Medical Education Physical (H&P) Examination

mal part of the complete history and Medical education physical (H&P) examination. Medicine continues to discard vari- ous taboos that encumber the assessment of patients’ well-being. In the 1950s and Spirituality in history taking 1960s, most physicians did not discuss the sexuality of their patients. The “S” DONALD G. SPAETH, DO, PhD word (sex) was not considered an appropriate subject to discuss, even in the private setting of the doctor’s office. Physi- cians were not trained in or were not Andrew Taylor Still, MD, DO, included in his founding postulates of osteopathy comfortable with discussing patients’ sex- the concept that a patient’s health includes the health of a patient’s spirit. In the uality or related issues. Physicians were recent past, medicine as a whole, and osteopathic medicine specifically, has either embarrassed by the subject or neglected this postulate. Recent research has confirmed the validity of Still’s pos- afraid that they would embarrass their tulate, and many medical training institutions have received grants and established patients, or both. If the patient’s condi- programs to incorporate spirituality into their curriculum. As with any patient eval- tion demanded that his or her sexuality uation, the history and physical examination is the starting platform. This arti- be addressed (for example, if the patient cle describes several tools that can be easily incorporated into the history and phys- had a sexually transmitted disease), the ical examination, along with some of the obstacles in evaluating the health of the physician treated the disease with mini- patient’s spirit. mal discussion or intervention into sur- (Key words: spirituality, history and physical examination) rounding issues such as sexual practices. Of course, physicians had been dealing with many of the consequences of their s far back as Plato’s time, physicians fore, physicians should not neglect a patients’ sexual activities for centuries, Awere encouraged to care for the patient’s spirit if they are to maximize but this was usually done covertly, ret- whole person. Plato admonishes, “As their healing ministrations. Yet for too rospectively, and with minimal educa- you ought not to attempt to cure the long, we physicians have been doing just tion. As a result of the sexual revolution eyes without the head, or the head with- this—ignoring the spirit while trying to and subsequently available sexual edu- out the body, so neither ought you to heal the body. cation, physicians are now better trained attempt to cure the body without the According to a 1990 Gallup poll, to address sexuality and its many sur- soul. The part can never be well unless 95% of Americans believe in God, 57% rounding issues (practices, preferences, the whole is well.”1 Andrew Taylor Still, pray daily, and 42% attended a place of etc). Physicians can now intervene proac- MD, DO, expanded on this concept in worship in the past week.5 Recent surveys tively and not just retroactively in their laying the foundations for osteopathic indicate that more than 75% of patients patients’ sexual health, and they are medicine. Still recognized that man com- want their physicians to pray with them; expected to include a sexual history in prises body, mind, and spirit. Dysfunction however, only 10% or fewer of the their complete history and physical exam- in any one of these areas affects the health patients were actually prayed for by their ination. of the others. Corrections of the dys- physicians.6-9 One of the strengths of Today, spirituality is the new “S” functions in any of these components family medicine is the patient-physician word. Spirituality and religion are in the will help the body to heal itself.2-4 There- relationship. Simply inquiring about a analogous position that sex and sexual- patient’s spiritual status produces a ity were in the 1960s. Medicine has real- strong, positive response. If physicians ized that not addressing patients’ spiri- Dr Spaeth is an assistant professor of family would engage the spiritual arena, the tuality detracts from the healing process. medicine in the Department of Family patient-physician relationship would But recognition is only the beginning. Medicine, Ohio University College of Osteo- increase by a quantum leap. There are many barriers to discussing pathic Medicine, Athens, Ohio. Presented as part of a series of lectures on Data support the need for and the spirituality with patients, including the spirituality in medicine, summer selective benefits of including spiritual aspects in unease of physicians in dealing with spir- series, College of Osteopathic Medicine, Ohio physicians’ interactions with their itual matters; lack of physician training University, July/August 1999. 