expressed within the physician-patient relationship? In your relationships with colleagues and other health care professionals? If so, under what circumstances and to what extent?• Should a spiritual needs assessment or “spiritual status exam” be carried out with patients? How, when, and where should this be done?• Should physicians pray with their patients if requested by them? If so, should this be done publicly or privately? Should physicians ever offer to pray?• What ethical guidelines should guide the above decisions?

Spiritual Assessment Tools

FICA Spiritual History Tool

HOPE Questions for Spiritual Assessment The Open Invite Mnemonic

Saguil A, Phelps K. The Spiritual Assessment. American Family Physician 2012; 86(6):546-550. http://www.aafp.org/afp/2012/0915/p546.pdf

Effects of Spiritual Assessment on Medical Management

Take no further action Incorporate spirituality into

preventive health care Include spirituality in adjuvant

care Modify the treatment plan

Anandarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Physician 2001;63:81-8,

89.

Selected Academic Medical Centers

The George Washington Institute for Spirituality and Health http://www.gwish.org

University of Chicago – Program on Medicine and Religionhttps://pmr.uchicago.edu

University of Minnesota - The Center for Spirituality and Healing http://www.csh.umn.edu

University of Florida - The Center for Spirituality and Health

http://www.spiritualityandhealth.ufl.edu

Duke University - Center for Spirituality, Theology and Health http://www.dukespiritualityandhealth.org

Texas Medical Center – Institute for the Spirituality and Health http://www.ish-tmc.org/

Tanenbaum Center for Interreligious Understanding

The Medical Manual for Religio-Cultural Competence: Caring for Religiously Diverse Populations, 2011 (fee $) https://www.tanenbaum.org/programs/health

CME: Improving Religio-Cultural Competence in Patient Care (fee $)https://www.tanenbaum.org/store/cme-improving-religio-cultural-competence-patient-care

Realin AP, ed. A Desk Reference to Personalizing Patient Care. Orlando: Florida Hospital Publishing, 2012 (fee $) http://floridahospitalpublishing.com/patientcare

HealthCare Chaplaincy. Cultural & Spiritual Sensitivity: A Learning Module for Health Care Professionals and Dictionary of Patients' Spiritual & Cultural Values for Health Care Professionals. New York, NY, 2009 (revision & update of earlier work by the Rev. Susan Wintz and the Rev. Earl Cooper)http://www.healthcarechaplaincy.org/userimages/Cultural_Spiritual_Sensitivity_Learning_%20Module%207-10-09.pdfhttp://www.healthcarechaplaincy.org/userimages/doc/A-Dictionary-of-Patients-Spiritual-Cultural-Values-for-Health-Care-Professionals.pdf

Religio-Cultural Competence Resources

Selected Cultural Competency Continuing Education

Programs

Office of Minority Health A Physician’s Practical Guide to Culturally Competent Care https://cccm.thinkculturalhealth.org

Health Resources and Services Administration Effective Communication Tools for Healthcare Professionals (formerly Unified Health Communication 101) http://www.hrsa.gov/publichealth/healthliteracy

Private Sector Live and Online Programs Like RC. Educating Clinicians About Cultural Competence and Disparities in Health and Health Care.

The Journal of Continuing Education in the Health Professions 2011; 31(3):196-206

“Adding wings to caterpillars does not create butterflies - it creates

awkward and dysfunctional caterpillars. Butterflies are created through transformation.”

Stephanie Pace Marshall http://www.stephaniepacemarshall.com/articles/SPM-Article8.pdf

A Closing Meditation