"I can fix this."
The neurosurgeon was nothing if not confident.
"The cyst is pushing on your spinal cord. If it continues to expand, it will damage your nerves and you may lose the ability to walk. But I can remove the cyst, and cure you."
The patient was a business school professor, a man comfortable with risk-benefit ratios and complex decisions. He probed for more information. The surgeon was happy to provide him with some numbers.
"There's an 80 percent chance you're cured. You sail through surgery. But there is a 3 percent chance of a very bad outcome -- death or paralysis. And then a 15-17 percent chance of more minor side effects, things you will recover from."
The professor was not happy to learn these numbers, but given the inevitability of paralysis if he didn't get the procedure, the 3 percent figure sounded well worth the risk. So he agreed to undergo the surgery.
"To ignore spirituality is to ignore a central piece of what it means for many people to be a patient."
Days later, he lay on a bed in the pre-operative suite, an IV in his arm and blue hospital socks adorning his feet. The neurosurgeon came by to check in on him. He re-explained the procedure and its risks. The professor was unmoved. He understood the situation and felt good about his chances. Then, just when it looked like the surgeon would head back to the operating room, he instead lowered his head and held the professor's hands.
And began to pray.
Not pray as in silently meditate by the bedside. But pray out loud, in an almost Pentecostal, sermon-y kind of way. The professor told me his story several weeks after that day: "He went on for what felt like three or four minutes," he told me.
"Was it generic mono-theism?," I asked.
"No. It was very explicitly Christian. Lots of 'Jesus this' and 'Christ that.' Specific scripture quotes too, replete with the names and numbers of the book of origin."
"He 2-Corinthianed you?"
"That was what was so strange. We hadn't talked about religion before that moment. And if he had looked in my medical record, he would have seen that I listed myself as an atheist. I was flabbergasted. I looked over at my wife, and she was as bewildered as me. When we caught each other's eyes, we had to look away to keep from laughing."
As physicians, we interact with patients during some of the most important moments of their lives -- at their births and at their deathbeds, at events bursting with spiritual significance. And yet most of us are afraid to talk about spirituality with our patients, much less discuss religion, out of fear that such conversations would be inappropriate. We are afraid even though many patients want to discuss these matters with their. By one estimate, 48 percent percent of patients would like physicians to pray with them.
That is what is so striking about the professor's story. Here he was, a hyper-rational atheist, on the receiving end of a sermon from a surgeon who was clearly not afraid to "talk God" with his patients. He was so unafraid, in fact, that he didn't bother to figure out whether his patient was interested in sharing a moment of Christian prayer.
The surgeon was also oblivious to the likelihood that a Corinthian-laden bedside prayer would have caused most patients to worry about the risks of the procedure. The professor's take: "He told me everything would be fine, and then he prayed over me like a priest doling out last rites! If I didn't understand the statistics, I would have wondered what I was getting myself into."
In Critical Decisions, I write about the difficulty physicians have had achieving the goals of the patient empowerment revolution. Most doctors now understand that all healthcare decisions should involve the patient -- that their values are critical to making the right choices. But many of us don't know how to effectively partner with our patients in making these decisions. We don't know if we are supposed to simply give patients information and get out of the way or, instead, guide patients to what we consider to be the right choice.
Some get so caught up in the role of information provider that they overwhelm patients with jargon-filled soliloquies. Others are so comfortable running the show that they make assertive clinical recommendations before they have even taken a moment to diagnose their patients' preferences.
The story of the professor makes me wonder whether a similar sort of imbalance is affecting the way physicians discuss spirituality with their patients. Most physicians are so afraid of this topic that they avoid it, worrying that asking patients about their spiritual beliefs will cross an ethical line. Indeed, a group of bioethicists and palliative care specialists led by UCSF Professor Bernie Lo have written that physicians should avoid asking patients to pray with them."Because physicians hold considerable power over them, it may be difficult for patients to decline a physician's invitation to pray." They list another reason doctors should be hesitant to invite such prayer sessions: "Physicians generally lack expertise in leading prayer, particularly if they do have not have chaplaincy training or formal religious training."
So, on one hand we have recognition that many patients want to pray with their physicians; but on the other, we have admonition to avoid coercing patients into prayer.
One problem is that most physicians haven't been taught how to address spirituality at the bedside -- except for palliative care experts, who are well versed at tackling this topic. Palliative care guidelines even list spiritual suffering as one of the symptoms clinicians need to assess and address. According to James Tulsky, a palliative care specialist at Duke University, "Spiritual issues are central to patients' experience of illness, particularly when they are really sick. To ignore spirituality is to ignore a central piece of what it means for many people to be a patient."
Tulsky thinks physicians can address spirituality without unduly coercing patients, by asking them about spirituality without inviting them to pray. "I ask a simple question of all patients. 'What role, if any, does faith or spirituality play in your life?' I've asked it hundreds of times and have never gotten a negative response. I have received some very long or conflicted responses, but everyone has an opinion, whether it's 'None --- I don't believe in that stuff and think religion is baloney' or 'My faith is what has kept me alive all these years.' The end result of this inquiry is that it opens up an important line of communication, and helps physicians better understand their patients' values and needs." Sometimes that line of inquiry leads to joint prayer. More often, it simply helps doctors understand their patients better, while giving patients license to talk about what is on their minds.
It was wrong for that neurosurgeon to preach at his patient's bedside without first inquiring about his patient's spirituality. It is equally wrong for physicians to act as if patients' spiritual beliefs have no relevance in their medical care.
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