Dr Graham McAll discusses how his practice approaches patients' personal beliefs in consultations.
Be they atheist, agnostic, pantheist or deist – whatever ‘ism' or meaning they have found in life, a patient's worldview has a huge impact on how they handle illness. And illness itself can change a patient's worldview.
It is known that patients want their doctors to take their worldview seriously into account when advising them, and that doctors regularly underestimate how important these issues are to patients. In a multicultural society assumptions about worldview can lead to inappropriate or unaccepted treatments, and possible therapeutic options get ignored.
For example one patient wasn't taking pain killers for her back pain because she felt she should ‘take the punishment'. Another patient didn't jump in front of a train when suicidal because ‘I'm a Catholic, you see'. Another was angry when told she was ‘just unlucky' to have repeated UTIs after normal investigations, thinking the comment implied she had bad karma. Another was grateful that a twice daily antibiotic was prescribed so he didn't have to break fast during Ramadan. And then there is much research to show that active involvement with religion has substantial positive health benefits across a range of illnesses for about 80% of patients, but negative effects for about 20%.
What we did
Our inner city practice serves a multiethnic community. It declares a ‘Christian ethos' in its practice leaflet. This explains that illness affects the physical, psychological, social and spiritual aspects of a patient's life and staff will seek to address any area of concern. We hoped that patients discovered they were each worth far more than they thought, with an accessible non-judgmental service. It also meant that, whatever their religion, they needn't feel embarrassed to mention their ideas, fears and doubts about the meaning of their illness.
In the practice new patient check there is a question about religion, to get some baseline information. To expand on this I use the helpful mnemonic from Washington University ‘FICA' to elucidate a patient's religious history. ‘F' stands for faith – so a question might be: 'Do you have a religious faith that is important to you?' ‘I' stands for impact or involvement, so a question could be 'Tell me how being a Hindu will affect your approach to this illness/this medication?' ‘C' stands for community and discussion might include what faith community the patient is part of and how this might affect care (e.g. post-operatively or during terminal illness). ‘A' stands for actions needed after the discussion. This might involve some action by the patient, advice, onward referral or even occasionally an offer of prayer.
As with discussing any potentially sensitive issue, great gentleness, permission and respect is required. It is the patient's consultation and religious issues are only discussed in the context of the patient's needs as a part of ‘going the extra mile'. The current GMC guidelines are very clear on this and they don't try to gag either the patient or the doctor, and yet protect both.
Results
The doctors and nurses in the practice would explore these issues with patients, if it is wanted. In my experience I have had more chats about beliefs later in my career as a GP. Recently I estimate I discussed worldview issues in about one in thirty consultations. I think this was because trust had built up over the years and patients realized it was OK to raise the subject.
The fact a doctor respects God is immensely important to a Muslim for example, and any degree of shared religious conviction can bring a sense of deepened understanding. When I didn't understand an aspect of someone's spirituality they were only too pleased to explain how it impacted their life. Many patients described their relief after resolution of guilt or fears when their faith was encouraged. Our Muslim and Christian patients enjoyed telling us they were praying for our work. There was also much gratitude that we took our patients' worldview and faith issues as seriously as the other aspects of disease.
The future
Clinicians want more training to be comfortable approaching this area with patients, finding language that works, and not being fearful. There has been plenty of research but more is needed. I was surprised that improved understanding of worldview seemed to help resolve people's problems quicker and possibly actually reduce the consultation rate. We need more curiosity about what makes our patients ‘tick'. We also need to examine our own worldviews and see how they impact our values and behaviour and how they affect our approach to the suffering of others.
Dr Graham McAll, a former GP in Sheffield, is author of ‘At A Given Moment – faith matters in healthcare encounters'.
