1. Spiritual Review of Systems: Helping Find the Real Diagnosis Behind the Symptoms Richard Sams, MD, MA, CDR MC USN Program Director, Naval Hospital Jacksonville Family Medicine Residency Gray Dawson, MD, MBA, LCDR MC USN Officer in Charge, Naval Branch Health Clinic, St. Mawgan, UK

2. Goals  Why Bother?  Medicine of the Whole Person, Dr. Paul Tournier  Spiritual Review of Systems (ROS) vs. Spiritual History (Hx)  Spiritual ROS leads to spiritual diagnoses  Introduce a non-threatening approach to taking a spiritual history  Show concrete examples of how this can change your practice

3. EBM Disclaimer "Nothing in life is more wonderful than faith--the one great moving force which we can neither weigh in the balance nor test in the crucible-- mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potence." Sir William Osler, “The Faith that Heals,” British Medical Journal, 1910.

4.  Bringing up spiritual issues improves health outcomes  Most patients (75-95%) want us to  Lack of training means we need to train doctors (not stop doing it)

5. Medicine of the Whole Person  Dr. Paul Tournier, Swiss Doctor (GP), Christian Psychoanalyst and Philosopher  Author of 20+ books from 1940-1986  Medicine is made up of two parts: –Academic / Scientific –Spiritual, Meaning, Significance  Wanted to get to the meaning of illness and what the problem was behind the symptoms and diagnoses that his patients faced  Would take time to be with patients / fireside discussions and walks in the wilderness

6. Quotes from Dr. Paul Tournier  "Health is not the mere absence of disease. It is a quality of life, a physical, psychical, and spiritual unfolding, and exaltation of personal dynamism.“  "Man is not just a body and a mind. He is a spiritual being. It is impossible to know him if one disregards his deepest reality.“  "It is an unscientific assumption of materialist philosophy which supposes that material facts (anatomical and physiological) are the cause, and that moral (psychological and spiritual) facts are the consequences, and not the other way about.“ The Healing of Persons, 1965

7. Goal: Understand the Patient “We doctors are not called upon by God to preach. Our task is rather to listen and to understand. If we give our patients an opportunity of speaking of what is in their hearts they will get to know themselves better; they will discover what are the real problems they have to face, and perhaps see the meaning of their sickness. But what are we to do, faced with this flood of problems to which science has no answer and which exhortation does not suffice to resolve?” Paul Tournier, The Healing Spirit, 1979

8. Challenges  Gaining the courage to engage with our patients in order to understand them  Discerning which patients to ask and when  Time  Not taking advantage of our patients (doctor has a unique position of power)  What to do with problems for which science has no answer?

9. Spiritual Hx vs. Spiritual ROS  Spiritual ROS: –Questions that are both targeted and tailored (like any other ROS) –Information that will lead to specific diagnoses and underlying problems –Not asked of all patients  Spiritual History: –General questions about faith background –Part of social history –Information that will help you understand your patient generally –Asked of all patients at some point in their health history

10. Spiritual History HOPE Model  Sources of Hope, meaning, comfort, strength, peace, love and connection  Organized religion (or faith community)  Personal spirituality and practices  Effects on medical care and end-of-life issues FICA Model  Faith: “What is your faith background?”  Influence: “Would you say that your faith is still an important part of your life?”  Community: “Are you part of a faith community?”  Address: “How should I address your faith concerns?”

11. Symptom vs. Diagnosis  Symptom: A sign or an indication of disorder or disease, especially when experienced by an individual as a change from normal function, sensation, or appearance.  Diagnosis: The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.  Examples that can be a symptom or a diagnosis: depression, anxiety, insomnia, headaches, tremor, alcoholism, TMJ pain, etc.

12. Spiritual Diagnoses  Stem from disordered relationships –Self –Others –God  DSM IV and ICD-9 sometimes might be lacking  Treatment may be more complicated – need to understand referral sources

13. Spiritual Diagnoses  Anger / Bitterness  Addiction  Guilt (act of comission or omission)  Greed / Envy / Covetous  Fear  Loneliness / Isolation  Immorality / Deceit  Identity (lacking significance / purpose)  Self-centeredness  Spiritual pride / faulty view of God

14. Nonthreatening Questions:  Have you experienced or are you experiencing any personal problems in your life? (Have you experienced any personal problems in the past that may affect your relationships with others now?)  Are there any wrongs you need to make right with someone? (Do you need to say sorry to anyone or give an apology? Are you feeling guilty about anything in your life? Is there something or someone that is weighing heavy on your heart?)

15.  Do you have any ongoing resentment, anger or bitterness towards someone? (Is there anyone you may need to forgive for something they have done to you? Do you have a broken relationship with a loved one because of something that happened between you in the past?)  Are you fearful of anything or anyone? (Do you feel like fear is controlling your life in any way? If so how are you managing your fear?)

16.  Are there any activities in your life that may have control over you? (Examples might include gambling, drinking alcohol, drug use, cutting yourself or pornography. Do you engage in any of those activities? Do you feel like your work excessively controls your life?)  Do you feel alone or isolated? (Do you feel as if no one cares for you? Do you feel you have people that you can turn to? Do you have at least one person that you feel you can trust enough to share your feelings with?)

17.  What are you striving for in life? (What do you consider your top priorities? What do you spend your time thinking about? How do you spend your free time? Do you spend a significant part of your day thinking about your finances, making money, or acquiring something you don’t have?)

18.  What do you sense is your purpose in life? (Do you feel like life has any meaning for you? If not, why do you think so? Where do you find your identity?)  How would you describe your relationship with God? (How would you describe your faith journey? How do you picture God? Are you angry at God about anything?)

19. Cases  LCDR Gray Dawson –36 yo wife of AD USN with tremor –61 yo wife of RET USAF with recent diagnosis of rheumatoid arthritis –27 yo male AD USN with self-referral for EtOH treatment and suicide attempt  CDR Richard Sams –Mrs. H, 58yo w/ incapacitating anxiety despite multiple meds –Mrs. M, 31yo w/ OCD symptoms lacking direction in life

20. References  Tournier, P. The Healing Spirit. Good News Publishers. 1979.  Tournier, P. A Doctor’s Casebook in the Light of the Bible. London: SCM Press, 1954.  Tournier, P. The Meaning of Persons. London: SCM Press, 1957.  Tournier, P. The Healing of Persons. London: Collins, 1965.  Tournier, P. Guilt and Grace. London: Hodder and Stoughton, 1962.  Cox, J., Campbell, A. V., and Fulford, B. Medicine of the Person: Faith, science and values in health care provision. London: Jessica Kingsley Publishers, 2007.  Hodge, D. R. Spiritual Assessment: Handbook for Helping Professionals. Botsford, CT: North American Association of Christians in Social Work, 2003.  Koenig, H. G., McCullough, M. E., and Larson, D. B. Handbook of Religion and Health. New York: Oxford Univ Press, 2001.  Anandarajah, G. and Hight, E. “Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment,” American Family Physician. 2001; 63:81-88.  Puchalski CM. Taking a spiritual history: FICA. Spirituality & Medicine Connection. 1999;3:1.