God in the exam room

My profession does not allow me the luxury of suffering fools, but neither does it allow me the luxury of always being blunt in my beliefs.

Readers may have noticed a slight tendency toward snarkiness, especially when dealing with woo. I refuse to pull punches when it comes to people peddling quackery. Religion is different.

In my work, my religious beliefs (or lack of them) are irrelevant, and I don’t intend to “confess” to either belief or non-belief to my patients. Being a physician is not the same as being an academic scientist. As a bench scientist, your cell cultures don’t really care who you are—not so with patients. Patients are acutely interested in their doctors–their marital status, if they have kids, where they grew up. I spend quite a bit of time just chatting with my patients. Mrs. S. always likes to see the latest pictures of my daughter, and I oblige her.

Not that I don’t enjoy showing off my kid, but there is a greater purpose to these activities. Patients who know you and like you are more likely to trust you and follow your advice. That’s why I usually go along with whatever my patients say regarding religion. That’s not a cop-out, it’s real medicine.

People are different from primers and test tubes. They require comfort and trust. I never mock (or even contradict) their religious beliefs (I save that for cafe arguments). Telling a cancer patient that God is a fairy tale is not only wrong, it’s cruel.

Patients believe, and nothing a doctor says is going to change that. Yes, sometimes these beliefs get in the way of good medical care, but more often they are benign, strongly attached to the patient, and their removal would cause more harm than good. Primum non nocere.

There are lots of things in this world that I don’t believe in—fairies, God, good Chinese food in the Midwest—but my patients can believe whatever helps them get by (except the Chinese food thing). It’s my job to heal, not evangelize.

That being said, whenever my patients show me the latest bottle of get-well potion they’ve purchased, I gently explain why it won’t do them much good. I won’t take God away from a patient, but I’ll happily separate them from Gary Null.

Comments

  1. #1 Mark Hadfield
    March 27, 2008

    Even if they’re Scientologists? What would you say to a Scientologist patient who had read your previous post?

    I’m not trying to score points, here, I’m genuinely curious.

  2. #2 PalMD
    March 27, 2008

    I’m fairly certain I have patients who are scientologists. I have a bunch of Jehovah’s Witnesses. I think their beliefs are bat-shit insane, but I respect them (in the boundary sense). I’m quite frank with Witnesses about the medical aspects of their care, and question them carefully. I then note their wishes in the chart, and requestion them as necessary.

  3. #3 Kagehi
    March 27, 2008

    If the faithfuls *own* research on the subject tells us anything, belief may have some positive benefit, but the “wrong” belief may make you die faster. Mind you, that is only one case study. I agree its got to be damn hard to avoid the subject at all, but there are 200,000+ sets of rules to that particular game, just counting one religion, and playing at all means you risk breaking one of them and making things worse in some cases. I don’t envy you the task at all.

  4. #4 PhysioProf
    March 27, 2008

    Dude, you’re fucking prolific! You’re making those Hoofknocker brothers look like lazy shits.

  5. #5 PalMD
    March 27, 2008

    Entirely my fault. Some of it is that I’ve been locked in the hospital for days on end, some of it is migrating favorite posts from my old place, albeit in edited form.

    Shift work can give you lots of gaps to work with.

    I expect that when flu season dies down, and when I run out of old posts, the Hoofs will get a word in edgewise.

    Either that, or they’ll just revoke my posting priv’s.

  6. #6 Will
    March 27, 2008

    I worked in an ER for almost 10 years, and I know exactly what you mean. The patient’s beliefs are often benign. But sometimes not. For example in one case I remember a patient with a ruptured appendix who believed surgery was evil and that he could heal himself through prayer. It took an hour or so of very careful negotiations for the surgeon to talk him into an appendectomy without bluntly contradicting his religious beliefs. Not an easy task at all, but I think sometimes you do have to subtly contradict.

  7. #7 PalMD
    March 27, 2008

    You mean surgery isn’t evil?

  8. #8 Crudely Wrott
    March 27, 2008

    PalMD, I have been present in the last moments or days of the lives of three people. In each case the dying spoke of things that were at odds with my world view. It didn’t bother me. To some degree I played along. In two of the cases it was obvious that the guys knew the end was approaching and were doing what they could to cope with the immediacy of the end.

    On the one hand I could see this as a cop out; an appeal to something outside of human strength. I have made similar appeals. On the other I could see that these guys were doing the best that they could to hold terror at bay; to find some comfort in the face of the ultimate foe.

