[NOTE: Due to the windstorm last week, I was knocked out of the blogging game for a while and even had to stay in a hotel for one night. We did get our power back late Friday night, but we also didn’t get Internet back until much later in the weekend, because our cable went out too. So, I thought I’d have a new post for today, but, alas, I did not. So, continuing on the them of Friday, I thought I’d repost an article of a sort that I almost never do any more. This one was posted over 11 years ago and was last reposted over 5 years ago. Tomorrow, I’ll definitely be back.]

The patient list for the day had simply the words “abnormal mammogram” next to her name. That used to be the most common reason that of breast patients came to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal. The next thing they know, they’re sitting in one of my examining rooms. However, the patient list is quite brief. It’s just meant to be a quick capsule of what patient has what basic complaint. These days, because at my current institution so many more practitioners order breast biopsies, most of the patients I see are already pre-diagnosed with breast cancer. Be that as it may, nothing on the list prepared me for the woman I greeted when I walked in the examination room.

This woman was enormous, and I do mean enormous. Morbidly obese, she told me she wasn’t sure how much she weighed, but that it was at least 450 lbs. As she sat in a wheelchair massive enough to support her, rolls of fat hung over the armrests, and her breath wheezed like a mortally wounded Darth Vader near the end of Return of the Jedi, right before he took his helmet off and revealed Anakin Skywalker beneath the mask. Indeed, on the same theme, I could not help but be reminded of Jabba the Hutt. Yes, I know that physicians aren’t supposed to think that way about their patients, and, honestly, I tried not to. However, we’re human, just like everyone else, and even our years of professional training can’t entirely suppress our baser thoughts. Of course, years of practice prevented me from doing the unprofessional and voicing such thoughts to my nurse or any of the clinic staff at all. Not all clinicians exercise such self-restraint, unfortunately, but I try very hard to.

Normally, dealing with a patient with suspicious microcalcifications on her mammogram is fairly simple. A biopsy is indicated, and there are basically two techniques to choose from. You can do an image-guided core needle biopsy, either a stereotactic biopsy (in which the image guidance is mammography) or an ultrasound-guided core biopsy (in which the image guidance is from, well, ultrasound). If neither of these are possible, then the patient will require an old-fashioned surgical biopsy, known as a wire localization or needle localization biopsy. This is a technique in which a wire is placed into the breast under local anesthesia such that the wire sits next to the abnormality that needs to be biopsied. In essence, the wire placed under either mammographic guidance or ultrasound guidance, leads the surgeon to the lesion. Given that even the surgical option is usually a same day surgery using local anaesthesia and sedation, even that isn’t so hard. The surgery can sometimes be a little trickier than one might think, but even then it’s usually not all that hard. Oh, sometimes you get patients with multiple abnormalities, and you have to decide if you want to go after them all or if you want to perform a triage and decide that some of them need to be biopsied and some of them don’t, all the while realizing that if you miss a cancer it can be a major disaster for the patient.

Of course, a 450+ lb. patient adds a new level of challenge. For one thing, she was way too heavy for the stereotactic table; so stereotactic biopsy wasn’t even an option, at least not then. (The equipment that we have available now might be able to accommodate someone that large.) Not surprisingly, her health was horrible. She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians’ Desk Reference. I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it. So I made do and did my best to examine her while she was sitting in her wheelchair. It was a suboptimal examination, but it was all I could manage. Morbidly obese patients, because of their size, frequently make it very difficult to provide optimal care to the, particularly surgical care.

By the time I was done, I felt profoundly sorry for this woman. How on earth does such a person live the way she was living, given her physical and medical problems? Despite my empathy, I maintained the professional bedside manner that we’re all trained to keep up and explained what was abnormal about her mammogram, that she would need a biopsy, and how the biopsy would be done. I also explained the risks (which, for her, were much higher than the minuscule risks most patients undergoing this procedure face), and arranged for her to be seen by her pulmonologist and cardiologist in case something more than local anaesthesia were needed.

When finished, I asked if there were any more questions, gave her my card, and made my way past the family members to the door. Although it was near the end of the day, there were still a couple of more patients to see.

There was.

“Do you believe in God?” she said, looking at me expectantly.

