Mark R. Ellis, MD, MSPH

Evidence summary

The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,² the posttest probability of a positive exam is still <30%.

A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.³ For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.

In another meta-analysis including 9 studies of meniscal injury diagnosis,⁴ individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.

Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.

Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)⁵ and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.

TABLE
Physical exams for meniscal tear

Recommendations from others

The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.⁶ The guideline fails to list the strength and type of supporting evidence for these associations.

The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.⁷

Evidence summary

The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,² the posttest probability of a positive exam is still <30%.

A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.³ For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.

In another meta-analysis including 9 studies of meniscal injury diagnosis,⁴ individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.

Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.

Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)⁵ and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.

TABLE
Physical exams for meniscal tear

Recommendations from others

The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.⁶ The guideline fails to list the strength and type of supporting evidence for these associations.

The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.⁷

Evidence summary

The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,² the posttest probability of a positive exam is still <30%.

A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.³ For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.

In another meta-analysis including 9 studies of meniscal injury diagnosis,⁴ individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.

Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.

Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)⁵ and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.

TABLE
Physical exams for meniscal tear

Recommendations from others

The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.⁶ The guideline fails to list the strength and type of supporting evidence for these associations.

The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.⁷

Evidence summary

Although breastfeeding jaundice is a benign entity, other risk factors for bilirubin toxicity can coexist. These include jaundice in the first day of life, previously jaundiced sibling, early gestational age, significant bruising or cephalohematoma, Rh and ABO incompatibility, G6PD deficiency, and elevated hour-specific serum or transcutaneous bilirubin levels.^2,3

Late initiation of breastfeeding and temporary cessation or supplementation of breastfeeding increase the likelihood of premature breastfeeding termination.⁴ In a prospective cohort study of 138 breastfed term infants, more than twice as many mothers of jaundiced infants had stopped breastfeeding compared with mothers of nonjaundiced infants, at the end of 1 month (42% vs 19%; number needed to harm [NNH]=4; P<.01). In addition, 64% of the jaundiced infants whose nursing had been interrupted in the hospital had stopped breastfeeding by 1 month, compared with only 36% of those who had no interruption (relative risk [RR]=1.8; P<.05; NNH=4).⁵

Whether they require phototherapy or not, continuing breastfeeding in jaundiced infants is not associated with adverse outcomes. In a prospective cohort study of 163 healthy, jaundiced newborn infants undergoing phototherapy (total serum bilirubin ≥17 mg/dL), exclusively breastfed infants had slower response to phototherapy in the first 24 hours than formulafed or formula-supplemented infants (bilirubin decreases of 17.1% vs 18% and 22.9%, respectively; P=.03). However, there were no significant differences in total length of phototherapy among the 3 groups (phototherapy time of 64.5 hours vs 54.1 hours and 54.9 hours, respectively; P=.06).⁶

In a randomized, nonblinded clinical trial, 125 jaundiced breastfed newborns (total serum bilirubin level of ≥17mg/dL) were assigned to 4 treatment groups: (1) continue breastfeeding and observe; (2) discontinue breastfeeding, substitute with formula; (3) discontinue breastfeeding, substitute with formula, and administer phototherapy; and (4) continue breastfeeding, administer phototherapy. The study did not find a clinically significant difference in serum bilirubin reduction to normal levels at 48 hours between breastfed and bottle-fed groups undergoing phototherapy (RR=1.07; 95% confidence interval [CI], 0.6–1.92; P=.818), or between breastfed and bottle-fed groups who did not have phototherapy (RR not calculated; P=.051). No patient required exchange transfusion, and in no case did total serum bilirubin exceed 23 mg/dL.⁷

Recommendations from others

The American Academy of Pediatrics (AAP) has reported numerous positive health outcomes in infants who are breastfed, including reduced incidence and less-severe diarrhea; lower incidence of otitis media, fewer respiratory infections; and lower incidence of bacteremia, bacterial meningitis, botulism, urinary tract infections and necrotizing enterocolitis.

In addition, they reported association between breastfeeding and enhanced cognitive development; and decreased incidence in sudden infant death syndrome, insulin-dependent diabetes mellitus, atopy, and inflammatory bowel diseases. They noted maternal benefits including less postpartum bleeding and lactational amenorrhea; more rapid postpartum weight loss and improved bone remineralization; and reduced risk of ovarian cancer and premenopausal breast cancer.¹

The AAP discourages the termination of breastfeeding in jaundiced healthy term newborns and encourages continued and frequent breastfeeding (at least 8 to 10 times every 24 hours), encouraging physician’s judgment and patient’s preferences to determine final treatment options for breastfeeding jaundiced newborns.²

Evidence summary

Although breastfeeding jaundice is a benign entity, other risk factors for bilirubin toxicity can coexist. These include jaundice in the first day of life, previously jaundiced sibling, early gestational age, significant bruising or cephalohematoma, Rh and ABO incompatibility, G6PD deficiency, and elevated hour-specific serum or transcutaneous bilirubin levels.^2,3

Late initiation of breastfeeding and temporary cessation or supplementation of breastfeeding increase the likelihood of premature breastfeeding termination.⁴ In a prospective cohort study of 138 breastfed term infants, more than twice as many mothers of jaundiced infants had stopped breastfeeding compared with mothers of nonjaundiced infants, at the end of 1 month (42% vs 19%; number needed to harm [NNH]=4; P<.01). In addition, 64% of the jaundiced infants whose nursing had been interrupted in the hospital had stopped breastfeeding by 1 month, compared with only 36% of those who had no interruption (relative risk [RR]=1.8; P<.05; NNH=4).⁵

Whether they require phototherapy or not, continuing breastfeeding in jaundiced infants is not associated with adverse outcomes. In a prospective cohort study of 163 healthy, jaundiced newborn infants undergoing phototherapy (total serum bilirubin ≥17 mg/dL), exclusively breastfed infants had slower response to phototherapy in the first 24 hours than formulafed or formula-supplemented infants (bilirubin decreases of 17.1% vs 18% and 22.9%, respectively; P=.03). However, there were no significant differences in total length of phototherapy among the 3 groups (phototherapy time of 64.5 hours vs 54.1 hours and 54.9 hours, respectively; P=.06).⁶

In a randomized, nonblinded clinical trial, 125 jaundiced breastfed newborns (total serum bilirubin level of ≥17mg/dL) were assigned to 4 treatment groups: (1) continue breastfeeding and observe; (2) discontinue breastfeeding, substitute with formula; (3) discontinue breastfeeding, substitute with formula, and administer phototherapy; and (4) continue breastfeeding, administer phototherapy. The study did not find a clinically significant difference in serum bilirubin reduction to normal levels at 48 hours between breastfed and bottle-fed groups undergoing phototherapy (RR=1.07; 95% confidence interval [CI], 0.6–1.92; P=.818), or between breastfed and bottle-fed groups who did not have phototherapy (RR not calculated; P=.051). No patient required exchange transfusion, and in no case did total serum bilirubin exceed 23 mg/dL.⁷

Recommendations from others

The American Academy of Pediatrics (AAP) has reported numerous positive health outcomes in infants who are breastfed, including reduced incidence and less-severe diarrhea; lower incidence of otitis media, fewer respiratory infections; and lower incidence of bacteremia, bacterial meningitis, botulism, urinary tract infections and necrotizing enterocolitis.