    John, whose father delivered my step father, died in a hospital room. I entered that room about an hour before he died. Because I had visited him frequently at his home before his hospitalization and was a familiar and welcome presence, he thought that he was back at home, in his own bed. He pointed to where the kitchen would be relative to his bed and asked me to fix him “a little drink.” (Brandy and water, IIRC) I made as if to move in the direction he indicated. He went into seizure. Hospital people swarmed in. I left. He died.

    Ol’ Tony grew up on Crow Creek in Fremont County, Wyoming. He was born about 1922. He lived there until he was drafted early in WWII. He became a Marine, served in the Pacific. He fought on Tarawa and other islands that I have forgotten (sorry, Tony). Upon discharge he bought a used car in San Diego and drove it back to Crow Creek where he lived until he got sick. He moved into town and I met him and discovered he knew my father.

    Near the end I would visit him twice a week, bringing some food and some drink. Cleaned up his shit like I did for John. Cajoled him to eat more and wash once a day. He was part Indian (excuse; Native American. Crow tribe.) He insisted that his second wind was immanent. Spirits told him. I could do nothing more than to tell him to take hold when the spirits moved.

    The third I did not know and there was nothing to be done for him.

    Three people. Three was of dying. One by hallucination, convinced by my mere appearance that the painful truth had just been replaced by the common, the familiar. A second by a nondescript faith in tribal heritage, trusting that his courage and assurance would keep me and the spirits aware of the warrior he once was. And a third by means unknown. In each case I did nothing by dogma; nothing by ingrained instruction; nothing by assuming that the person was going to be anything but dead. I indulged John and Tony. Not to reassure them (for there was at those moments no assurance). Not to ease my burden (for I was raised around livestock and was familiar with death; had also lost dear mentors and friends). The case of third is a null set, containing all the factors but no avenue of access to that guy. I was a bit surprised when I walked away without feeling that something terrible had happened. Still remember feeling a new sense of freedom.

    I am at peace with each episode. Even while, in the first two cases, having an emotional connection to the dying, I could have cried and prayed, I chose to not destroy the illusion of life that John and Tony felt. To do so could have made their passing a confusion, a fearful thing. To do so would have been wrong.

  9. #9 Will
    March 28, 2008

    You mean surgery isn’t evil?

    Spoken like a true internist! ;-)

  10. #10 Karen
    March 28, 2008

    Neither of my parents ever knew I’d become an atheist. They were old by then, and they wouldn’t have understood. I took my mom to receive (the Catholic sacrament of) Confession, because she wanted it, and I never spoke of my frustration with her church. I said all the right things to encourage the hospital Chaplain when she died, and the right things when her favorite priest tried to comfort my dad and me. I even said, and still say, the right things when Dad’s friends talk about how wonderful my parents were and how they must be happy in heaven.

    I know these people well; as far as I can tell, all of them adhere to a dogma-light version of Christianity that emphasizes being honest and supportive of one’s neighbors, and judging others with great reluctance and much compassion. So why should I perturb the faith of these people? As far as my own sense of morality goes, it’s put them on the right path. I don’t mess with stuff that’s not broken, even if it isn’t MY cotter pin keeping it together.

  11. #11 Will
    March 28, 2008

    If I’m personally attached to the patient, it’s all I can do to keep my mouth shut and maybe nod my head occasionally. After the doctor came out to the ER waiting room to tell us that resuscitation efforts on my father were unsuccessful, another patient’s family member came over to “comfort” us with her prayers. I know she had good intentions, but I can not express the sense of outrage I felt (and demonstrated) at that moment. I avoid clergy (and other religious folk) at funerals of loved ones for the same reason.

  12. #12 Bee
    March 28, 2008

    I think most of us, doctor or layperson, will say just about anything we can to comfort the very ill or the dying, and their grieving next of kin. Lying about religion is probably the least of it.

  13. #13 Richard Lowe
    March 28, 2008

    Thanks for this – it is encouraging for me to see that you can stick to (what I would call) a strong moral principle: Providing the best care using only evidence-based medicine, while navigating the complexities of the psychology of your patients’ beliefs to help them willingly participate.

    Too often, I hear only about the science or the debunking of the woo and it’s nice to see an example of a non-believer with compassion and social agency among believers.

  14. #14 JC
    March 28, 2008

    You mean surgery isn’t evil?

    Surgery is OK it is just surgeons that are evil.