I was still standing there, hesitating. To be honest, my first thought was: Why on earth should it matter whether I believe in God or not? Belief in God has nothing whatsoever to do with whether I’m a competent surgeon or not. Personally, if I needed surgery I’d prefer a surgeon who is a flame-throwing “militant” atheist Richard Dawkins, as long as he or she is highly competent and has a bedside manner that doesn’t bother me (and, of course, doesn’t push his or her beliefs on me), over an incompetent believer. In the same vein, it wouldn’t matter to me if the surgeon is a Bible thumper, again as long as he or she is highly competent, easy for me to get along with, and doesn’t push fundamentalist beliefs on me. To me, the question of belief in God is irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way. Thinking back on this incident, I can’t help but remember an interview I had heard with Eddie Tabash, an atheist attorney who mentioned during the interview that he sometimes defended prostitutes. During the interview, he went on to mention that it was not infrequent for prostitutes to become very uneasy about having him as their attorney when they found out about his atheism. I had never before encountered this phenomenon among my patients, however.

Worse, the question brought into sharp focus a question that I myself have been wrestling with myself for the last three years or so, a question whose answer seems to be yes one day and no on others. There’s nothing like being trapped in a small examination room with a 450 lb. woman and three members of her family, with nowhere to run and no way to dodge the question. I was trapped. A believer might have said that the woman’s question was God’s way of making me face my fluctuation between belief and disbelief; an atheist might say that such an assertion is wishful thinking. Whichever was the truth, that didn’t prevent the formation of a little bead of sweat that was slowly enlarging on my brow. I suspect the question would have still been uncomfortable for me to answer even if I were as religious as I had been when I was younger, as even then I tended to view religion as a private matter, one I didn’t usually talk about much, if at all.

What if I were to tell her that I was an agnostic or an atheist, that I didn’t believe in God? Would she have sought out another surgeon? For a fleeting moment, I was sorely tempted to say just that. It could have been an out, a way of not having to do the operation and deal with all the attendant risks of major complications from what is normally a pretty minor operation. On the other hand, this woman had no insurance and had to rely on charity care (this was before the Affordable Care Act, obviously), which meant that she probably didn’t have the option of going to a different surgeon, at least not at a different institution. The problem was that, if she went to one of my partners, it might have been perceived as “dumping” on them. If that were the case and I said I was an agnostic/atheist/whatever, she would then be going into surgery with no confidence in her surgeon, clearly an undesirable situation. A patient needs to have confidence in her surgeon, and anything that undermines that confidence, regardless of the reason or what I think of the reason, is to be avoided if it is possible to do so within reason.

So what did I finally say?

“I’m Catholic,” I said. A pause. “But, to be honest, I don’t go to Mass much anymore.”

This answer was true, of course, but incomplete. I had been raised Catholic but long ago drifted away from the Church and, more recently, away from belief itself. It seemed to answer her question, but in reality didn’t. Not really. The truth was much more complicated, but she didn’t need to know that. Fortunately, because the woman was Catholic herself, my answer seemed to satisfy her. “God will guide your hand,” she said.

“I hope so,” I replied. Bullet dodged.

I walked out of the examination room not looking forward to the day when this patient and I would meet again in the operating room–or to contemplating the way I had handled the situation. To this day, I still can’t make up my mind whether my choice was a complete cop out or a clever and diplomatic strategy not to undermine a patient’s confidence in me. It was probably a little of both. Whatever the case, in that situation on that day it worked.

Doctors have to make these decisions sometimes.

Comments

  1. #1 Eric Lund
    March 13, 2017

    Most of the time, I find that the more loudly someone proclaims his religion, the more likely his version of that religion is a hopelessly warped version of it. With people who identify themselves as Christians, I find specifically that they are more likely to behave as if the words printed in red in their bibles were mistakes, rather than the words attributed to Jesus. I don’t have as much firsthand contact with Muslims, but ISIS/al Qaeda seem to be cut from the same cloth.

    OTOH, a patient who is so inclined who has been referred to you has better reason than most to consider the nature of any afterlife that might exist. So yes, it’s much more uncomfortable for you than for me. You can’t simply blow it off like I can.