In addition, they reported association between breastfeeding and enhanced cognitive development; and decreased incidence in sudden infant death syndrome, insulin-dependent diabetes mellitus, atopy, and inflammatory bowel diseases. They noted maternal benefits including less postpartum bleeding and lactational amenorrhea; more rapid postpartum weight loss and improved bone remineralization; and reduced risk of ovarian cancer and premenopausal breast cancer.¹

The AAP discourages the termination of breastfeeding in jaundiced healthy term newborns and encourages continued and frequent breastfeeding (at least 8 to 10 times every 24 hours), encouraging physician’s judgment and patient’s preferences to determine final treatment options for breastfeeding jaundiced newborns.²

Evidence summary

Although breastfeeding jaundice is a benign entity, other risk factors for bilirubin toxicity can coexist. These include jaundice in the first day of life, previously jaundiced sibling, early gestational age, significant bruising or cephalohematoma, Rh and ABO incompatibility, G6PD deficiency, and elevated hour-specific serum or transcutaneous bilirubin levels.^2,3

Late initiation of breastfeeding and temporary cessation or supplementation of breastfeeding increase the likelihood of premature breastfeeding termination.⁴ In a prospective cohort study of 138 breastfed term infants, more than twice as many mothers of jaundiced infants had stopped breastfeeding compared with mothers of nonjaundiced infants, at the end of 1 month (42% vs 19%; number needed to harm [NNH]=4; P<.01). In addition, 64% of the jaundiced infants whose nursing had been interrupted in the hospital had stopped breastfeeding by 1 month, compared with only 36% of those who had no interruption (relative risk [RR]=1.8; P<.05; NNH=4).⁵

Whether they require phototherapy or not, continuing breastfeeding in jaundiced infants is not associated with adverse outcomes. In a prospective cohort study of 163 healthy, jaundiced newborn infants undergoing phototherapy (total serum bilirubin ≥17 mg/dL), exclusively breastfed infants had slower response to phototherapy in the first 24 hours than formulafed or formula-supplemented infants (bilirubin decreases of 17.1% vs 18% and 22.9%, respectively; P=.03). However, there were no significant differences in total length of phototherapy among the 3 groups (phototherapy time of 64.5 hours vs 54.1 hours and 54.9 hours, respectively; P=.06).⁶

In a randomized, nonblinded clinical trial, 125 jaundiced breastfed newborns (total serum bilirubin level of ≥17mg/dL) were assigned to 4 treatment groups: (1) continue breastfeeding and observe; (2) discontinue breastfeeding, substitute with formula; (3) discontinue breastfeeding, substitute with formula, and administer phototherapy; and (4) continue breastfeeding, administer phototherapy. The study did not find a clinically significant difference in serum bilirubin reduction to normal levels at 48 hours between breastfed and bottle-fed groups undergoing phototherapy (RR=1.07; 95% confidence interval [CI], 0.6–1.92; P=.818), or between breastfed and bottle-fed groups who did not have phototherapy (RR not calculated; P=.051). No patient required exchange transfusion, and in no case did total serum bilirubin exceed 23 mg/dL.⁷

Recommendations from others

The American Academy of Pediatrics (AAP) has reported numerous positive health outcomes in infants who are breastfed, including reduced incidence and less-severe diarrhea; lower incidence of otitis media, fewer respiratory infections; and lower incidence of bacteremia, bacterial meningitis, botulism, urinary tract infections and necrotizing enterocolitis.

In addition, they reported association between breastfeeding and enhanced cognitive development; and decreased incidence in sudden infant death syndrome, insulin-dependent diabetes mellitus, atopy, and inflammatory bowel diseases. They noted maternal benefits including less postpartum bleeding and lactational amenorrhea; more rapid postpartum weight loss and improved bone remineralization; and reduced risk of ovarian cancer and premenopausal breast cancer.¹

The AAP discourages the termination of breastfeeding in jaundiced healthy term newborns and encourages continued and frequent breastfeeding (at least 8 to 10 times every 24 hours), encouraging physician’s judgment and patient’s preferences to determine final treatment options for breastfeeding jaundiced newborns.²

Evidence summary

Infants experience normal physiologic variation in stool frequency and consistency, moderated in part by diet.¹ Childhood functional defecation disorders represent a continuum from infant dyschezia, to functional constipation, to functional fecal retention^2,3 (Table 1). Most infants have dyschezia or functional constipation. Infant dyschezia, a self-limited condition related to immature muscle coordination, requires only parental reassurance.

We found no placebo-controlled trials of osmotic laxatives in infants. One uncontrolled trial of 220 functionally constipated, bottle-fed infants younger than 6 months showed normalization of stools in 90% of infants within 2 weeks of treatment with 2% or 4% lactulose.⁴ No other evidence has been published about the benefits or harms of sorbitol-containing juices, fiber, osmotic laxatives, formula switching, rectal stimulation with rectal thermometers, or glycerin suppositories.

We found no trials of mineral oil or sodium phosphate enemas in constipated infants. Mineral oil has been associated with lipoid aspiration pneumonia in infants less than 1 year of age.^5,6 Sodium phosphate enemas in children under 2 years of age have been associated with electrolyte disturbances, dehydration, and cardiac arrest.⁷

TABLE 1
Rome II childhood functional defecation disorders²

Recommendations from others

The North American Society for Pediatric Gastroenterology and Nutrition recommends glycerin suppositories for rectal disimpaction for acutely constipated infants; sorbitol-containing juices, such as prune, pear, and apple, for decreasing constipation; barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) as stool softeners; and avoidance of enemas, mineral oil, and stimulant laxatives due to potential adverse effects⁸ (Table 2).

TABLE 2
Recommended interventions for infant constipation⁸

Clinical Commentaries by Brian T. Easton, MD, and Susan E. Graves, MD, at http://www.fpin.org.

Evidence summary

Infants experience normal physiologic variation in stool frequency and consistency, moderated in part by diet.¹ Childhood functional defecation disorders represent a continuum from infant dyschezia, to functional constipation, to functional fecal retention^2,3 (Table 1). Most infants have dyschezia or functional constipation. Infant dyschezia, a self-limited condition related to immature muscle coordination, requires only parental reassurance.

We found no placebo-controlled trials of osmotic laxatives in infants. One uncontrolled trial of 220 functionally constipated, bottle-fed infants younger than 6 months showed normalization of stools in 90% of infants within 2 weeks of treatment with 2% or 4% lactulose.⁴ No other evidence has been published about the benefits or harms of sorbitol-containing juices, fiber, osmotic laxatives, formula switching, rectal stimulation with rectal thermometers, or glycerin suppositories.

We found no trials of mineral oil or sodium phosphate enemas in constipated infants. Mineral oil has been associated with lipoid aspiration pneumonia in infants less than 1 year of age.^5,6 Sodium phosphate enemas in children under 2 years of age have been associated with electrolyte disturbances, dehydration, and cardiac arrest.⁷

TABLE 1
Rome II childhood functional defecation disorders²

Recommendations from others

The North American Society for Pediatric Gastroenterology and Nutrition recommends glycerin suppositories for rectal disimpaction for acutely constipated infants; sorbitol-containing juices, such as prune, pear, and apple, for decreasing constipation; barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) as stool softeners; and avoidance of enemas, mineral oil, and stimulant laxatives due to potential adverse effects⁸ (Table 2).

