The New Frontier: Religious
Diversity in Patient Care:
A Family Physician’s Perspective
Robert C. Like, MD, MS
Professor and Director
Center for Healthy Families and Cultural Diversity
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
© 2013 Center for Healthy Families and Cultural Diversity/UMDNJ-RWJMS
“Man is not destroyed by
suffering; he is destroyed by
suffering without meaning.”
Victor Frankl. Man’s Search for Meaning.
New York: Simon and Schuster, 1984
Existential Issues
in Health Care

When patients are ill, they often ask themselves the
following questions:
“Why did this happen? Why me? Why now?”

While medicine generally addresses the how of disease
(i.e., pathophysiology, diagnosis, and treatment), many
patients are also concerned about the why of sickness
and suffering, and may seek out support from
counselors, clergy, and pastoral care providers to cope
with other existential personal, family, and societal life
issues.
Question 1
Why is developing religio-cultural
competence important for clinical care,
hospitals, and other healthcare
organizations?
Model Hospital Programs:
The Importance of Community
Engagement and Partnerships
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Lutheran HealthCare
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Meridian Health
Clinical Case Vignette
Like RC. A Religious and Ethical Dilemma, in Patients and Doctors: Life-Changing
Stories of Healing, Steinmetz D, Borkan J et al. (eds.), Madison, WI: University of
Wisconsin Press, 1999, pp. 78-79.
Spiritual Distress
“Spiritual distress and spiritual crisis occur when
individuals are unable to find sources of meaning,
hope, love, peace, comfort, strength and connection
in life or when conflict occurs between their beliefs
and what is happening in their life. This distress can
have a detrimental effect on physical and mental
health. Medical illness and impending death can
often trigger spiritual distress in patients and family
members.”
Anandarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE Questions as
a Practical Tool for Spiritual Assessment. American Family Physician 2001;63:81-8, 89.
Research into the beneficial influence
of spiritual and religious practice
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Stress reduction
Recovery from illness
Reduction of depression
Substance abuse prevention and recovery
Prevention of heart disease and hypertension
Mitigation of pain
Adjustment to disability
Recovery from cardiac surgery in the elderly
Palliative and end-of-life care
Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and
Ethics. Annals of Internal Medicine 2000; 132(7): 578583 http://www.annals.org/cgi/reprint/132/7/578.pdf
Selected Clinical Care
and Bioethical Issues
Canadian Medical Association Journal – Religion/Spirituality Resources
http://www.cmaj.ca/cgi/collection/religion_spirituality
Cultural Competence: Caring for your Muslim patients
http://medicaleconomics.modernmedicine.com/memag/Young+Doctors%27+Resource+Center%3A+Practice+Management
%3A+Patient+relations/Cultural-Competence-Caring-for-your-Muslimpatient/ArticleStandard/Article/detail/158977?contextCategoryId=8727
Recommendation for Management of Diabetes During Ramadan
http://care.diabetesjournals.org/cgi/reprint/28/9/2305
Recent Developments in Medical Care of Jehovah’s Witnesses
http://www.ajwrb.org/wjm/wjm.htm
Joint Commission
Hospitals, Language, and Culture: A Snapshot of the Nation,
March 2007
http://www.jointcommission.org/assets/1/6/hlc_paper.pdf
One Size Does Not Fit All: Meeting the Health Care Needs of
Diverse Populations, April 2008
http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf
Advancing Effective Communication, Cultural Competence, and
Patient- and Family-Centered Care: A Roadmap for Hospitals,
August 2010
http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf
Advancing Effective Communication, Cultural Competence, and
Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual,
and Transgender (LGBT) Community: A Field Guide, October, 2011
http://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf
National Center for Cultural
Competence - Georgetown University
•
A Guide to Planning and Implementing Cultural Competence
Organizational Self-Assessment
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Cultural Competence Health Practitioner Policy Assessment
•
Planning for Cultural and Linguistic Competence in Systems
of Care
•
Bridging the Cultural Divide in Health Care Settings:
The Essential Role of Cultural Broker Programs
•
Sharing a Legacy of Caring: Partnerships between Health
Care and Faith-Based Organizations
http://www11.georgetown.edu/research/gucchd/nccc
http://nccc.georgetown.edu/documents/faith.pdf
Cultivating Cultural Humility
•
A lifelong commitment to self-evaluation
and self-critique
•
Redressing power imbalances
•
Developing mutually beneficial
partnerships with communities on behalf
of individuals and defined populations
Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining
physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved
1998; 9(2):117-124.
Cultural Humility: People, Principles & Practices. A film by Vivian Chávez, 2012
http://www.youtube.com/watch?v=SaSHLbS1V4w&feature=relmfu
Question 2
What are best practices and available
resources for integrating religio-cultural
competence into health professions
education and staff diversity training
initiatives?
Model Educational Programs:
Live and Web-Based Strategies
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Maria Fareri Children’s Hospital
Tanenbaum Center for
Interreligious Understanding
Teaching about Spirituality and
Religion in Medical Education
and Clinical Practice
Booth B. More schools teaching spirituality in medicine. American Medical News, March 20, 2008
http://www.ama-assn.org/amednews/2008/03/10/prsc0310.htm
In 1992, “2% of U.S. medical schools offered course work in spirituality.
By 2004, the figure was 67%. Now 100 of the approximately 150 U.S.
medical schools offer some variation of spirituality-in-medicine course work.
