KevinMD.com published a post a couple of days ago from medical student Joyce Ho in which she admitted to discomfort raising the topic of religion with patients. As a "polarizing" issue that could make the doctor-patient relationship "more unprofessional," Ms. Ho imagined that patients would fear playing into their doctors' prejudices, particularly if the doctor were atheist, and that this fear would push some patients away from the inquiring doctor. Despite her instructor's recommendation to ask gentle, open-ended questions about faith and spirituality in the context of a patient's support systems, "personally, I still will not actively ask about religious preferences if the patient does not bring the issue up."
As a new reader of KevinMD, I was first to comment — a mistake, in retrospect. I imagined her concerns were merely new-doctor jitters, a phenomenon as old as medicine itself. I pointed out that students at first find religion, sex, and many other topics difficult to broach with patients. Yet uncomfortable topics such as these are often important, and may go unmentioned unless the doctor asks. Trying to be supportive, I noted that patients usually worry less about a doctor's own religious beliefs, or lack thereof, than they do about their doctor's care and concern. Frankly, I didn't imagine my comment was controversial in the least.
To my dismay, comment after comment followed that a patient's religion is none of his or her doctor's business. To some extent this was conflated with complaints of unbidden chaplains appearing at hospital bedsides, and awkward offers by medical staff to pray with a patient who wanted no such thing. But even leaving aside those obvious blunders, there was rampant mistrust of doctors even inquiring about religion, spirituality, or faith.
Apparently, Joyce Ho was right. Commenters on the blog assumed we doctors jump to false conclusions — "assume certain things about certain religions" — and are apt to over-interpret based on limited information; that we are "busybodies" to ask about such matters; that the information is irrelevant at best; that "doctors might judge you"; and that we cannot help but oversimplify the beliefs of any patient who has given religion or spirituality serious thought. A self-identified atheist living in the Bible Belt was grateful no doctor had ever asked: "We in the South have enough problems ... without also having doctors who think they should be discussing religion with their patients...." The comment with the most "agrees" was this anonymous one-liner:
I wouldn't want my doctor asking about my religion. That's not necessary. I'm glad mine don't do that.
How has it come to this? Haven't patient advocates and caring doctors fought for years — decades — to retain humanism in a medical system that inexorably drifts toward the impersonal and mechanical? What happened to the hope, if not expectation, that one's doctor sees the person behind the symptoms, the whole patient? And what on earth happened to the premise that one's doctor can be trusted with sensitive personal information? Religion, after all, is hardly the riskiest thing one might tell a physician in confidence.
A close look at the commentary reveals the sad truth. The healing doctor-patient relationship is no more. The Bible Belt atheist sees religion as a source of doctor-patient antagonism. For the rest, the patient's relationship is not to a doctor, but to a "system of care." This system aims to fill blanks in an electronic record; one commenter advised doctors to ask, "Would you like me to list a religious affiliation?" in order that this particular blank can be left unfilled if the patient desires.
Of course, antagonism and "listing" a religion in a database are not why medical students learn to take a patient's social history, including hobbies, interests, and social supports secular and otherwise. It's to know their patients as people, to build rapport, to honor beliefs and relationships their patients hold dear, to appreciate their patients' strengths as well as weaknesses. It's to offer personalized counsel, so that (to take the most basic example) the non-religious are not advised to seek solace in church, nor the faithful to neglect it. Occasionally it's to develop a differential diagnosis for a medical condition unexpectedly related to a patient's social interests or behavior. And often it's to learn a patient's values and preferences regarding end of life care, so that when that patient is unable to express them, his or her trusted doctor already knows.
All of this applies to a doctor, a well-meaning, trustworthy (if fallible) human fiduciary who listens in confidence. In stark contrast, systems of care suffer diffusion of responsibility. They spread personal information in unpredictable ways, outside the patient's control and awareness. Thus, one commenter wrote, "I don't want that kind of information in my medical record," while another elaborated, "Blue Cross and the xray technician and everyone else who comes in contact with the chart have no need to know what religion the patient is unless the patient chose to share it with everybody."
Health reform provides long-overdue expansion of health coverage. On the supply side, it promotes systems of care to enhance efficiency and decrease costs. It's important to realize what we may already be losing in the bargain: the traditional personal relationship with a physician entrusted to handle intimate details of one's life with discretion and wisdom. If it is no longer safe to divulge one's religion, what about one's sexual habits, recreational drug use, risky hobbies, and myriad other touchy subjects? Widespread self-censoring of this information, to prevent it from entering large medical databases, may turn out to be more hazardous to public health than all the inefficiencies of the old approach.
This fourth installment in my "sloppy thinking" series turns to psychotherapy, or what passes for it in some psychiatric practices. A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago. It was, first and foremost, a treatment that involved talking — not merely a conversation that happened to make the patient feel better. Years later, the object-relations school of psychoanalysis and the humanistic psychology movement of the 1960s partly shifted the focus of dynamic psychotherapy away from technique and toward a healing relationship, a shift prefigured by pastoral counseling and by the ministrations of the nursing profession. Nonetheless, dynamic psychotherapy remained a treatment: a professional service with clear goals and a coherent rationale, aimed to remedy defined psychological conflicts or deficits. Meanwhile, over the same century or so, academic psychologists developed the theories and practices of behaviorism via experiments with animals, and later applied behavior modification and various behavioral and cognitive therapies to human suffering. While such treatments could be offered in a humane and caring manner, the relationship itself was not considered curative.
Psychoanalysis and psychodynamic therapy originated in a medical context, and psychiatrists historically have been trained in its theory and practice. (In contrast, psychologists historically tended to practice the empirically based behavioral and cognitive therapies developed in academia, although this distinction between the disciplines has faded.) Prior to the advent of psychoanalysis, psychiatry was a medical specialty focused on the management of severe mental illnesses that rendered sufferers incapable of living in mainstream society. But by the mid-20th century, the field had adopted the new "talking cures" to treat higher functioning patients. For a few decades, roughly 1950 to 1980, the popular image of the psychiatrist was a psychoanalyst with the trademark couch in the office.
As posted below, I joined 
Tara Parker-Pope of the New York Times blog