TABLE 2
Recommended interventions for infant constipation⁸

Clinical Commentaries by Brian T. Easton, MD, and Susan E. Graves, MD, at http://www.fpin.org.

Evidence summary

Infants experience normal physiologic variation in stool frequency and consistency, moderated in part by diet.¹ Childhood functional defecation disorders represent a continuum from infant dyschezia, to functional constipation, to functional fecal retention^2,3 (Table 1). Most infants have dyschezia or functional constipation. Infant dyschezia, a self-limited condition related to immature muscle coordination, requires only parental reassurance.

We found no placebo-controlled trials of osmotic laxatives in infants. One uncontrolled trial of 220 functionally constipated, bottle-fed infants younger than 6 months showed normalization of stools in 90% of infants within 2 weeks of treatment with 2% or 4% lactulose.⁴ No other evidence has been published about the benefits or harms of sorbitol-containing juices, fiber, osmotic laxatives, formula switching, rectal stimulation with rectal thermometers, or glycerin suppositories.

We found no trials of mineral oil or sodium phosphate enemas in constipated infants. Mineral oil has been associated with lipoid aspiration pneumonia in infants less than 1 year of age.^5,6 Sodium phosphate enemas in children under 2 years of age have been associated with electrolyte disturbances, dehydration, and cardiac arrest.⁷

TABLE 1
Rome II childhood functional defecation disorders²

Recommendations from others

The North American Society for Pediatric Gastroenterology and Nutrition recommends glycerin suppositories for rectal disimpaction for acutely constipated infants; sorbitol-containing juices, such as prune, pear, and apple, for decreasing constipation; barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) as stool softeners; and avoidance of enemas, mineral oil, and stimulant laxatives due to potential adverse effects⁸ (Table 2).

TABLE 2
Recommended interventions for infant constipation⁸

Clinical Commentaries by Brian T. Easton, MD, and Susan E. Graves, MD, at http://www.fpin.org.

Evidence summary

Conjunctivitis accounts for 1% to 2% of office visits to primary care practitioners.¹ Conjunctivitis is more commonly caused by bacteria in children (50% in 1 study²) than in adults, in whom viral conjunctivitis predominates.³ Treating suspected or culture-proven acute bacterial conjunctivitis with topical antibiotics significantly shortens the clinical course of the disease and results in higher microbiological cure rates than placebo.^1,4,5 A meta-analysis of 3 trials based in specialty clinics or hospitals reported significant clinical cure or improvement of bacterial conjunctivitis with 2 to 5 days of topical antibiotics compared with placebo (RR = 1.31, 95% CI, 1.11-1.55, number needed to treat = 5).¹ Other articles have reported corneal or systemic complications of bacterial conjunctivitis. For example, 1 review reports that 25% of children with Haemophilus influenzae conjunctivitis develop otitis media.²

Although there is a small risk of complications and longer time course when bacterial conjunctivitis is left untreated, the disease is often self-limited, with a 64% clinical remission rate in patients treated for 2 to 5 days with placebo.¹ The rate of spontaneous remission is much higher for adults than for children (71.6% vs 28%, respectively). The Cochrane meta-analysis reported a similar clinical cure rate in children for 6 to 10 days of treatment with topical antibiotics versus placebo. A systematic review of 5 placebo-controlled RCTs reported no serious adverse outcomes in conjunctivitis patients regardless of treatment group.⁴

Antibiotic resistance is a growing problem. Studies of fluoroquinolone resistance rates report a range of 4% to 50% for ocular bacteria.⁶ The 50% resistance rate occurred after 4 weeks of topical treatment in postcataract surgery patients.

Overall, this evidence suggests that for adults, watchful waiting rather than initially treating with antibiotics is reasonable, given the self-limited nature and lack of serious outcomes in untreated patients as well as growing concern about antibiotic resistance. Note that this recommendation applies only to acute nonvenereal conjunctivitis. It is generally accepted that conjunctivitis caused by gonococcus or chlamydia should be suspected in all newborns and in severe cases in sexually active young adults. These cases warrant culturing and antibiotic treatment to prevent serious complications.⁷

Recommendations from others

The American Optometric Association consensus guideline states that ideal treatment should be based on the specific causative organism. The guideline concludes that treatment of bacterial conjunctivitis with antibiotics can reduce symptoms, duration of illness, and chances of recurrence.⁸

Clinical Commentary by Carin Reust, MD, MSPH, at http://www.fpin.org.

Evidence summary

Conjunctivitis accounts for 1% to 2% of office visits to primary care practitioners.¹ Conjunctivitis is more commonly caused by bacteria in children (50% in 1 study²) than in adults, in whom viral conjunctivitis predominates.³ Treating suspected or culture-proven acute bacterial conjunctivitis with topical antibiotics significantly shortens the clinical course of the disease and results in higher microbiological cure rates than placebo.^1,4,5 A meta-analysis of 3 trials based in specialty clinics or hospitals reported significant clinical cure or improvement of bacterial conjunctivitis with 2 to 5 days of topical antibiotics compared with placebo (RR = 1.31, 95% CI, 1.11-1.55, number needed to treat = 5).¹ Other articles have reported corneal or systemic complications of bacterial conjunctivitis. For example, 1 review reports that 25% of children with Haemophilus influenzae conjunctivitis develop otitis media.²

Although there is a small risk of complications and longer time course when bacterial conjunctivitis is left untreated, the disease is often self-limited, with a 64% clinical remission rate in patients treated for 2 to 5 days with placebo.¹ The rate of spontaneous remission is much higher for adults than for children (71.6% vs 28%, respectively). The Cochrane meta-analysis reported a similar clinical cure rate in children for 6 to 10 days of treatment with topical antibiotics versus placebo. A systematic review of 5 placebo-controlled RCTs reported no serious adverse outcomes in conjunctivitis patients regardless of treatment group.⁴

Antibiotic resistance is a growing problem. Studies of fluoroquinolone resistance rates report a range of 4% to 50% for ocular bacteria.⁶ The 50% resistance rate occurred after 4 weeks of topical treatment in postcataract surgery patients.

Overall, this evidence suggests that for adults, watchful waiting rather than initially treating with antibiotics is reasonable, given the self-limited nature and lack of serious outcomes in untreated patients as well as growing concern about antibiotic resistance. Note that this recommendation applies only to acute nonvenereal conjunctivitis. It is generally accepted that conjunctivitis caused by gonococcus or chlamydia should be suspected in all newborns and in severe cases in sexually active young adults. These cases warrant culturing and antibiotic treatment to prevent serious complications.⁷

Recommendations from others

The American Optometric Association consensus guideline states that ideal treatment should be based on the specific causative organism. The guideline concludes that treatment of bacterial conjunctivitis with antibiotics can reduce symptoms, duration of illness, and chances of recurrence.⁸

Clinical Commentary by Carin Reust, MD, MSPH, at http://www.fpin.org.