6,10-13 Correspondence to Donald G. Spaeth, DO, patients. To interact with patients, with regard to spiritual health; the need PhD, Assistant Professor of Family Medicine, physicians need to learn the means of of physicians to support spiritual con- Department of Family Medicine, Room 351, assessing patients’ spiritual status, the cepts with which they disagree; physi- Grosvenor Hall, College of Osteopathic tools used to do this, and how to recog- cians’ concern that they may be consid- Medicine, Ohio University, Athens, OH 45701. E-mail: [email protected]. nize obstacles that need to be avoided ered to be proselytizing; confusion edu or overcome to make spirituality a nor- between religion and spirituality; and the

Spaeth • Medical education JAOA • Vol 100 • No 10 • October 2000 • 641 perceived conflict between science and one whole being with three interactive own spiritual health. The physician must spirituality. parts—is the working paradigm. lay aside his spiritual beliefs and func- One of the biggest barriers to dis- Unfortunately, the training of the care tion within the beliefs of the patient. It cussing spirituality with patients is the providers has been and continues to be becomes too easy to avoid the whole dis- comfort level of the physician with his fragmented. All have been trained only in cussion of spiritual matters and stay with- own spirituality, or the status of the the realm associated with their discipline. in the realm of the physical, where appro- physician’s own spiritual health. Open The theologian deals with spiritual mat- priate and inappropriate concepts are discussion of spirituality with a patient ters, the psychologist deals with matters better defined and better understood—the may cause the physician to reveal what of the soul (mind, will, and emotions), exact error that the resurgence of inclu- he considers personal and private issues. and the physician deals with physical sion of spiritual matters in medicine is If physicians are not prepared or not matters. For this reason, most physicians struggling to correct. capable of dealing with personal spiri- are not adept at dealing with spiritual Separation of the biological from the tual matters, they will be reluctant to matters and hence are reluctant to broach spiritual or the physical from the meta- address those of the patient because it the subject with their patients. With the physical is another barrier to addressing would force them to address their own new insight, that spiritual health influ- spiritual matters. Modern physicians are concerns. It is often difficult to discuss an ences physical health, physicians are hav- trained in the scientific method and not alternate spiritual lifestyle if one is threat- ing to (re)learn spiritual matters.14-16 in ways of incorporating the metaphys- ened by that lifestyle, if one is ignorant There is also the pressure not to pros- ical aspects of a patient into the physical about that lifestyle, or if one is opposed elytize patients. This pressure has sever- “reality.” If the physician concerns him- to that lifestyle. To openly discuss or al aspects, the most obvious aspect being self with patients’ spirituality, he is question spirituality (or any subject, for that, as physicians, we want to know the believed to have lost his “objectivity” that matter) in a nonthreatening, inviting truth of a matter. We obviously accept and is no longer deemed to be a compe- manner requires the physician to be com- our own spiritual parameters as truth, tent physician. If the physician cannot fortable and confident in his or her own or else we would change them. When see, feel, measure, or manipulate the issue, knowledge and feelings about spiritual patients express concepts that are differ- then that issue is not real and is consid- matters. So the first step in dealing with ent from our own beliefs, or when they ered to be irrelevant. If the physician the patient’s spiritual health is for the express concepts that are harmful accepts that there is a metaphysical aspect physician to assess his own spiritual (according to our beliefs), we want to to healing, then he is admitting that his health—a topic not addressed in any change their beliefs. Because we have training is incomplete, that he is lacking, medical school’s curriculum. access to patients at their vulnerable that he may not be in control. These are Inadequate training presents several moments, our urge to correct their belief all anathemas to the traditional, mod- obstacles to dealing with patients’ spiri- system needs to be curtailed until the ern, training of physicians.17 Physicians tual health. In antiquity, the spiritual was patient gives us permission to address are therefore often reluctant to open the not separated from the physical, and the these