  2. #2 Sarah Sorlien
    March 13, 2017

    As another (atheist) physician I have encountered this question often. Part of the reason for the discomfort is the patient is asking a personal question that breaches the boundaries of the relationship. It would have been just as uncomfortable for her to ask how much money you had in you portfolio or how often you had sex with your wife. The patient’s belief system leads them to consider religion part of their health care, and you correctly interpreted it that way. IMO, you gave a compassionate, healing, respectful, and honest enough answer.

  3. #3 Anonymous Pseudonym
    In Your Head
    March 13, 2017

    Orac, To answer your final question. Yes it was a very un-machine like cop out.
    Entirely understandable as you are human and subject to human frailties and foibles.
    Out of curiosity, what would your answer be now? After eleven years, would you still dodge the question, or would you give a straight-forward answer?
    For the entirely nothing that it is worth, to spare her feelings and in the spirit of good bedside manner, I probably would have said much the same thing. Outside of professional obligations, I would have shrugged and said I grew out of belief around the same time I realized the Easter bunny and the fey folk were just as real as God.

  4. #4 Anonymous Pseudonym
    In Your Head
    March 13, 2017

    @2 Sarah
    In-line with your reasoning that it is compassionate, healing and respectful etc to pander to their religious beliefs. Would you be inclined to prescribe placebo/ineffective cures if the patient really believed that they would help? Where is the limit on pandering to someones beliefs? I’m guessing that the state medical boards don’t have guidelines on things like this, so I am genuinely curious, and not trying to be any more of an ass then is normal for me.
    The thought that asking about someones religious belief is an invasive personal question honestly never occurred to me. I think of it more along the lines of what sports eam do you cheer for or what political group do you like.

  5. #5 Eric Lund
    March 13, 2017

    @AP: I think you are being a bit hard on Sarah (and Orac) here. The boundaries are not quite so bright.

    If you are just the regular attending physician, then I agree with Sarah that the question is inappropriate. The doctor does not need to know your religious preferences (other than cases where certain specific treatments should be avoided if possible, which is on a par with allergies to commonly prescribed drugs and such). What is different about Orac’s work is that he is a specialist in a disease which is potentially fatal. Thus, as I pointed out in my previous comment, he is dealing with patients who have a reason to consider the afterlife. I don’t fault Orac for telling the truth but not the whole truth here (i.e., that he’s a lapsed Catholic). The best solution might be to refer such a patient to the hospital chaplain, but that may not be practical for people being treated on an outpatient basis.

    I am aware that often in terminal cases, there is nothing the doctor can do beyond pain management. In such cases the doctor is prescribing a drug that he knows will not help the patient’s underlying disease but may help alleviate one of the symptoms. There is a fine line between doing this and prescribing a placebo, and even finer between doing this and prescribing an ineffective cure. Pain management does have a definite downside as well, which is why this technique is normally only used in terminal patients: you worry less about such a patient becoming addicted to painkillers because that is the least of her worries.

  6. #6 Daniel Corcos
    March 13, 2017

    Do you believe in sugar pills?
    – I love sweet.

  7. #7 StrangerInAStrangeLand
    March 13, 2017

    Was the name of the woman Gretchen? 🙂

    Your story was the best real-life example of the “Gretchenfrage” (Gretchen Question) I ever read. In the book “Faust” by Goethe (for those who don´t know this, Goethe is to German literature what Shakespeare is for the English), the girl Gretchen asked the scientist Faust what his stand on religion is, something he would rather not answer (having made a deal with the devil and so). This term is now used in Germany in general to characterize a question that is aiming at the core of a subject and that the other person would like to avoid answering.

    I can understand your decision to “avoid” the question, I guess as a medical doctor you are more inclined to put your patient´s well being over your own beliefs. When I was asked similar questions in the past I state my atheism in a simple, matter-of-fact way. No problem here in Europe, but I did get some shocked responses while visiting the USA a few times. 🙂

  8. #8 Calli Arcale
    http://fractalwonder.wordpress.com
    March 13, 2017

    I think the hardest thing about a question like that is not merely what impact the answer will have but wondering what the motivation is. It’s a minefield, and there will never be a perfectly safe answer for all situations. I think you answered appropriately, for what it’s worth.

    It looks like this was a case where the woman wanted to give you encouragement, as her surgeon, and first wanted to see if the way she wanted to encourage would offend you. That’s about the best-case scenario in which someone asks. They’re not asking to trap you, but to see whether this sort of faith-based encouragement would be welcome.

