Spirituality and Medicine

Ajay K. Singh, MBBS, FRCP, MBA
October 19, 2017

“Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.” —Christina Puchalski

An interview with Christina Puchalski on integrating spirituality into medicine in BigQuestionsOnline caught my eye. So I dug a bit more into this topic.

I came across a 2001 article by Puchalski titled, “The role of spirituality in health care” that I would strongly recommend to anyone who takes care of patients. In her article, Puchalski writes: “Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.”

According to Puchalski, physicians should incorporate spiritual practice into their interactions with patients. This could happen by physician’s being “fully present and attentive to their patients…actively listen and allow their patients to share “fears, hopes, pains and dreams.” She also recommends that physicians pay attention to “all dimensions of patients and their families: body, mind, and spirit.” Puchalski supports physician’s involving chaplains as members into the interdisciplinary health care team.

Puchalski is an advocate of “compassionate care,” which she defines as physicians walking “with people in the midst of their pain, to be partners with patients rather than experts dictating information to them.” Merriam-Webster defines compassion as “sympathetic consciousness of others’ distress together with a desire to alleviate it.”

Puchalski writes that compassion is important because:

While patients struggle with the physical aspects of their disease, they have other pain as well: pain related to mental and spiritual suffering, to an inability to engage the deepest questions of life. Patients may be asking questions such as the following: Why is this happening to me now? What will happen to me after I die? Will my family survive my loss? Will I be missed? Will I be remembered? Is there a God? If so, will he be there for me? Will I have time to finish my life’s work?

Studies support Puchalski’s contention that physicians generally underestimate patients’ spiritual needs. Ehman and colleagues performed a self-administered survey to 177 patients in a hospital-based pulmonary clinic: only 15% were asked about spiritual or religious beliefs. Nearly two-thirds of the patients said that they would welcome a question about whether they were spiritual from their doctors while they were taking the medical history. In another study, also a survey, but in primary care clinics of six academic medical centers in three states, MacLean and colleagues report that many patients want their physician to ask them about spiritual beliefs; indeed, this desire for inquiry about spiritual beliefs increases strongly with the severity of the illness. The MacLean study enrolled 456 patients who were dying. Seventy percent of these patients said that they would welcome physician inquiry into their religious beliefs, 55% said that they would appreciate silent prayer, and 50% believed their physician should pray with them.

So what’s the bottom-line? While most physicians focus on the physical aspects of illness, a more holistic approach may be what patients want. Arguably to be complete, physicians should consider discussing spirituality with patients. Christina Puchalski concludes: “I think we can be better physicians and true partners in our patients’ living and in their dying if we can be compassionate: if we truly listen to their hopes, their fears, and their beliefs, and incorporate these beliefs into their therapeutic plans.”


Harvard Medical School CME:
Lifestyle Medicine: Nutrition & The Metabollic Syndrome


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

 

HMS Responds to the Opioid Crisis with Education

Harvard Medical School’s dean, George Daley, recently hosted a panel presentation to highlight “the transformative role that education can and should play in solving the opioid crisis.” HMS speakers at the event presented a three-pronged approach taken by the medical school to address the current epidemic of opioid use and abuse which includes educating medical students, health care professionals, and the general public. Other notable invitees spoke about health care policy in our government.

The following is a summary of the event by Dean David Roberts, one of the presenting speakers:

By David Roberts, MD
HMS Dean for External Education
October 13, 2017

On October 3rd, my colleagues Todd Griswold, Bertha Madras, and I joined Massachusetts governor Charlie Baker and HMS dean George Daley to make a presentation on Harvard Medical School’s response to the opioid crisis. The live-streamed event held at the HMS Martin Conference Center was attended by a large in-person audience with an additional remote audience of more than 6,000 viewers.

For my part, I presented on the great work Harvard Medical School teams are doing creating free online learning resources for clinicians, recovery coaches, first responders, and family members who are wrestling with the opioid crisis every day.

Todd, who is responsible for educating HMS students on opioids, described the innovative ways that substance use and pain medication education is being integrated into all four years of our medical students’ curriculum. Of particular note, is a plan for HMS students to graduate with training in the administration of naloxone and buprenorhine as well as in safe prescribing techniques.

Bertha is a member of the President’s Commission on Combating Drug Addiction and the Opioid Crisis alongside Governor Baker and other national leaders. They each spoke to the policies being created on state and national levels to address the opioid crisis.

To view a recording of the event on YouTube, you may click on the following link: HMS Responds with Education/The Opioid Crises

Whether you are a health care professional or a member of the general public affected by the current opioid epidemic, we hope you will take the opportunity to check out the free online resources that Harvard Medical School has created, and we welcome your feedback and comments!

For Health Care Professionals

The Opioid Use Disorder Education Program (OUDEP) is an accredited, free, online medical education program for nurses, nurse practitioners, physician assistants, physicians and other health care professionals collaborating to treat patients with substance use disorder.