Evidence summary

Conjunctivitis accounts for 1% to 2% of office visits to primary care practitioners.¹ Conjunctivitis is more commonly caused by bacteria in children (50% in 1 study²) than in adults, in whom viral conjunctivitis predominates.³ Treating suspected or culture-proven acute bacterial conjunctivitis with topical antibiotics significantly shortens the clinical course of the disease and results in higher microbiological cure rates than placebo.^1,4,5 A meta-analysis of 3 trials based in specialty clinics or hospitals reported significant clinical cure or improvement of bacterial conjunctivitis with 2 to 5 days of topical antibiotics compared with placebo (RR = 1.31, 95% CI, 1.11-1.55, number needed to treat = 5).¹ Other articles have reported corneal or systemic complications of bacterial conjunctivitis. For example, 1 review reports that 25% of children with Haemophilus influenzae conjunctivitis develop otitis media.²

Although there is a small risk of complications and longer time course when bacterial conjunctivitis is left untreated, the disease is often self-limited, with a 64% clinical remission rate in patients treated for 2 to 5 days with placebo.¹ The rate of spontaneous remission is much higher for adults than for children (71.6% vs 28%, respectively). The Cochrane meta-analysis reported a similar clinical cure rate in children for 6 to 10 days of treatment with topical antibiotics versus placebo. A systematic review of 5 placebo-controlled RCTs reported no serious adverse outcomes in conjunctivitis patients regardless of treatment group.⁴

Antibiotic resistance is a growing problem. Studies of fluoroquinolone resistance rates report a range of 4% to 50% for ocular bacteria.⁶ The 50% resistance rate occurred after 4 weeks of topical treatment in postcataract surgery patients.

Overall, this evidence suggests that for adults, watchful waiting rather than initially treating with antibiotics is reasonable, given the self-limited nature and lack of serious outcomes in untreated patients as well as growing concern about antibiotic resistance. Note that this recommendation applies only to acute nonvenereal conjunctivitis. It is generally accepted that conjunctivitis caused by gonococcus or chlamydia should be suspected in all newborns and in severe cases in sexually active young adults. These cases warrant culturing and antibiotic treatment to prevent serious complications.⁷

Recommendations from others

The American Optometric Association consensus guideline states that ideal treatment should be based on the specific causative organism. The guideline concludes that treatment of bacterial conjunctivitis with antibiotics can reduce symptoms, duration of illness, and chances of recurrence.⁸

Clinical Commentary by Carin Reust, MD, MSPH, at http://www.fpin.org.

I saw a young woman with a heart problem in clinic yesterday. Her chest pain was sharp and fleeting, and she described no coronary risk factors other than “heart problems” in her mother. I examined her, then attempted to reassure her that her heart was fine. Only then did I notice her broken gaze and realize that no, her heart was not fine. I subsequently learned that her heart was broken—because of betrayal of trust in childhood relationships, estrangement from her ex-husband and daughter, and ultimately, because she believed God had deserted her. In my haste to reassure her, I had assumed she was concerned about a biomedical problem and nearly missed the spiritual substance of her pain.

I fear that I am not alone in this error. At a time when medical literature gives more attention to spiritual issues,^1-3 health care providers are nevertheless crippled by our inability to deal with patients’ spiritual concerns. Physicians’ acceptance of a scientific world-view and use of scientific methodology create tunnel vision that impedes our consideration of religious issues. Our attitudes toward suffering and death make discussions of end-of-life issues less fruitful. Differences between scientific and religious language create barriers to spiritual discussions. The importance of considering our patients as whole persons demands that we face these challenges to the consideration of spiritual issues.

Scientific tunnel vision

Science and religion share the view that each person has value and dignity. Science and religion differ, however, principally in that science seeks to answer “how,” and religion seeks to answer “why” and “who.” Unfortunately, scientists and religionists may embrace their world-view so strongly that they fail to appreciate alternative views and to identify their perspective’s limitations. This leads to tunnel vision.

Dogmatism is one source of tunnel vision. Both science and religion create dogma in that they provide ways of understanding our world and define sets of rules that govern it. Science and religion also share a risk of unthinking adherence to dogma. Scientists can be dogmatic in defending the rightness of their world-view and in denouncing religion as primitive or anti-intellectual.⁴

Scientific methodology intensifies scientific tunnel vision. The adage that what we cannot measure, we cannot know, and therefore is unworthy of our observation⁴ articulates a common position in the scientific community. Even spiritual health researchers are subject to the quantifiable. Indeed, the association of religiosity with disease incidence and biomedical parameters is increasingly well studied.⁵ Spirituality’s qualitative effects, however, are incompletely discussed in the medical literature.

A strictly scientific approach to medical care overlooks important considerations—life’s meaning and purpose, the quest for a relationship with our maker, and the gift of hope. If we disavow these spiritual entities, we lose opportunities to stress their value in our patients’ lives.

Attitudes toward suffering and death

Physicians’ attitudes toward suffering and death are additional obstacles to consideration of spiritual issues. The notion that suffering can foster spiritual growth is common to Christianity, Judaism, Islam, and Eastern religions. Yet affirming the value of suffering clashes with medicine’s appropriate goal of relieving suffering. Similarly, many view death as the ultimate adversary rather than as a natural part of existence. As Stanley Hauerwas suggests, “Cure, not care, has become medicine’s primary purpose, [and] physicians have become warriors engaged in combat with … death.”⁶

Numerous reasons may explain physicians’ discomfort with suffering and death. Physicians may regard discussions of suffering and dying as requiring an emotional commitment that adversely affects their role.⁷ Dealing with patients’ deaths may require physicians to face personal fears of dying or confusion about spiritual issues.⁸ Physicians may view patients’ deaths as a sign of defeat.⁹ They may regard suffering as having no intrinsic value.⁸

Medicine’s discomfort with suffering and death has unfortunate consequences. Our profession’s pursuit of longevity counters the need to prepare for death. Suffering can lead to a heightened awareness of the importance of one’s inner life and to a daily cherishing of life.¹⁰ By overlooking these aspects of suffering, we lose opportunities to share meaningful experiences with our patients.

Communication barriers

Physicians discussing patients’ spiritual issues also face communication barriers. C.S. Lewis suggests that these barriers result from differences between scientific and religious language.¹¹

Religious language is qualitative and descriptive, much like poetry. Consider these examples:

• “Ah, bitter chill it was! The owl, for all his feathers was a-cold; The hare limped trembling through the frozen grass, /And silent was the flock in woolly fold: Numb’d were the Beadsman’ fingers.” (John Keats)¹¹
• “God is light.” (1 John 1:5)

Keats’s poem uses factors within our experience (being cold) as pointers to something outside our experience (a shepherd’s experience on a winter night). Lewis maintains that to benefit from this qualitative information, readers must trust the poet’s observations and insight. Understanding religious language requires similar trust. A person understanding only scientific language might dismiss the religious creed “God is light,” because “a sentient Being cannot be a stream of subatomic particles.” In doing so, that person would be overlooking the writer’s key concept—perhaps that God, like light, is infinite and life-giving. Here we see the limitations of a scientific vocabulary. Quantitative language cannot convey the content of religious beliefs.