    But you couldn’t have known that before answering her question, and that’s the tricky part. What if she was troubled by the fear of surgery gone horribly wrong, and wanted to talk about the afterlife? Awkward x1,000 at that point, and a conversation better had with a clergyperson or other religious advisor. But I could totally see someone asking.

    Kudos to you for how you handled it.

  9. #9 Anonymous Pseudonym
    In Your Head
    March 13, 2017

    @5 Eric
    I don’t mean to be overly harsh or hard on either of them. I understand that different people will have different boundaries as I alluded to with saying **I** saw it as no different then what sports team do you cheer for or what political group do you like. I am also honestly curious what Sarah sees as the difference between prescribing something a patient wants that is useless(placebo or quackery), and encouraging a belief that is false (The doctor shares their religious convictions)

    Terminal patient management is another kettle of fish entirely. That is NOT placebo. That is making the patients last days as comfortable as possible. The patient and the doctor should both know that is the case. If the patent doesn’t, then there is a major failure in communication. The physicians faith or lack there-of, in my mind, should have no bearing on the treatment provided. Here is where you get into the right-to-die, and religious beliefs interfering with a patients desires. Hence me wondering, where is the line drawn by physicians. I assumed that the state boards don’t provide anything more then broad brush guidance, but I don’t know and am curious.

  10. #10 Mark Thorson
    March 13, 2017

    So what happened with this patient? Sounds kind of iffy whether she’d be alive today, even if she didn’t have cancer.

  11. #11 Narad
    March 13, 2017

    Outside of professional obligations, I would have shrugged and said I grew out of belief around the same time I realized the Easter bunny and the fey folk were just as real as God.

    And if the patient were then to ask how you knew you were “real” or – even better – whether you though she was “real,” how would you roll on with this Easter bunny patter?

  12. #12 RobNYNY1957
    March 13, 2017

    . To me, the question of belief in God is irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way.

    I would see it as a handicap. To believe in something as silly as ‘god’ is an indication if soft-headedness. Religion is just as bad as woo,since there is absolutely no evidence to support a man the sky.

    This is worse than homeopathy. I would believe in homeopathy over Christianity anyday.

  13. #13 Anonymous Pseudonym
    In Your Head
    March 13, 2017

    @11 Narad
    I’d keep it simple. If I can see, hear, touch and interact with you, then we are both real. If she wanted a philosophical debate on what is real and reality, I’d tell her I have other obligations and she can find a philosophy major to debate at the local pizzeria (Yes I am mostly kidding). In essence, anything that can be scientifically proven to exist, I’m happy to acknowledge the existence of. All else is fantasy and word games. Fantasy does have its place, but not in medicine.

  14. #14 Paul de Boer
    Canada
    March 13, 2017

    Hey Orac,

    I had a similar situation recently, but this involved my new dog! Not to say this has any equivalence or catharsis with your turmoil. I’m just reminded and amused.

    The shelter said he was boston terrier mix. He is not. He looks very much like a pit bull. Of course that breed has a stigma associated with it. Some building and communities have bans on the breed. My province has a muzzle law. He’s the sweetest dog though. Then it became time to register him with the city. Primary breed : Boston Terrier [hey, you guys said it not me] Secondary breed : ____. So should I say pit bull and fight the stigma with my pal? or should I put people at ease and keep my living arrangements open?

  15. #15 Ross Miles
    Barrie ON
    March 13, 2017

    Out of bounds questions do not get direct answers. As a general rule, state your role and then elicit support from the questioner to try and address the concern. In short: My job here is to assess the possibility that you have breast cancer as that is what I specialize in. I will also be calling on additional help from your pulmonologist and cardiologist in order to get the best possible outcome for your problems. We will need your co-operation in order to achieve that, and if you find it helpful, we will accept your prayers with gratitude. My experience says next to no-one is aggressive enough to ask the same question again, but if they did, in this case, there is 3 members of the family, which is good, as then one can get more specific on co-operations to take care of her diabetes, hypertension, smoking etc but do not repeat the religion or god part, and I think I would leave the obesity alone, even though there is almost certain probability that the adiposity is the root cause.