Koenig HG, et al. Spirituality in medical school curricula: findings from a national survey.
Int J Psychiatry Med 2010; 40(4):398-398.
“Ninety percent (range 84%-90%) of medical schools have courses or content
on spirituality and health (S&H), 73% with content in required courses
addressing other topics and 7% with a required course dedicated to S&H.”
(85% response rate from 122 U.S. Medical Schools)
The John Templeton Foundation (http://www.templeton.org) has been a
major source of funding for many of these spirituality in medicine curricula.
Post SG, Puchalski CM, Larson DB. Physicians and Patient
Spirituality: Professional Boundaries, Competency, and Ethics.
Annals of Internal Medicine 2000; 132(7): 578583
http://www.annals.org/cgi/reprint/132/7/578.pdf
• What are the potential risks/benefits of mixing religion and
medicine/faith and science?
• What is the clinical relevance of spirituality, religion, faith, and
prayer?
• What role does spirituality and religion play in your own personal
and professional life?
• Should physicians discuss spiritual issues with patients?
Do patients want us to?
• Is it ever appropriate to try to encourage or discourage religious
beliefs for the “benefit” of the patient?
• What should be the professional boundaries between physicians
and chaplains, who can be clergy or nonclergy lay persons with
clinical pastoral education?
Post SG, Puchalski CM, Larson DB. Physicians and Patient
Spirituality: Professional Boundaries, Competency, and Ethics.
Annals of Internal Medicine 2000; 132(7): 578583
http://www.annals.org/cgi/reprint/132/7/578.pdf
• Should an appreciation of spirituality be expressed within the
physician-patient relationship? In your relationships
with colleagues and other health care professionals?
If so, under what circumstances and to what extent?
• Should a spiritual needs assessment or “spiritual status exam”
be carried out with patients?
How, when, and where should this be done?
• Should physicians pray with their patients if requested by them?
If so, should this be done publicly or privately?
Should physicians ever offer to pray?
• What ethical guidelines should guide the above decisions?
Spiritual Assessment Tools
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FICA Spiritual History Tool
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HOPE Questions for Spiritual Assessment
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The Open Invite Mnemonic
Saguil A, Phelps K. The Spiritual Assessment. American Family Physician 2012;
86(6):546-550. http://www.aafp.org/afp/2012/0915/p546.pdf
Effects of Spiritual Assessment
on Medical Management
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Take no further action
Incorporate spirituality into preventive
health care
Include spirituality in adjuvant care
Modify the treatment plan
Anandarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE Questions as
a Practical Tool for Spiritual Assessment. American Family Physician 2001;63:81-8, 89.
Selected Academic
Medical Centers
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The George Washington Institute for Spirituality and Health
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University of Chicago – Program on Medicine and Religion
http://www.gwish.org
https://pmr.uchicago.edu
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University of Minnesota - The Center for Spirituality and Healing
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University of Florida - The Center for Spirituality and Health
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Duke University - Center for Spirituality, Theology and Health
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Texas Medical Center – Institute for the Spirituality and Health
http://www.csh.umn.edu
http://www.spiritualityandhealth.ufl.edu
http://www.dukespiritualityandhealth.org
http://www.ish-tmc.org/
Religio-Cultural
Competence Resources
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Tanenbaum Center for Interreligious Understanding
The Medical Manual for Religio-Cultural Competence:
Caring for Religiously Diverse Populations, 2011 (fee $)
https://www.tanenbaum.org/programs/health
CME: Improving Religio-Cultural Competence in Patient Care (fee $)
https://www.tanenbaum.org/store/cme-improving-religio-cultural-competence-patient-care
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Realin AP, ed. A Desk Reference to Personalizing Patient Care.
Orlando: Florida Hospital Publishing, 2012 (fee $)
http://floridahospitalpublishing.com/patientcare
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HealthCare Chaplaincy. Cultural & Spiritual Sensitivity: A Learning
Module for Health Care Professionals and Dictionary of Patients'
Spiritual & Cultural Values for Health Care Professionals. New York,
NY, 2009 (revision & update of earlier work by the Rev. Susan
Wintz and the Rev. Earl Cooper)
http://www.healthcarechaplaincy.org/userimages/Cultural_Spiritual_Sensitivity_Learning_%20Module%207-10-09.pdf
http://www.healthcarechaplaincy.org/userimages/doc/A-Dictionary-of-Patients-Spiritual-Cultural-Values-for-Health-Care-Professionals.pdf
Selected Cultural Competency
Continuing Education Programs
Office of Minority Health
A Physician’s Practical Guide to Culturally Competent Care
https://cccm.thinkculturalhealth.org
Health Resources and Services Administration
Effective Communication Tools for Healthcare Professionals
(formerly Unified Health Communication 101)
http://www.hrsa.gov/publichealth/healthliteracy
Private Sector Live and Online Programs
Like RC. Educating Clinicians About Cultural Competence and Disparities in Health and Health Care.
The Journal of Continuing Education in the Health Professions 2011; 31(3):196-206
A Closing Meditation
“Adding wings to caterpillars does not
create butterflies - it creates awkward
and dysfunctional caterpillars.
Butterflies are created through
transformation.”
Stephanie Pace Marshall
http://www.stephaniepacemarshall.com/articles/SPM-Article8.pdf