differences. This requires tact and Pandora’s box of spirituality. priest was also the doctor. In modern, is often time-consuming. Misunderstanding of the differences politically correct terms, the spiritual Another aspect of the pressure not to between religion and spirituality creates leader was also the healthcare provider. proselytize our patients is the concept of another problem. Spirituality is defined as Then, as man became more understand- tolerance. This concept supposes that having to do with the spirit and is often ing of the physical world, the metaphys- each of us has an equal right to believe thought of as the better or higher part of ical realm was denigrated and separated what we believe and that each belief sys- man. Spirituality has to do with man’s from the treatment of the body. Physical tem is equally valid. This has two con- search for a sense of meaning or pur- healing, medicine, was relegated to the sequences. The first consequence is that pose to life, and it is that part of a per- physician. Soul and spirit remained under the concept of absolute right or absolute son’s psyche that strives for transcen- the realm of the priest. With the advent wrong is removed from any dealings with dental values, meanings, and experiences. of psychology, care of the soul was the patient. The physician should not The spirit is that aspect or essence of a extracted from the responsibility of the evaluate the patient’s belief system. If the person that gives power and energy and priest and delegated to the psychologist. physician forms an opinion that the motivates the pursuits of virtues such as The division of man was complete. Man, patient has a wrong belief system, then love, truth, and wisdom. who used to be cared for by one per- the physician is seen as judgmental and Religion is any specific system of son—the priest-physician—is now cared intolerant (this is as deadly as being belief, worship, conduct, etc, often involv- for by three persons—physician, psy- accused of being racist or sexist). This ing a code of ethics and a philosophy. It chologist, and theologian. This division forced tolerance leads to the second con- may include doctrine, dogma, metaphors, failed to yield complete understanding sequence, that the physician may be myths, and a way of perceiving the and control of the wellness of man. So forced to function within a framework world. Organized religion is one way of now, the original concept—that man is that is in opposition to the physician’s expressing one’s spirituality. Common

642 • JAOA • Vol 100 • No 10 • October 2000 Spaeth • Medical education themes to many religions include purity up on verbal and nonverbal clues. These and other more existential issues. Fac- of life, peace, and beliefs in immortality are the applications of the five aptitudes tor 4 (Humility/Personal Application) and a supreme being. The wide variety of listed previously. Unfortunately, most contains items that deal with humility religions attests to the importance of spir- history taking is done by junior physi- and application of spiritual principles in ituality to humans.15 Therefore, it is all cians who machine-gun questions at daily activities. The goals of the Spiritu- the more important for a physician to patients, prevent patients from talking al Involvement and Beliefs Scale are to provide medical skills to aid in the heal- in their own terms, and avoid asking provide physicians with a quantitative, ing of the spirit as well as to use the spir- questions about mood, reaction to ill- credible method of spiritual inquiry that it to aid in the healing of the body. The ness, or the impact of the illness on allows integration of spiritual assessment physician of today is faced with treating patients’ families. Many aspects of med- into traditional medicine (much the way patients not only in the biomedical ical training, such as performing the mental status exams such as the Beck’s model, not in a biopsychosocial model, H&P, are undertaken by junior physi- Depression Scale25 are used) and to pro- but in a biopsychosocial-spiritual cians. These aspects are expected to devel- vide an objective measurement of spiri- model.18,19 op and improve as their experience tuality to aid in research into the role of Medicine and spirituality intersect in increases. The distressing aspect of this is spirituality in medicine.2 at least four areas: (1) meanings of health that physicians do not improve in estab- The next tool is designed not for and illness; (2) relation of health to other lishing rapport with patients or in let- objective data gathering, but for aiding human values; (3) attitudes toward the ting patients talk.23 Many experienced physicians in inquiring into all the aspects aged, the incurable, and the weak; and physicians