  16. #16 Rich Bly
    Ocean Shores
    March 13, 2017

    Orac,

    As I’ve stated in the past, I was over 511 pounds and had prostate cancer 31/2 years ago. I never would have worried about what religion my doc and other medical providers were or weren’t. (Prostate cancer is gone or in remission and I’ve lost 200lbs)

    This woman seemed more concerned with her religion than her health.

    How long would this woman have complained if your first question to her was do you believe in god. I would imagine it would have been long and loud.

  17. #17 Michael J. Dochniak
    Minnesota
    March 13, 2017

    @ Rich Bly,

    I was a power lifter in college and my best dead lift was 475 lbs. (once).

    You must have been very strong to walk with such weight.

  18. #18 Johnny
    127.0.0.1
    March 13, 2017

    It’s a minefield, and there will never be a perfectly safe answer for all situations.

    I agree. In a polite conversation, I’ve used the Tom Hanks line in Angels & Demons “Faith is a gift that I have yet to receive”.

    I’ve also been known to answer with a flat “no”, which can be fun. There is often a follow-up question along the lines of ‘are you spiritual?’, which I answer ‘define spiritual’. I’ve never received a coherent answer.

    I don’t have as much firsthand contact with Muslims, but ISIS/al Qaeda seem to be cut from the same cloth.

    In my experience, yeah. I’ve worked with a few Muslims over the years, even supervised two, one of which made the hadj twice while I knew him. We had several chats about the theory and culture. He gave me a copy of the Koran on his last day.

    Like most people, most of them are good guys (and gals). The ones that aren’t, aren’t.

    I think the biggest problem with the perception of Islam is that there isn’t an overall leader to denounce ISIS and associated groups. Individual Muslims and Imams do, but that never makes the news.

  19. #19 Jazzlet
    March 13, 2017

    Anonymous Pseudonym I think that the asking of someone what their religion is is one of those things that has a very variable acceptability in dfferent cultures. In the UK it has traditionally been in distinctly bad taste to discuss ones religious beliefs, although it’s quite often possible to guess someones likely beliefs/denomination from various social cues one just doesnt talk about it and actually asking is really rather too intimate in most contexts.

  20. #20 Rich Bly
    Ocean Shores
    March 13, 2017

    MJD,

    Back when I could leg press 1100 lbs and in my mid thirties I slant boarded 875 lbs to show off to a future first round draft choice (9th grade at the time), he played middle linebacker for 10 years.

    So when I am in shape, I am fairly strong. I am working my way back, I am now 320lbs. It is a lot of work when you are in your 60’s.

  21. #21 jrkrideau
    At the bottom of the lake (the bottom end that is)
    March 13, 2017

    # 19 Jazzlet

    Essentially the same here in Canada. I was talking to an America and he suggested that is was a friendly way of getting to know who you were in the USA. Weird.

  22. #22 herr doktor bimler
    March 13, 2017

    “God will guide your hand,” she said.
    Perhap God guided her own hand away from the cigarettes.

  23. #23 Panacea
    March 13, 2017

    Funny how I view this patient’s question in a totally different light . . . and her answer as well . . . than most everyone else here.

    My response would have been quite different. For me, it would be a golden opportunity to elicit more information about her health care needs from a spiritual perspective.

    My answer would have been something like, “What does my answer mean to you?” or “What role do you want God to play in your health care choices?” or “What do you think your diagnosis will mean for you and your relationship with God?” or even a simple, “Do you want me to pray with you?”

    I would want to find out if this patient is in spiritual distress. Is she thinking she might soon be meeting her maker? Is she frightened she might die and have to account for her life? If she is, that anxiety is going to impact her decision making process, her response to a cancer diagnosis, her choices in regards to treatment, and even her response to that treatment.

    It doesn’t matter whether her God exists or not, or if he exists the way she envisions he does (and as a Catholic myself, even in the Catholic Church there is a spectrum of belief, liberal through conservative thinking). It’s her anxiety that matters regardless of its source, and it’s part of her health care needs.

    What her answer to me indicates is she wanted to talk about her own mortality, and had to accept she couldn’t do so with Orac. She wanted someone she could pray with, because she was afraid.