Much of patients’ language is poetic. Schooled in scientific language, physicians may mistakenly view their patients’ language as imprecise and unsophisticated and trivialize spiritual issues. To justify studying spirituality, researchers may use quasi-scientific language that fails to express spiritual truths. Finally, we may argue with the poet. In my opening scenario, uncovering the spiritual content of the chest pain was not possible until I accepted that a broken heart could be caused by estrangement from God.

Beyond the barriers

How can we overcome language barriers, our attitudes toward suffering and death, and scientific tunnel vision? First, we should remember that simply sitting and listening has value. The act of listening fosters human connectedness and healing, so our primary response to physician-patient language barriers should be to listen. Also, we should remove labels that hinder spiritual communication. In considering spiritual issues, we are not physician, scientist, patient, and subject. We are all spiritual beings; this frees us to take the bold step of relating as equal partners in a spiritual realm.

Overcoming biases toward suffering and death requires a personal solution. We must challenge ourselves to find meaning in our own struggles. Perhaps this will allow us to affirm that growth is possible in our patients’ suffering. To enhance the quality of our dying patients’ lives, we must come to terms with the inevitability of our patients’ deaths—and our own deaths.

To avoid tunnel vision, we must ask questions. What is the purpose of spirituality? Is it a tool for prolonging life and enhancing health, or is it something broader, such as a source of life purpose? What are the nonquantifiable health benefits of spirituality? How does it enhance patients’ ability to cope with and grow from suffering?

These fundamental questions are for us all to ponder—clinician, teacher, researcher, and patient. As we simultaneously ask questions about the purpose and health benefits of spirituality, we should be reminded that at their core, medicine and religion are closely linked. Nowhere is this more apparent than in the image of a heart—a biological pump; a symbol of love; a symbol of life’s power; for many, a symbol of life’s creator. As scientists and spiritual beings we should affirm the importance of all broken hearts whatever their source—because the heart is life.

I saw a young woman with a heart problem in clinic yesterday. Her chest pain was sharp and fleeting, and she described no coronary risk factors other than “heart problems” in her mother. I examined her, then attempted to reassure her that her heart was fine. Only then did I notice her broken gaze and realize that no, her heart was not fine. I subsequently learned that her heart was broken—because of betrayal of trust in childhood relationships, estrangement from her ex-husband and daughter, and ultimately, because she believed God had deserted her. In my haste to reassure her, I had assumed she was concerned about a biomedical problem and nearly missed the spiritual substance of her pain.

I fear that I am not alone in this error. At a time when medical literature gives more attention to spiritual issues,^1-3 health care providers are nevertheless crippled by our inability to deal with patients’ spiritual concerns. Physicians’ acceptance of a scientific world-view and use of scientific methodology create tunnel vision that impedes our consideration of religious issues. Our attitudes toward suffering and death make discussions of end-of-life issues less fruitful. Differences between scientific and religious language create barriers to spiritual discussions. The importance of considering our patients as whole persons demands that we face these challenges to the consideration of spiritual issues.

Scientific tunnel vision

Science and religion share the view that each person has value and dignity. Science and religion differ, however, principally in that science seeks to answer “how,” and religion seeks to answer “why” and “who.” Unfortunately, scientists and religionists may embrace their world-view so strongly that they fail to appreciate alternative views and to identify their perspective’s limitations. This leads to tunnel vision.

Dogmatism is one source of tunnel vision. Both science and religion create dogma in that they provide ways of understanding our world and define sets of rules that govern it. Science and religion also share a risk of unthinking adherence to dogma. Scientists can be dogmatic in defending the rightness of their world-view and in denouncing religion as primitive or anti-intellectual.⁴

Scientific methodology intensifies scientific tunnel vision. The adage that what we cannot measure, we cannot know, and therefore is unworthy of our observation⁴ articulates a common position in the scientific community. Even spiritual health researchers are subject to the quantifiable. Indeed, the association of religiosity with disease incidence and biomedical parameters is increasingly well studied.⁵ Spirituality’s qualitative effects, however, are incompletely discussed in the medical literature.

A strictly scientific approach to medical care overlooks important considerations—life’s meaning and purpose, the quest for a relationship with our maker, and the gift of hope. If we disavow these spiritual entities, we lose opportunities to stress their value in our patients’ lives.

Attitudes toward suffering and death

Physicians’ attitudes toward suffering and death are additional obstacles to consideration of spiritual issues. The notion that suffering can foster spiritual growth is common to Christianity, Judaism, Islam, and Eastern religions. Yet affirming the value of suffering clashes with medicine’s appropriate goal of relieving suffering. Similarly, many view death as the ultimate adversary rather than as a natural part of existence. As Stanley Hauerwas suggests, “Cure, not care, has become medicine’s primary purpose, [and] physicians have become warriors engaged in combat with … death.”⁶

Numerous reasons may explain physicians’ discomfort with suffering and death. Physicians may regard discussions of suffering and dying as requiring an emotional commitment that adversely affects their role.⁷ Dealing with patients’ deaths may require physicians to face personal fears of dying or confusion about spiritual issues.⁸ Physicians may view patients’ deaths as a sign of defeat.⁹ They may regard suffering as having no intrinsic value.⁸

Medicine’s discomfort with suffering and death has unfortunate consequences. Our profession’s pursuit of longevity counters the need to prepare for death. Suffering can lead to a heightened awareness of the importance of one’s inner life and to a daily cherishing of life.¹⁰ By overlooking these aspects of suffering, we lose opportunities to share meaningful experiences with our patients.

Communication barriers

Physicians discussing patients’ spiritual issues also face communication barriers. C.S. Lewis suggests that these barriers result from differences between scientific and religious language.¹¹

Religious language is qualitative and descriptive, much like poetry. Consider these examples:

• “Ah, bitter chill it was! The owl, for all his feathers was a-cold; The hare limped trembling through the frozen grass, /And silent was the flock in woolly fold: Numb’d were the Beadsman’ fingers.” (John Keats)¹¹
• “God is light.” (1 John 1:5)

Keats’s poem uses factors within our experience (being cold) as pointers to something outside our experience (a shepherd’s experience on a winter night). Lewis maintains that to benefit from this qualitative information, readers must trust the poet’s observations and insight. Understanding religious language requires similar trust. A person understanding only scientific language might dismiss the religious creed “God is light,” because “a sentient Being cannot be a stream of subatomic particles.” In doing so, that person would be overlooking the writer’s key concept—perhaps that God, like light, is infinite and life-giving. Here we see the limitations of a scientific vocabulary. Quantitative language cannot convey the content of religious beliefs.

Much of patients’ language is poetic. Schooled in scientific language, physicians may mistakenly view their patients’ language as imprecise and unsophisticated and trivialize spiritual issues. To justify studying spirituality, researchers may use quasi-scientific language that fails to express spiritual truths. Finally, we may argue with the poet. In my opening scenario, uncovering the spiritual content of the chest pain was not possible until I accepted that a broken heart could be caused by estrangement from God.

Beyond the barriers

How can we overcome language barriers, our attitudes toward suffering and death, and scientific tunnel vision? First, we should remember that simply sitting and listening has value. The act of listening fosters human connectedness and healing, so our primary response to physician-patient language barriers should be to listen. Also, we should remove labels that hinder spiritual communication. In considering spiritual issues, we are not physician, scientist, patient, and subject. We are all spiritual beings; this frees us to take the bold step of relating as equal partners in a spiritual realm.