For the Public

HarvardX: The Opioid Crisis in America is designed for nonclinicians. This free online course provides critical information on the nature of addiction, pain management without opioids, harm reduction, and evidence-based treatment alternatives.

For Everyone

Breaking the Cycle is a free weekly e-letter with news, HMS faculty insights and personal stories on addiction, recovery, treatment options and more.

Doctors, Patients, and Guns—Revisited

October 5, 2017

In light of the mass shooting that occurred earlier this week in Las Vegas, it seems prudent to update the information in the following previously published blog post, Doctors, Patients, and Guns, and re-open a discussion on whether or not doctors can impact gun deaths by identifying patients as gun owners.

In the February 7, 2017 post by Dr. Ajay Singh, Dr. Singh brought attention to a 2011 law passed in Florida that sought to prohibit health care providers from asking patients if they owned guns. Nicknamed the “docs vs glocks” law, it had been found unconstitutional for violating the 1st Amendment rights of doctors. That decision was subsequently vacated by the 11th US Circuit Court of Appeals, and a further appeal had yet to be ruled on.

On Feb. 17th, a week after the post was published, the full appellate court struck down the law, and the state did not file any further appeals. According to an article in the Palm Beach Post, Judge Adalberto Jordon wrote, “Florida may generally believe that doctors and medical professionals should not ask about, nor express views hostile to, firearm ownership, but it ‘may not burden the speech of others in order to tilt public debate in a preferred direction.’”

Now that Florida doctors are free once again to ask patients about gun ownership, the question remains as to whether or not this is a fair medical question or an invasion of privacy? In a 2016 post by Olga Khazan in The Atlantic, Khazan noted that while guns were used to kill people in about 250 justified shootings in 2014, they were used in over 21,000 suicides during that same time period, or by half of all Americans who committed suicide. She then continued:

Having a gun in the home is also strongly correlated with accidental shootings. As I’ve written, about 1.7 million children live in homes with guns that aren’t safely stored. Toddlers alone have shot at least 23 people this year.

Most unintentional shootings of children happen in homes where guns are legally owned, but not stored safely, and 70 percent of them could have been prevented if the gun had been stored safely.

Presumably then, the idea behind asking patients if they own guns is to follow up an affirmative answer with a conversation on safe gun storage, much like doctors discuss other health and safety issue with their patients such as wearing helmets or seat belts. It may also open up conversations about depression or other mental health issues.

Here is Dr. Singh’s original post. We hope that you will read it and share with us your opinions and/or experiences with this important issue.


 

By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, Febraury 7, 2017

A few months back when I saw my primary care physician at one of the Brigham and Women’s Hospital practices, I noticed that there was a question on the pre-visit questionnaire asking about whether I owned a gun. I do not own a gun and never have and so had no problem in answering no to this question.

Recently, however, I noticed an article in Kaiser Health News discussing whether physicians should be allowed under the law to ask about their patients’ gun ownership. Really? [continue reading…]

National Recovery Month: Jack’s Story

“I used to follow the signs on the highway to find a hospital, and I would fake an injury.”

Every day, we hear distressing news about the impact of the opioid epidemic on our communities and on our loved ones, but this month we are focusing on something positive—recovery.

Each year, the Substance Abuse and Mental Health Services Administration (SAMHSA) designates September as National Recovery Month, and we are encouraged to turn our attention toward stories of hope instead of despair.

Several courageous individuals recently shared their personal stories of opioid addiction and recovery with Harvard Medical School to inspire more healthcare providers to treat opioid use disorder patients. Jack’s story is the third of three inspirational patient videos we are sharing with you in recognition of National Recovery Month:

After 13 years in recovery, Jack Kelly is now the chief addiction policy advisor to the Boston City Council. and has a mobile app called iRecover which connects people with drug and alcohol use disorders to the resources they need for recovery help.


Jack’s story is part of HMS Global Academy’s Opioid Use Disorder Education Program—an accredited, free, online medical education program intended for nurses, nurse practitioners, physician assistants, physicians, and other healthcare professionals collaborating to treat patients with substance use disorder. We encourage you to click on the link above to learn more about the program, and to share this valuable resource with other healthcare providers.

Together, we hope to bring healing and recovery to our communities.


[View Shannon’s Story. View Bugzy’s story.]

National Recovery Month: Bugzy’s Story

September 21, 2017

Once I started to change who I hang with, what activities I did, because of that new state of mind, I was making the right choices, and I moved forward.

Every day, we hear distressing news about the impact of the opioid epidemic on our communities and on our loved ones, but this month we are focusing on something positive—recovery.

Each year, the Substance Abuse and Mental Health Services Administration (SAMHSA) designates September as National Recovery Month, and we are encouraged to turn our attention toward stories of hope instead of despair.