    You don’t have to be a believer to offer spiritual comfort to a patient who is. You don’t even have to admit you’re not a believer. All you have to do is offer to pray with the patient. I do this all the time with patients, and did before the gift of faith (to paraphrase Tom Hanks’s character) came my way. It makes a world of difference.

    If the thought of invoking God or Jesus really bothers you that much, let the patient lead the prayer. Or use the term “We call upon our Higher Power.” A friend of mine who is a minister often does that when he’s leading an interdenominational effort (especially when he knows some of the audience may be atheists or agnostics).

  24. #24 Ross Miles
    Barrie ON
    March 13, 2017

    Panacea @23 I have no problem with your approach as, for you, it is a question which is in bounds. However, I would have to be a believer in order to pray with someone in that circumstance, as otherwise, one is condoning a misrepresentation, and from my point of view breaks a bond of trust. Gotta be who you say you are.

  25. #25 Panacea
    March 13, 2017

    You really are not misrepresenting yourself. You are supporting a need of the patient. You can tell the patient I’m not a believer but I will pray with you if you really feel you must. I find it’s the support patients really want, not belief.

  26. #26 Michael J. Dochniak
    Minnesota
    March 13, 2017

    I noticed the examination room chosen by Orac to begin this post contains boxes of gloves formed exclusively from polychloroprene.

    Thank Orac, oh what a relief it is!

  27. #27 Ross Miles
    Barrie ON
    March 13, 2017

    Panacea @25 Would the patient then not see that in reality a praying non believer / atheist then would not be actually praying? Does that not start one down the road to the patient thinking about what else may be compromised? Or is the answer as I interpret you, is that believers have a different mindset and are happy to get all the support they can in the world in which they live, not thinking about the implications?

  28. #28 Gilbert
    March 13, 2017

    Ohh. That is a big woman. Baby got back. I would have thought that the most uncomfortable and practical question would be “did you just fart?”

    “She wanted to know whether she was contaminating the operating theatre she worked in by quietly farting in the sterile environment during operations…

    “Our deduction is that the enteric zone in the second Petri dish was caused by the flatus itself, and the splatter ring around that was caused by the sheer velocity of the fart, which blew skin bacteria from the cheeks and blasted it onto the dish. It seems, therefore, that flatus can cause infection if the emitter is naked, but not if he or she is clothed.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121900/

  29. #29 Panacea
    March 14, 2017

    @Ross #25:

    I’ve never met a patient who thought someone praying with them compromised their beliefs. If anything, they might think they’re opening the door to faith for such a person. I don’t really know what they think about the implications; that’s a philosophical discussion not a spiritual one, and it’s counterproductive to their needs at the moment to raise the issue.

    What matters is the support system we offer. If we’re seriously going to claim that we provide holistic care, we have to include the spiritual. Otherwise, we’re full of shit, and it’s why the quack crowd is able to get a wedge in with some folks–they don’t hesitate to stroke someone’s spiritual ego whether the quack themselves are believers or not.

    Now I’m not suggesting stroking anyone’s ego just to get them to go with the SBM program. Far from it. I’m suggesting we take the spiritual needs of our patients seriously regardless of what we ourselves believe. It really doesn’t have to be that complicated. You simply have to ask the patient what they need form you on a spiritual level. Be available to the patient on a spiritual level. You don’t have to claim to have all the answers or even share the faith or any faith with the patient. You don’t have to lie to them or compromise your own beliefs. Just be sensitive.

    Sometimes the needs are as simple as allowing a woman from some faiths to cover her head when an unrelated male is present. It only takes a second, but I’ve known many male physicians and nurses who are oblivious to this need and just barge into a room even when there’s a sign on the door asking them to knock and wait for permission to enter first.

    Really, how hard is it to hold someone’s hand and pray for them?

  30. #30 Jay
    March 14, 2017

    Quite easy for me, I do believe, but not in any dogma. No books or prophets for me. I feel it quite wrong for a man to get between a man and the creator.