Overcoming biases toward suffering and death requires a personal solution. We must challenge ourselves to find meaning in our own struggles. Perhaps this will allow us to affirm that growth is possible in our patients’ suffering. To enhance the quality of our dying patients’ lives, we must come to terms with the inevitability of our patients’ deaths—and our own deaths.

To avoid tunnel vision, we must ask questions. What is the purpose of spirituality? Is it a tool for prolonging life and enhancing health, or is it something broader, such as a source of life purpose? What are the nonquantifiable health benefits of spirituality? How does it enhance patients’ ability to cope with and grow from suffering?

These fundamental questions are for us all to ponder—clinician, teacher, researcher, and patient. As we simultaneously ask questions about the purpose and health benefits of spirituality, we should be reminded that at their core, medicine and religion are closely linked. Nowhere is this more apparent than in the image of a heart—a biological pump; a symbol of love; a symbol of life’s power; for many, a symbol of life’s creator. As scientists and spiritual beings we should affirm the importance of all broken hearts whatever their source—because the heart is life.

I saw a young woman with a heart problem in clinic yesterday. Her chest pain was sharp and fleeting, and she described no coronary risk factors other than “heart problems” in her mother. I examined her, then attempted to reassure her that her heart was fine. Only then did I notice her broken gaze and realize that no, her heart was not fine. I subsequently learned that her heart was broken—because of betrayal of trust in childhood relationships, estrangement from her ex-husband and daughter, and ultimately, because she believed God had deserted her. In my haste to reassure her, I had assumed she was concerned about a biomedical problem and nearly missed the spiritual substance of her pain.

I fear that I am not alone in this error. At a time when medical literature gives more attention to spiritual issues,^1-3 health care providers are nevertheless crippled by our inability to deal with patients’ spiritual concerns. Physicians’ acceptance of a scientific world-view and use of scientific methodology create tunnel vision that impedes our consideration of religious issues. Our attitudes toward suffering and death make discussions of end-of-life issues less fruitful. Differences between scientific and religious language create barriers to spiritual discussions. The importance of considering our patients as whole persons demands that we face these challenges to the consideration of spiritual issues.

Scientific tunnel vision

Science and religion share the view that each person has value and dignity. Science and religion differ, however, principally in that science seeks to answer “how,” and religion seeks to answer “why” and “who.” Unfortunately, scientists and religionists may embrace their world-view so strongly that they fail to appreciate alternative views and to identify their perspective’s limitations. This leads to tunnel vision.

Dogmatism is one source of tunnel vision. Both science and religion create dogma in that they provide ways of understanding our world and define sets of rules that govern it. Science and religion also share a risk of unthinking adherence to dogma. Scientists can be dogmatic in defending the rightness of their world-view and in denouncing religion as primitive or anti-intellectual.⁴

Scientific methodology intensifies scientific tunnel vision. The adage that what we cannot measure, we cannot know, and therefore is unworthy of our observation⁴ articulates a common position in the scientific community. Even spiritual health researchers are subject to the quantifiable. Indeed, the association of religiosity with disease incidence and biomedical parameters is increasingly well studied.⁵ Spirituality’s qualitative effects, however, are incompletely discussed in the medical literature.

A strictly scientific approach to medical care overlooks important considerations—life’s meaning and purpose, the quest for a relationship with our maker, and the gift of hope. If we disavow these spiritual entities, we lose opportunities to stress their value in our patients’ lives.

Attitudes toward suffering and death

Physicians’ attitudes toward suffering and death are additional obstacles to consideration of spiritual issues. The notion that suffering can foster spiritual growth is common to Christianity, Judaism, Islam, and Eastern religions. Yet affirming the value of suffering clashes with medicine’s appropriate goal of relieving suffering. Similarly, many view death as the ultimate adversary rather than as a natural part of existence. As Stanley Hauerwas suggests, “Cure, not care, has become medicine’s primary purpose, [and] physicians have become warriors engaged in combat with … death.”⁶

Numerous reasons may explain physicians’ discomfort with suffering and death. Physicians may regard discussions of suffering and dying as requiring an emotional commitment that adversely affects their role.⁷ Dealing with patients’ deaths may require physicians to face personal fears of dying or confusion about spiritual issues.⁸ Physicians may view patients’ deaths as a sign of defeat.⁹ They may regard suffering as having no intrinsic value.⁸

Medicine’s discomfort with suffering and death has unfortunate consequences. Our profession’s pursuit of longevity counters the need to prepare for death. Suffering can lead to a heightened awareness of the importance of one’s inner life and to a daily cherishing of life.¹⁰ By overlooking these aspects of suffering, we lose opportunities to share meaningful experiences with our patients.

Communication barriers

Physicians discussing patients’ spiritual issues also face communication barriers. C.S. Lewis suggests that these barriers result from differences between scientific and religious language.¹¹

Religious language is qualitative and descriptive, much like poetry. Consider these examples:

• “Ah, bitter chill it was! The owl, for all his feathers was a-cold; The hare limped trembling through the frozen grass, /And silent was the flock in woolly fold: Numb’d were the Beadsman’ fingers.” (John Keats)¹¹
• “God is light.” (1 John 1:5)

Keats’s poem uses factors within our experience (being cold) as pointers to something outside our experience (a shepherd’s experience on a winter night). Lewis maintains that to benefit from this qualitative information, readers must trust the poet’s observations and insight. Understanding religious language requires similar trust. A person understanding only scientific language might dismiss the religious creed “God is light,” because “a sentient Being cannot be a stream of subatomic particles.” In doing so, that person would be overlooking the writer’s key concept—perhaps that God, like light, is infinite and life-giving. Here we see the limitations of a scientific vocabulary. Quantitative language cannot convey the content of religious beliefs.

Much of patients’ language is poetic. Schooled in scientific language, physicians may mistakenly view their patients’ language as imprecise and unsophisticated and trivialize spiritual issues. To justify studying spirituality, researchers may use quasi-scientific language that fails to express spiritual truths. Finally, we may argue with the poet. In my opening scenario, uncovering the spiritual content of the chest pain was not possible until I accepted that a broken heart could be caused by estrangement from God.

Beyond the barriers

How can we overcome language barriers, our attitudes toward suffering and death, and scientific tunnel vision? First, we should remember that simply sitting and listening has value. The act of listening fosters human connectedness and healing, so our primary response to physician-patient language barriers should be to listen. Also, we should remove labels that hinder spiritual communication. In considering spiritual issues, we are not physician, scientist, patient, and subject. We are all spiritual beings; this frees us to take the bold step of relating as equal partners in a spiritual realm.

Overcoming biases toward suffering and death requires a personal solution. We must challenge ourselves to find meaning in our own struggles. Perhaps this will allow us to affirm that growth is possible in our patients’ suffering. To enhance the quality of our dying patients’ lives, we must come to terms with the inevitability of our patients’ deaths—and our own deaths.

To avoid tunnel vision, we must ask questions. What is the purpose of spirituality? Is it a tool for prolonging life and enhancing health, or is it something broader, such as a source of life purpose? What are the nonquantifiable health benefits of spirituality? How does it enhance patients’ ability to cope with and grow from suffering?