do not demonstrate these apti- of spirituality that are understood to be (4) attitude toward nature.20 Nine spe- tudes. appropriate, as listed previously. The cific ideas embodied in most religious As in most history taking, the aspects developers of this tool formed it into the systems that provide an ethical basis for of spirituality are best broached using mnemonic SPIRIT.26 The letters of this medical practice are stewardship, cre- open-ended questions: “Do you belong to mnemonic remind physicians to ask ation, human dignity, freedom, love, a particular church, fellowship, or prac- about the different factors of spirituality covenant, justice, vocation, and fini- tice?” “Do you consider yourself reli- and spiritual health: S spiritual belief tude.21 gious or spiritual?” These questions give system; P personal spirituality; I Five aptitudes that physicians should the patient permission to talk about the integration with a spiritual community; have to meet the spiritual needs of their subject without being judged. Because R ritualized practices and restrictions; patients are to (1) be trustworthy, (2) spirituality is an intimate subject, it must I implications for medical care; and T treat the patient as a person, (3) be kind, be approached gently and nonjudgmen- terminal events planning. To use this (4) maintain hope, and (5) assist in deter- tally. As this is a new aspect of history tool, a physician has to develop a safe, mining what it means to live.22 With taking, several guides/acronyms have comfortable relationship with the patient. these aptitudes, physicians can approach been proposed to help physicians obtain A suggested style of questioning may be their patients’ spirituality. The first step the necessary information quickly and similar to this: “Many people have strong in healing the spirit is to determine the efficiently. Three examples follow. spiritual or religious beliefs that shape status of the patient’s spiritual well-being. The first is a series of 26 questions to their lives, including their health and The goal of including spirituality in his- which the patients scale their agreement. experiences with illness. If you are com- tory taking is to assess the patient’s spir- The Spiritual Involvement and Beliefs fortable talking about this topic, would itual health. A patient who has spiritual Scale24 is purported to allow assessment you please share any of your beliefs and health (1) attaches meaning and purpose of four factors involved in spirituality.* practices that you might want me to to life events, including the illness; (2) Factor 1(External/Ritual) typically ad- know, as your physician?” has hope, faith, and relative absence of dresses spiritual activities/rituals that are Once patients are prompted to talk guilt; (3) is able to love and forgive self consistent with belief in an external about their beliefs, they will share impor- and others; (4) participates in laughter power. Factor 2 (Internal/Fluid) includes tant detailed information. Specific sug- and celebration; and (5) is involved in a items that refer to evolving beliefs and gested questions for each of these six community of faith and practices wor- items that focus on internal beliefs and areas include the following: S, What is ship, prayer, and meditation.19 growth. Factor 3 (Existential/Meditative) your formal religious affiliation? P, De- Including an evaluation of the clusters items dealing with meditation scribe the beliefs and practices of your patient’s spiritual well-being in the com- religion that you do not personally ac- plete H&P requires that the patient be at *The factor analysis used to establish the scales of cept; I, Do you belong to any spiritual or ease, that there is a rapport established this tool were completed using small sample sizes. religious group or community? R, Are Evaluations using larger sample sizes and factor anal- between the physician and patient, and yses may yield different factor loadings than has been there specific practices that you carry out that there is a working relationship previously published.24 Therefore caution must be as part of your religion/spirituality? I, used in applying this instrument in everyday practice. between the physician and patient. The Anyone interested in using this tool is encouraged to What aspects of your religion/spirituali- physician needs to discern and follow contact the author, as cited in Hatch et al.24 ty would you like for me to keep in mind