    It really throws em

  31. #31 Chris Hickie
    March 14, 2017

    Similar to Panacea’s posts, her question could have been her way of trying to do a good deed for a doctor who did an excellent job of caring for her, Orac. Patients with multiple morbidities like hers are, sadly (as you note), often either openly disrespected by health care providers or criticized harshly during office visits for their lifestyle choices; so, when a doctor doesn’t do that, they are very grateful. People with strong faith can be more concerned about what happens after they die than having/keeping good health while alive on planet earth, and this could have been her reaching out to help with that (from her perspective). If you had told her you didn’t believe in God, she might have told you why she feels you should (and offered to pray for you) instead of dismissing all you’d just covered with her–but I also agree there’s no easy way of knowing and the safer answer was not to say no out of fear of derailing the whole visit). I’ve never had that question asked of me–and I agree it’s a tough one to field especially at the end of a clinic visit.

  32. #32 Ross Miles
    Barrie ON
    March 14, 2017

    Panacea @29
    Thanks for taking the time to expand.
    Seems we are essentially back to what Orac wrote: “To this day, I still can’t make up my mind whether my choice was a complete cop out or a clever and diplomatic strategy not to undermine a patient’s confidence in me. It was probably a little of both.”

  33. #33 Panacea
    March 14, 2017

    You’re welcome, Ross 🙂

    I would suggest that this post (repost) is an opportunity for those of us here who are health care providers to think about the issue, and how we would respond to a patient who asks a question like this.

    Addressing the spiritual aspect of our patients is something many providers don’t do well, and feel uncomfortable doing. It doesn’t have to be hard and it doesn’t have to mean compromising our own values or beliefs systems.

  34. #34 StellaB
    March 14, 2017

    I tried the “I was raised Catholic” dodge once, but it didn’t work.

    Who ordered a mammogram for a woman with so many comorbidities? I covered the hospital one weekend and cared for an 84 year old with recently diagnosed BC and end-stage COPD. At that age, with an FEV1 of 0.27, and frequent lung-related admissions, a mammogram was not indicated. The cancer diagnosis was more cruel than helpful.

  35. #35 JustaTech
    March 14, 2017

    Panacea, what you have described is literally a nightmare for me. I am having a physical reaction to the idea of someone asking me to pray with them, let alone the idea that *I* would ask them to pray with me.
    It’s just about the most private thing I can imagine and I have never been able to understand why people want to share it outside of a designated space (eg worship).

    If that’s what’s required of clinicians and anyone who works directly with the public then I guess I’m going to have to stay on the investigation/data side of public health.

  36. #36 JustaTech
    March 14, 2017

    StellaB @34: Maybe the patient found a lump herself and asked for a mammogram?

  37. #37 Panacea
    March 14, 2017

    @JustaTech: it might surprise you to hear me say one of my favorite Bible verses is Matthew 6:5, which pretty much tells the faithful to keep their prayers private.

    In health care though, when a patient asks me to pray with them, they’re typically looking for support and comfort, not to proselytize.

    Naturally if a patient traps a caregiver trying to convert them, the caregiver is not obligated to stick their hand in a steel trap.

    Required is a loaded term. You won’t find it in any job description, and lots of people dodge the bullet.

  38. #38 JustaTech
    March 14, 2017

    Panacea @37: And if you can’t give them comfort that way? I can fake it through grace before dinner, but I really don’t think I could hide how uncomfortable I am at someone praying out loud in a language I understand.

    My spiritual beliefs (or lack thereof) are no one else’s business, and anyone else’s spiritual beliefs (or lack thereof) are none of my business. And I really resent when people interrupt an unrelated situation, like a visit to the doctor’s office, to ask.

    A psychologist as part of determining a treatment plan? Sure. My GP? No. It would seriously damage the relationship I had with my doctor.

  39. #39 JP
    March 14, 2017

    My spiritual beliefs (or lack thereof) are no one else’s business, and anyone else’s spiritual beliefs (or lack thereof) are none of my business. And I really resent when people interrupt an unrelated situation, like a visit to the doctor’s office, to ask.

    Aye, and it can go both ways, so to speak. I was told by one of the staff members at the psych ward I was in this past summer that suicides go to hell. I don’t know if she was aware that my dad committed suicide when I was a kid.

    At the same place, another staff guy explicitly asked during group therapy who believed in the “power of prayer.” I was the only one among the two staff members and numerous patients who didn’t raise my hand. This was uncomfortable, to say the least. I was then later interrogated by yet another (very Catholic) staff member later on when I was reading the Bible if I “didn’t believe in it.” I answered that it was because it was the only piece of real literature in the library there, and it sure beat reading crappy mystery novels. Granted, when the other patients told me I was going to hell or tried to preach to me or whatever, that couldn’t be blamed on the institution, but staff members?

