Case Scenario

I have a very religious patient who attends one of the more conservative churches in town. My medical practice is nondenominational, and I personally have no religious affiliations. My patient once mentioned that she preferred a Christian practice, but she chose my practice based on her insurance coverage and its proximity to her home. I said that I would not be offended if she decided to go to another practice. At first she made comments such as “the Lord has helped me a lot.” To this I replied that I was glad and went on with the visit. However, at her next visit she said, “I have always found it helpful to pray with someone else about my health.” I asked her if she had someone to pray with, and she said, “Actually, would you pray with me?” I felt uncomfortable with this request and thought she may have been trying to find out about my private beliefs. How should I respond to this patient?

Commentary

This complex scenario poses many challenges. At first glance, it seems to just be about prayer—should the physician pray with a patient? However, on closer inspection it becomes clear that this scenario is about successfully balancing the patient's beliefs and stated needs with the physician's beliefs and training while maintaining healthy boundaries in the physician-patient relationship.

Whether the health benefits of prayer can be proved scientifically is controversial.^1–3 However, the use of prayer for health and coping remains common worldwide. A 2002 study of 31,044 adults showed that prayer is the most commonly used complementary and alternative medical treatment in the United States.⁴ Sixty-two percent of participants had used a complementary or alternative treatment in the preceding year. Of those, 43 percent prayed for their own health, 24.4 percent were prayed for by others, and 9.6 percent participated in a prayer group.⁴

In addition, longitudinal survey data indicate that 76 percent of Americans pray daily.⁵ A national study of family physicians showed that 79 percent of participants reported a strong religious/spiritual orientation, and 35 percent reported participating in a private religious or spiritual practice daily.⁶

Because illness can trigger stress, it is not surprising that many patients pray during medical care or that physicians encounter prayer in clinical situations. In the scenario, the physician's discomfort is partially from not having a prepared response to a direct request for prayer. Although the physician may feel comfortable supporting the patient in her beliefs, the physician may be concerned that this request may threaten the boundaries in the physician-patient relationship.

How can physicians prepare themselves for this type of situation? The first step is introspection. Understanding one's own philosophy regarding prayer will help guide the professional response to a request for prayer. Table 1 includes questions that physicians can ask themselves to enhance self-understanding before responding to patients. Regardless of how physicians answer these questions, they should carefully examine the boundary between the roles of physicians and spiritual advisors, recognizing the training necessary to be a spiritual advisor. Physicians should also be mindful of the power differential between physician and patient. Finally, the physician should decide to what extent he or she is willing to compromise personal beliefs to support the patient's needs.

The second step is to examine the patient's motivations for the prayer request. How essential is it that her medical care includes prayer with her physician? Her request may simply represent a wish for support and connection, or it may be an attempt to change the physician's practice style. Possible strategies for examining the patient's motivations include determining if she really wants to know the physician's beliefs; if she assumes that the physician's beliefs are the same as hers; if she wants to convert the physician; and what role she wants the physician to fill (physician, spiritual advisor, savior, or all of these roles). Finally, it is important to have some understanding of what the patient would do if the physician declines her request for prayer.

In this scenario, there clearly is a mismatch between the physician's beliefs and those of the patient. The physician seems willing to support the patient in her religious practices but may not be willing to participate. The physician also prefers not to discuss his or her personal beliefs. It is unclear what the patient's motivations are and how she would respond if the physician were to decline to pray with her.

The physician can use skills developed for other challenging clinical scenarios to further examine the patient's request and the motivations behind it and to help guide the physician's response. It is possible that the patient wants more than the physician can provide. Conversely, it is possible that a compassionate, patient-centered exploration of the patient's spiritual beliefs, resources, and needs may present opportunities for new therapeutic options that are acceptable to both.

Negotiating this complex physician-patient scenario requires the following: (1) the physician's self-understanding of personal beliefs and biases; (2) exploration of the patient's needs and motivations; (3) ability to skillfully refocus attention toward the patient and away from the physician; (4) the seeking of common ground for acceptable compromise; (5) awareness of boundaries in the physician-patient relationship; (6) maintaining a compassionate and patient-centered approach; and (7) a prepared response for gracefully saying “no” to patients when needed.

Although physicians may not always be able to fulfill a patient's request for prayer, a compassionate, open-minded approach most likely will lead to a healthy and satisfying therapeutic relationship.