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 appro- priate 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.

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