By intuitions differently formed: how physicians assess and respond to spiritual issues in the clinical encounter.

In a salutary contribution to debates about spirituality in medicine, Kuczewski (2007) raises the question of whether “hard and fast rules” are suited to the subject of dialogue about spiritual matters. Those who argue that physicians should not engage patients’ spiritual concerns still suggest physicians should at least consider those concerns, and those who encourage physicians to assess and address spiritual issues have developed and published an array of practical tools to help in that task. Yet little has been known about how physicians actually assess and respond to patients’ religious and spiritual issues. This commentary relates Kuczewski’s analysis to empirical data about what physicians themselves report. We recently conducted semi-structured interviews with 21 physicians from a range of different religious and nonreligious worldviews to explore their perspectives on the intersection of religion, spirituality and medicine. Prior reports described participants’ perspectives on how religion and spirituality influence patient health (Curlin et al. 2005a) and on religiously-mediated conflict in medical decisionmaking (Curlin et al. 2005b). We here report the themes from what participating physicians said about how they assess and respond to patients’ spiritual concerns. These themes are illustrated with direct quotations from study participants. Participants described intuitive, patient-centered, caseby-case approaches to spiritual issues in the clinical encounter. They said they were more likely to inquire about spiritual concerns in contexts such as end-of-life care, communication of a grim prognosis, making decisions about pregnancy, and responding to symptoms of depression. Yet, physicians avoided strict rules or guidelines regarding when and how to inquire. Instead they talked about being “spiritually tuned in” to notice and respond to cues that suggest patients may have spiritual concerns that merit further attention. Verbal cues from patients included angry or anguished tones of communication, spiritually laden words such as “guilty” or “lonely,” and explicitly religious language. Visual cues included Bibles or other religious literature on patient’s bedside tables, religiously symbolic jewelry, and