These fundamental questions are for us all to ponder—clinician, teacher, researcher, and patient. As we simultaneously ask questions about the purpose and health benefits of spirituality, we should be reminded that at their core, medicine and religion are closely linked. Nowhere is this more apparent than in the image of a heart—a biological pump; a symbol of love; a symbol of life’s power; for many, a symbol of life’s creator. As scientists and spiritual beings we should affirm the importance of all broken hearts whatever their source—because the heart is life.

An emerging body of research supports the inclusion of spiritual issues in healthcare. Studies have correlated religious commitment with health.^1-3 Many patients affirm the importance of spiritual factors in their lives.^4-5 Recent studies demonstrate that many patients wish to have spirituality considered in their health care, especially during grave illness or emotional crisis.^4-6 How to accomplish this objective is less clear. Although physicians possess spiritual assessment tools,^7-11 broader issues such as physician attitudes, roles, and varied ways of dealing with spirituality have not been widely studied. Understanding this context is crucial if physicians are to include spiritual assessment in patient care.

Two studies of Midwestern family physicians found strong support for addressing patients’ spiritual concerns. In one survey, family physicians in Illinois (n = 210) believed that strong religious convictions positively affect older patients’ mental health (68%) and physical health (42%).¹² These doctors supported physicians’ pursuing spiritual issues at patients’ request (88%) and when patients faced bereavement or impending death (66%). Similarly, Missouri family physicians (n = 231) affirmed that spiritual well-being is an important health component (96%) and that hospitalized patients with spiritual concerns should be referred to chaplains (86%).¹³ A far smaller percentage of these physicians, however, felt they should personally address patients’ spiritual questions (58%).

Despite acknowledging the importance of spiritual issues, the Missouri physicians seldom engaged patients in conversations about death and dying, meditation or quiet reflection, prayer, forgiveness, giving and receiving love, the role of a deity in illness, and the meaning or purpose of illness. They reported such barriers to spiritual discussions as lack of time (71%), inadequate training for taking spiritual histories (59%), and difficulty in identifying patients who want to discuss spiritual issues (56%). The gulf between physicians’ attitudes and practice of spiritual assessment suggests an incomplete understanding of their role in spiritual health.

A study by Craigie and Hobbs¹⁴ of 12 family physicians who are themselves deeply spiritual represents early progress toward understanding this role. These physicians perceived that their spirituality enabled them to experience sacredness in patient encounters, to view medicine as a mission, to maintain centeredness, and to serve as instruments of healing. They described themselves as facilitators and encouragers of patients’ spiritual values and resources. We reasoned that unlike the deeply spiritual respondents in the Craigie and Hobbs study, family physicians in general are likely to have a broad range of attitudes and practices regarding spiritual assessment. We sought to better understand the spectrum of views about the physician’s role in spiritual encounters, to describe family physicians’ approaches to addressing spiritual issues, and to further explore barriers to spiritual discussions and facilitators of these discussions.

Methods

We conducted semistructured interviews¹⁵ with 13 family physicians. Participants assessed their frequency of addressing patients’ spiritual issues and provided demographic information and practice characteristics. Interview topics included spirituality in the doctor-patient relationship, the practice of addressing spiritual issues, and perceived facilitators and barriers to discussing spiritual issues. Interviews were conducted by one of the authors (either A.D.B. or D.H.) or by a research assistant trained in qualitative investigation techniques. Interviews averaged 45 minutes in duration.

To guard against bias in advocating a particular stance toward spiritual assessment, we stressed to respondents that we wanted their honest observations and confirmed their statements throughout the interview. Before analyzing the data, we noted our preconceptions toward spiritual assessment. We consciously sought to avoid these biases while reviewing the data.¹⁶ To further reduce the likelihood of bias, we selected a research team whose members represented multiple academic disciplines and religious backgrounds.

Qualitative research aims to uncover new information and perspectives rather than to draw definitive conclusions from a representative study sample.¹⁷ Study participants were deliberately selected¹⁸ to represent a range of demographic factors (sex, age, religious background), practice types (academic or community practice; urban and rural), and practice regarding physicians’ role in addressing patients’ spiritual issues.

All study participants were board-certified family physicians in Missouri. Three participants were white women; 10 were white men. They ranged in age from 37 to 63 years. Three were in full-time community practice; all others were medical school or residency faculty. All but 1 faculty member reported previous community practice experience. Two participants practice in rural locations; 2 in community health centers; 1 in a metropolitan community practice; 4 in metropolitan community-based residency clinics; and 4 in a metropolitan university-based residency clinic. Subjects’ religious affiliations were Jewish (1), Christian (6), “Unitarian Universalist with Muslim leanings” (1), “Unitarian Universalist with Buddhist leanings” (1), “Unitarian” (2), “none” (1), and agnostic (1).

Interviews took place in participants’ offices. We informed them of the use of audiotapes during the telephone recruitment and obtained verbal consent before audiotaping. An Institutional Review Board approved our study.

Study staff transcribed the interviews verbatim. Investigators verified interview content through comparison with interviewers’ notes and entered the text into Ethnograph,¹⁹ a computer database program designed to organize textual material. Investigators used an iterative process to make an initial template for organizing and coding data.²⁰ Our multiple readings of interviews led to further code revisions until consensus was reached regarding salient issues or themes.^21,22 We solicited respondents’ views of the validity of the final codes and themes and of the accuracy of illustrative quotations.

Results

Six respondents reported regularly addressing spiritual issues with patients. One respondent reported an intermediate level of involvement; 6 reported that they do not regularly address spiritual issues. One physician was opposed to physicians’ addressing spiritual issues with patients.

The themes that emerged from the coded interviews were associated with 5 issues: (1) the appropriate role for physicians in addressing spiritual concerns; (2) situations in which physicians focus on spiritual issues (the nature and setting of these discussions); (3) how physicians address spiritual issues; (4) barriers to addressing spiritual issues; and (5) facilitators of spiritual assessment.

Physician’s role

Physicians who regularly discussed spirituality believed that the scientific evidence linking spirituality and positive health outcomes justified their actions. One study participant stated, “Every physician ought to be dealing with [patients’] spiritual issues. [For example,] how can you justify not talking about spirituality to a patient with depression when you can prove scientifically that strengthening faith commitment helps them? It really comes down to a quality of care issue.”

Some respondents believed that the primacy of spirituality in life provided a justification for addressing spiritual issues with patients. As one stated, “These values . . . get at the core of who you are. I would hope that I would be respectful and supportive” [whether or not I was a physician].

The respondents universally viewed themselves as supportive resources for patients through listening, validating spiritual beliefs, and remaining with patients during times of need. One expressed that healing occurs as physicians and patients connect as people, stating, “I don’t have to be a spiritual master. I can be a human being, trying to connect with another human being. That is a healing experience.”

Although several participants seldom addressed spiritual matters, only one strongly opposed the initiation of such discussions, out of concern about role definition and invasion of patients’ privacy. This participant felt that spiritual matters were “no more in the physician’s domain than questions regarding patients’ finances or their most evil thoughts.”