Several courageous individuals recently shared their personal stories of opioid addiction and recovery with Harvard Medical School to inspire more healthcare providers to treat opioid use disorder patients. Bugzy’s story is the second of three of these short inspirational patient videos we are sharing with you in recognition of National Recovery Month:

Jose Matine, nicknamed Bugzy, is the proud owner of the Canal St. Gym in Lawrence, Ma., a nonprofit boxing gym that has produced multiple champions.


Bugzy’s story is part of the HMS Global Academy’s Opioid Use Disorder Education Program—an accredited, free, online medical education program intended for nurses, nurse practitioners, physician assistants, physicians, and other healthcare professionals collaborating to treat patients with substance use disorder. We encourage you to click on the link above to learn more, and to share this valuable resource with other healthcare providers.

Together, we hope to bring healing and recovery to our communities.


For further inspiration, view Shannon’s Story. Jack’s story will be published on Sept. 28th. Follow this blog to receive an email notification of the post.

National Recovery Month: Shannon’s Story

“There’s so many people who are going to be remembered for how they died because they overdosed, and I want to be remembered for how I lived.”

Every day, we hear distressing news about the impact of the opioid epidemic on our communities and on our loved ones, but this month we are focusing on something positive—recovery.

Each year, the Substance Abuse and Mental Health Services Administration (SAMHSA) designates September as National Recovery Month, and we are encouraged to turn our attention toward stories of hope instead of despair.

Several courageous individuals recently shared their personal stories of opioid addiction and recovery with Harvard Medical School to inspire more healthcare providers to become educated on how to better identify and treat opioid use disorder patients. The following video is the first of three short, moving patient stories we are sharing with you in recognition of National Recovery Month:

Shannon is now a certified recovery coach and community health educator currently serving as the community outreach coordinator for the Charlestown Coalition.


Shannon’s story is part of HMS Global Academy’s Opioid Use Disorder Education Program—an accredited, free, online medical education program intended for nurses, nurse practitioners, physician assistants, physicians, and other healthcare professionals collaborating to treat patients with opioid use disorder. We encourage you to click on the link above to learn more, and to share this valuable resource with other healthcare providers.

Together, we can bring healing and recovery to our communities.



Follow this blog to view Bugzy’s Story and Jack’s Story, which will be published in the coming weeks.

Does Increasing Cigarette Prices Impact Consumption?

Ajay K. Singh
September 7, 2017

An interesting article by Nicholas Bakalar in the Aug 23, 2017 New York Times “Well” section caught my eye. It discusses a paper by Stephanie Mayne and colleagues accepted in Epidemiology that supports a relationship between the price of cigarettes and consumption. Quoting from the abstract:

$1 increase in price [of cigarettes] was associated with a 3% reduction in risk of current smoking (aRR: 0.97, 95% confidence interval [CI]: 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93, CI: 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR 1.2, CI: 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65, CI: 0.45%, 0.93%). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

A CDC Grand Rounds article titled Current Opportunities in Tobacco Control, which cites earlier work, supports the conclusions reached by Mayne et al. A 10% increase in the price reduces cigarette consumption by about 4%. The data from the chart below is pretty impressive. The progressive rise in the sales price of a pack of cigarette has resulted in a steady decline in cigarette sales.

The CDC article makes the following point: “Increasing the price of cigarettes discourages initiation among youths, prompts quit attempts, and reduces average cigarette consumption among those who continue to smoke.”

However, since early 2000 the price of cigarettes has remained relatively steady, but sales have continued to fall, suggesting that factors beyond price are also important.  These factors include tobacco control programs run by states, media campaigns, health warnings on tobacco packaging, changing attitudes about smoking and the tobacco industry, and reduced youth tobacco initiation.

An interesting article looking at the economics in the UK of increasing cigarette taxes makes two points:

  1. Nearly two-thirds of the price of a pack of cigarettes goes to taxes.
  2. Because people are addicted to cigarettes, demand price is inelastic and sales are unlikely to fall much.

The article also reaches some harsh observations: “Smokers already pay a lot of tax …[and] they do not cost the government much because they die early and save pension and health care spending. Higher taxes will increase inequality because the poor will pay a higher percentage of tax than the rich who are more likely to have given up. Higher taxes will encourage people to smuggle illegal cigarettes and avoid paying the tax.”

In the US, there is tremendous variability in the price of a pack of cigarettes. In New York State, the price currently is around $10.50 (and there is a proposal to raise it to $13 per pack). In contrast, price elsewhere is about half this amount (According to the website Fairreporters.net which lists the prices of cigarettes by state, $5.40 per pack in Kentucky and between $6 to $8 per pack in other states).

In summary, the jury is out on precisely how elastic demand is based on price, but it is a fair conclusion from published data that price does impact sales. Further, there seems to be ample room among many states in the US to increase cigarette taxes and, therefore, price.

But, at least one thing is indisputable: the benefits of not smoking.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.