Doctors Can Be Doubters

By Manoj Jain
Special to The Washington Post
Tuesday, June 10, 2008

My patient is an elderly man with end-stage congestive heart failure, kidney failure and now an infected dialysis line, and he is unlikely to live more than six months. The Bible lies on his bedside table next to his hospital breakfast tray and the morning newspaper. I wonder if I should pray with him.

A neurosurgeon I know often prays with his patients prior to operating on their brains to remove a tumor or on their backs to relieve a herniated disk. In the pre-op holding area, he stands near the gurney and, with the patient's permission, clasps his or her hand and recites a prayer. He usually concludes the prayer with "in the name of our Lord, Jesus Christ."

My friend the neurosurgeon is unusual in this regard. Although studies show that 40 to 60 percent of hospitalized patients want their doctors to pray with them, fewer than 5 percent of doctors say they often or usually pray with patients.

As a doctor, I understand this. Although I am comfortable asking patients about their faith when I question them about their profession and their family or social support structure, I feel awkward, even squeamish, about praying with my patients. That may be because I was never taught how to pray with my patients in medical school, nor did I see my mentors praying with patients. Also, I am of the Jain faith, an Eastern religion based on the principle of nonviolence and the practice of meditation, and most of my patients are of the Christian or Jewish faith. In addition, at times I have seen religious beliefs compromise a patient's health: One young patient of mine died in my intensive care unit because she refused blood transfusions based on her religious beliefs.

My reluctance to pray with patients comes in the face of growing evidence that spiritual practices such as prayer and meditation might be healthy for us. A study published in 2003 found workers who attended a meditation training session had a more powerful immune response to the influenza vaccine than those who did not meditate. Another study has even shown a sort of dose-response curve -- the higher the church attendance, prayer and Bible study, the lower the average diastolic blood pressure -- as if religious practices act therapeutically, almost like a blood pressure pill. Although there's no solid proof of a causal relationship between religion/spirituality and improved health, researchers such as Harold Koenig, an associate professor of psychiatry and behavioral sciences at Duke University Medical Center, are convinced that spiritual practices can help you live longer.

Across medicine and society, there's increasing interest in the link between religion/spirituality and health. Three-quarters of all U.S. medical schools now offer courses in spirituality and medicine, and academic centers such as the George Washington Institute for Spirituality and Health, the Duke Center for Spirituality, Theology and Health, and the Center for Spirituality and Health at the University of Florida are being established across the nation.

Yet many researchers are skeptical about the union of religion/spirituality and medicine. (Or perhaps I should say "reunion" because religion/spirituality has been a part of medicine since ancient times: The words "holiness" and "healing" stem from a common root meaning "wholeness.")

Richard Sloan, a professor of behavioral medicine at Columbia University Medical Center, worries that the linkage oversimplifies and trivializes religion by limiting its value to its effect, if any, on health.

In 2007, the Agency for Healthcare Research and Quality commissioned a research team to evaluate 813 studies on meditation. The group reported mixed evidence from some of these studies; most of the remaining studies had design flaws that made it impossible to assess their conclusions.

I myself was a co-investigator on the largest study on the therapeutic effect of intercessory prayer, an 1,800-patient, six-center, $2.4 million study led by the Benson-Henry Institute for Mind Body Medicine, now at Harvard Medical School's affiliate Massachusetts General Hospital.

Our findings, published in 2006 in the American Heart Journal, showed that being prayed for did not improve outcomes, and it seemed to have a negative effect when patients knew they were the subject of prayers from afar.

Even if prayer were shown to improve outcomes, religious differences make it impractical for doctors to make it part of daily patient care.

I asked my neurosurgeon friend how he prays with patients who are Jewish, Muslim or Hindu. Does he end with the phrase about "our Lord, Jesus Christ"? He paused and then told me that it depends on the patient. I suspect that there is a selection bias and that he is more likely to offer prayers to Christian patients than others. He admits he feels uncomfortable offering a prayer in another faith or using the words "Allah," "Om" or "Shalom" because for him the prayer would not feel authentic.

In the end, this is what prompts my discomfort with praying with patients. If a doctor is using prayer because he feels it will help to heal a patient and not just to improve the doctor-patient relationship, then I believe it is unfair, even discriminatory, for a doctor to offer a Christian prayer with a Christian patient and not offer another prayer to patients of other faiths.

Because the research literature is equivocal on the benefits or drawbacks of prayer and meditation, I explored my own heart and soul for an answer.

Without hesitation, I believe that practices such as prayer and meditation offer benefits in addition to medication and surgery and the doctor-patient relationship. I have seen it myself. On several occasions, I have meditated with my patients.

Once, a young HIV-positive woman complained of shortness of breath after recovering from severe pneumonia. Medically, nothing helped, and no cause was obvious other than anxiety. With some hesitation, I offered to do a session of meditation with her. She agreed and subsequently improved.

Often, I wonder how I can incorporate spiritual practices in my routine therapeutic recommendations, just as I recommend exercise and a nutritious diet. I believe it's possible. But doing it, I believe, requires understanding two critical concepts.

First, we need to distinguish between religion (an organized institution with social boundaries, rituals and membership) and spirituality (the sense of the sacred within us and our relationship with a greater force). Spirituality may or may not be rooted in religion, but the core of all religions is spirituality. Once we can relate to the spiritual core of each patient, we do not have to agonize about finding the "appropriate" prayer and "politically correct" words for patients of different religions.

I think I could pray (using a generic prayer) or do a meditation exercise at a critical moment with my patient. At times, if this is uncomfortable or if there is not enough time, I could simply encourage the spiritual part of patients' lives.

This is what I did with my patient suffering from end-stage congestive heart failure. I touched his Bible and said, "Many patients find this very helpful. I am glad you are using it."

"Couldn't make it without it, Doc," he replied with a tone of hope and optimism.

Second, we doctors need to expand beyond medicine's traditional body-mind focus. Most of my patients see themselves as having a soul and a spirit, and if I, as a doctor and a scientist, wish to treat them in a holistic manner, I need to take this thinking into account.

I was reminded of this recently on morning rounds. I walked into a room, saying, "Hello, Mr. Jones." My patient was sitting in a chair in the corner, head bowed, lips moving silently.

I realized that I had interrupted his prayer. I bowed my head to join him. He continued. "Lord, I want to thank you for helping me heal and decreasing my pain . . . and now, Lord, I have to cut my prayers short this morning because my doctor is here."

We both said, "Amen."

Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:health @washpost.com.

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