    I mean, at St. Joe’s in Michigan they had Mass, and I think somebody once told me that it was available (for Catholics, I presume), but nobody ever pestered me about religion there. Not even the other patients, for whatever reason.

  40. #40 Panacea
    March 14, 2017

    I’m not asking anyone to do something if they’re so diametrically opposed to doing it. I’m merely suggesting spiritual care is something over looked or ignored by health care providers of all stripes, and something we should take more seriously as a profession.

  41. #41 Jim Hunt
    New Zealand
    March 14, 2017

    Belief can be dangerous, for example it can stop people considering the truth.
    Where’s your report on this study?
    Is it coming?
    http://www.medicalnewstoday.com/articles/316334.php
    I hope those that said vitamin c was quackery are held accountable for the deaths of the many people who were convinced not to try it.
    Insolence. Beliefs are like stones, the immovable ones are deeply entrenched

  42. #42 Perodatrent
    Italy
    March 15, 2017

    Maybe you noticed the study you quoted is an in vitro study?

  43. #43 Chris
    March 15, 2017

    Perhaps Mr. Hunt thinks petri dishes are equivalent to full human body. Relevant graphic:
    https://xkcd.com/1217/

  44. #44 Ross Miles
    Barrie ON
    March 15, 2017

    Jim Hunt @ 41

    Looks like you will have a long wait for a report on how it may work in humans, as the authors in the conclusion state: “Future studies will be necessary to test their potential for clinical benefit in cancer patients.”
    Always better to read and understand the study, rather than read a news summary. Saves on erroneous conclusions.

  45. #45 JustaTech
    March 15, 2017

    Panacea @40: You did say that if SBM clinicians don’t talk about spirituality with patients then the patients are driven to woo. That’s a pretty strong statement.

    I would also suggest that there is an entire profession of people who’s only job is to look out for the spiritual needs of people. Just as I wouldn’t ask my priest about this funny mole (she would tell me to go see a doctor) I wouldn’t ask my doctor to explain transubstantiation.
    But I guess most patients don’t have that kind of boundary?

  46. #46 Peter B
    March 15, 2017

    My first thought was that she was trying to find out if you were saved. And if not, to share the Good News™ with you. I am not a medical professional of any kind but if asked the same question the answer you gave substituting Baptist for Catholic would be accurate.

    Your reply did not answer her question. But it did defuse a potential awkward situation while maintaining professional conduct.

  47. #47 NumberWang
    March 15, 2017

    @ Chris #43

    Ha! I wondered how long before someone linked to that.

  48. #48 Chris
    March 15, 2017

    NumberWang, I think in this case it is pretty much mandatory.

  49. #49 Panacea
    March 15, 2017

    @JustaTech: uh, when did I say that? That’s not what I said.

    Here’s what I actually said: “If we’re seriously going to claim that we provide holistic care, we have to include the spiritual. Otherwise, we’re full of shit, and it’s why the quack crowd is able to get a wedge in with some folks–they don’t hesitate to stroke someone’s spiritual ego whether the quack themselves are believers or not. ”

    I stand by that statement. But what I said was if SBM providers ignore the spiritual needs of their patients, that opens the DOOR for the woo meisters; it gives them an avenue to make a connection with a patient who might otherwise not be inclined to it. What I said does not mean that every patient who is spiritual will go towards the woo, whether their spiritual needs are being met or not.

    We all know that the quacks are attractive to some patients because they are good at talking to their patients. We also know that some physicians, PAs, even some NPs and nurses, are lacking in the bedside manner department. Quacks work hard on building a personal connection with patients. People are inclined to trust practitioners who build a personal connection with them.

    So it follows that if a practitioner cannot or will not address the spiritual needs of a patient, even acknowledge that they exist, then patients who are looking for that connection will find it elsewhere, and they may find it with a quack. Improving our approach as SBM practitioners, we can head that off and keep patients where they can get care that actually works, and is in their best term long interest.

    None of that means that failing to address the spiritual literally drives patients to woo.