Spaeth • Medical education JAOA • Vol 100 • No 10 • October 2000 • 643 as I care for you? T, Are there any par- 4. Still AT. Philosophy of Osteopathy. Kirksville, 17. Patch Adams [videotape]. Universal City, ticular aspects of care that you wish to Mo: AT Still; 1899:27. Calif: Universal Studios; 1998. forgo or have withheld because of your 5. Gallup G Jr. Religion in America 1990. 18. Hiatt JF. Spirituality, medicine, and healing. faith? There are also other questions that Princeton, NJ: Princeton Religious Research South Med J 1986;79:736-743. can be used to assess patients’ spiritual Center; 1990. 19. Kuhn C. A spiritual inventory of the medi- 26,27 beliefs. 6. Larimore W, Peel W. The Saline Solution cally ill patient. Psychiatr Med 1988;6:87-89. Another mnemonic, FICA, was devel- [videotape]. Bristol, Tenn: Christian Medical oped by Puchalski28: F faith and belief; and Dental Society; 1999. 20. Barnard D. Religion and religious studies in health care and health education. J Allied I importance and influence; C com- 7. Puchalski CM. A spiritual assessment: lis- Health 1983;Aug:192-200. munity; and A address in care. Sample tening to your patients. Spirituality & Medicine questions for each follow: F, Do you Connection 1999;3:3. 21. Sevensky RL. The religious foundation of consider yourself spiritual or religious? I, health care: a conceptual approach. J Med 8. Jones AW. A survey of general practitioners’ Ethics 1983;9:165-169. What role do your beliefs play in regain- attitudes to the involvement of clergy in patient ing your health? C, Is there a group of care. Br J Gen Pract 1990;40:280-283. 22. Foster DW, Marty ME, Vaux KL, eds. Reli- people you really love or who are impor- gion and Medicine: The Physicians’ Perspec- 9. Naugans TA, Wadland WC. Religion and tive. Philadelphia, Pa: Fortress Press; 1982: tant to you? A, How would you like me, family medicine: a survey of physicians and 245-270. your doctor, to address these issues in patients. J Fam Pract 1991;32:210-213. your healthcare? No matter how the 23. History taking [editorial]. Med Educ 1982; 10. Larson DB, Sherill KA, Lyons JS, Craigie 16:245-246. patient answers, the physician should FC, Theilman SB, Greenwold MA, et al. Asso- encourage the patient to elaborate and to ciations between dimensions of religious com- 24. Hatch RL, Burg MA, Naberhaus DS, pursue any topics that would be of help mitment and mental health reported in the Hellmich LK. The spiritual involvement and to the patient. This is being sensitive to American Journal of Psychiatry and the beliefs scale. J Fam Pract 1998;46:485-486. Archives of General Psychiatry: 1978 through the patient’s needs—being a physician 1989. Am J Psychiatry 1992;149:557-559. 25. Beck AT, Ward C, Mendelson M, Mock J, instead of a technician. Erbaugh J. An inventory to measure depres- 11. Matthews DA, Larson DB, Barry CP. The sion. Arch Gen Psychiatry 1961;4:561-571. Faith Factor: An Annotated Bibliography of Comment Clinical Research on Spiritual Subjects. 26. Maugans T. The SPIRITual history. Arch The spiritual history, or spiritual health Rockville, Md: National Institute for Health- Fam Med 1996;5:11-16. evaluation, can be taken annually or at care Research; 1993. 27. Braverman ER. The religious medical any follow-up visits as appropriate. A 12. Larson DB. The Faith Factor: An Anno- model: holy medicine and the spiritual behav- close study of the two mnemonics, SPIR- tated Bibliography of Systematic Reviews and ior inventory. South Med J 1987;80:415-425. IT and FICA, shows that they each cover Clinical Research on Spiritual Subjects. the components that make up spiritual Rockville, Md: National Institute for Health- 28. Puchalski CM. Taking a spiritual history. care Research; 1993. Spirituality & Medicine Connection 1999;3:1. well-being. To successfully incorporate spirituality into the H&P, physicians 13. Matthews DA, Larson DB. The Faith Fac- need to answer these questions for them- tor: An Annotated Bibliography of Clinical Research on Spiritual Subjects. Rockville, Md: selves and thus be able to meet the spir- National Institute for Healthcare Research; itual needs of their patients. The heritage 1995. passed on to us by Andrew Taylor Still is 14. Aldridge D. Spirituality, healing and now being used by all of medicine. As medicine. Br J Gen Pract 1991;41:425-427. osteopathic physicians, we should be in the vanguard of applying the concept of 15. McKee DD, Chappel JN. Spirituality and spirituality to medicine. To do this, our medical practice. J Fam Pract 1992;35:201. training programs and trainers need to 16. McBride JL. The new focus on spirituality become adept at evaluating the spiritual in medicine. J Med Assoc Ga 1998;87:281- condition of our patients and at using 284. these strengths in our treatment.

References 1. Jowett B. Dialogues of Plato. New York, NY: Random House; 1937:4-12.

2. Still AT. Autobiography of Andrew Taylor Still. Kirksville, Mo: AT Still; 1896:99, 357.

3. Still AT. Osteopathy: Research and Practice. Kirksville, Mo: AT Still; 1910:252-253.

644 • JAOA • Vol 100 • No 10 • October 2000 Spaeth • Medical education