Nature and setting of discussions

Respondents reported specific patient illnesses and stressors that are likely to prompt spiritual discussions. These included terminal illness; chronic illness; specific conditions, such as heart disease, cancer, or miscarriage; depression, anxiety, or other psychiatric illness; pregnancy; and life stressors, including traumatic illness in the family. Other patient situations associated with spiritual discussions included the presence of symptoms without an explanation (eg, pain, insomnia, anorexia), loss of a bodily function, role change within the family, or an illness that erodes one’s self-concept.

Physician respondents also reported factors that often prompt them to ask spiritual questions. These included intensive care unit admission, new diagnosis of terminal illness, treatment failures, patients’ dissatisfaction with progress of treatment, and discussion of advanced care directives. The respondents who regularly address spiritual issues use screening questions that they tend to ask in response to a patient’s cues or crisis (Table 1).

Some respondents asserted that patients’ spiritual questions arise from their unique reactions to life stress and illness. One physician stated that patients’ questions have “more to do with their view of their illness than what the illness really is.” Spiritual questions commonly asked by patients covered a wide range of spiritual themes (Table 1).

TABLE 1
SELECTED SPIRITUAL QUESTIONS OF PATIENTS AND PHYSICIANS

Manner of addressing spiritual health issues

The physicians in our study believed that in most circumstances, patients should initiate spiritual discussions. One said, “It’s one of those areas where you need a small amount of the patient’s permission to get started and a lot more of the patient’s permission to finish.”

Those who regularly address spiritual issues reported using a variety of techniques and approaches (Table 2). These physicians allow for an inclusive definition of spirituality; they try to normalize spiritual discussions and to integrate spiritual discussions into the ongoing doctor–patient relationship. One said that “bringing [spirituality] to the table” along with other potentially sensitive issues helps patients know “what you’re interested in and gives them the option of deciding to pursue it or not.”

The physicians who address spiritual issues follow principles of spiritual assessment (Table 2). All respondents affirmed that spiritual discussions should be approached with sensitivity and integrity to avoid imposing their own belief systems on their patients. One said, “I can’t even describe how negative it [would be] for me to impose my spiritual beliefs on [my] patients.” Another respondent agreed, but also described a tension between faith-based and profession-based thoughts: “[Discussing one’s faith with a patient risks being] an abuse of power; yet if a patient dies tonight and I haven’t shared the Good News that I have . . . I’m neglecting something that’s very important. . . . How do we do this . . . with both gentleness toward the patient and reverence toward God?”

Respondents expressed divergent viewpoints concerning routine spiritual history taking. Although some considered this to be an essential skill, those who seldom addressed spiritual issues found it less pressing and more time consuming than medical concerns. None reported the routine use of currently available spiritual assessment tools. A respondent opposed to initiating spiritual discussions noted a Judeo-Christian bias in these tools, calling their use “cultural imperialism.”

TABLE 2
PHYSICIANS’ APPROACHES TO ADDRESSING SPIRITUAL ISSUES

Barriers to spiritual assessment

Our respondents noted significant barriers, including physician barriers, mutual physician–patient barriers, physician-perceived patient barriers, and situational barriers (Table 3). An example of a physician–patient barrier is the mutual feeling that neither wants to raise issues of spirituality for fear of alienating or causing discomfort in the other.

TABLE 3
SELECTED BARRIERS TO SPIRITUAL DISCUSSIONS AND FACILITATORS OF THEM

Facilitators of spiritual discussions

Respondents noted that characteristics facilitating patients’ discussions of sexuality and other sensitive issues also facilitate conversations about spirituality. These characteristics include communicating a willingness to engage in (and having the time for) such discussions and assuring patients that spiritual confidences will be received in a nonjudgmental fashion.

Physicians who are more spiritually inclined may be more likely to address spiritual issues with patients. As one respondent stated, “When I have conversations about spiritual issues, it’s [sic] usually been at my initiation . . . because I’m more concerned about religious sorts of things than many physicians.”

A final theme expressed by respondents is that physicians who model a life characterized by balance and spiritual maturity can facilitate patients’ spiritual growth. One stated, “My patients perceive something about my balance and spiritual strength that makes them believe they can do anything. It allows me to move to the next level with them . . . [by showing them how to foster] that strength in themselves with the help of family, community, and God.” Other facilitators are listed in Table 3.

Discussion

The relationship between religiosity and positive health outcomes does much to justify spiritual assessment.^1-3 Other justifications include enhanced coping in chronic illness states,²³ providing patients with hope in illness-coping and recovery;^24,25 the possibility that neglect of spiritual needs may drive patients away from medical treatment,²⁴ and evidence that some patients desire physicians to raise spiritual issues.^6,25,26

We sought to explore the context of spiritual assessment rather than to further justify such assessments. The context of spiritual assessment refers to the philosophical question of whether physicians should address spiritual questions and to practical questions of how spiritual matters arise, how physicians approach them, and what barriers and facilitators they perceive with regard to discussing spirituality. Our study adds to knowledge about this context in several important ways.

We found variance of opinion concerning the physician’s role in spiritual assessment. Respondents reporting infrequent spiritual assessment expressed the view that spiritual issues have lower priority than other medical concerns. Yet those who regularly address spiritual issues justified this with scientific evidence associating spirituality and health. They also proposed a justification not found in previous studies: that spirituality is central to life and therefore important for its own sake rather than simply as a means to a medical end. These findings support and augment previously cited justifications for physicians assisting patients with spiritual health issues.^1-3,6,24-26

Our study results add to the list of categories that prompt discussions of spiritual issues. Respondents affirmed a role for physicians in discussing end-of-life issues and advanced care directives, as in previous studies.^27-29 In addition, they observed that patients’ spiritual questions arise from their unique responses to chronic illness, terminal illness, and life stressors. They identified 2 new categories prompting spiritual discussions: unexplained symptoms and treatment failure.

All respondents affirmed a role for physicians in supporting patients who initiate spiritual discussions. As in a previous study,¹⁴ they viewed themselves as facilitators and encouragers of patients’ spiritual values and as resources rather than as spiritual counselors. The most reticent physicians believed in responding to patients’ questions rather than initiating discussions, an approach that may fail to identify spiritual issues. All respondents supported a patient-centered approach to spiritual assessment in which physicians act with integrity and take care not to abuse their position.

Many physicians saw value in spiritual history taking, though none reported routine use of spiritual assessment tools. The potential Judeo-Christian bias in assessment questions noted by one respondent highlights the need to use culturally sensitive, generic assessment tools³⁰ and to work toward further development of such tools.

We identified new barriers to spiritual assessment, including a physician’s upbringing and culture, lack of spiritual inclination or awareness, resistance to exposing personal beliefs, and belief that spiritual discussions will not influence patients’ illnesses or lives. Respondents also postulated patient barriers, including fears that their physician might judge them for their spiritual views or consider their raising spiritual questions inappropriate.

We identified facilitators of spiritual discussions, such as communicating a willingness to have these discussions. One respondent noted that physicians whose lives are characterized by spiritual maturity might serve as agents of patients’ spiritual growth, consistent with a previous study’s themes of caregiver spirituality and physician vocation and mission.¹⁴

Limitations

Because qualitative research aims to uncover new perspectives rather than to make generalizable assessments, our findings may not apply to all physicians or to all family physicians. Although our respondents did not represent all major world religions, ethnic groups, and cultures, they did offer a diversity of spiritual and religious perspectives. Finally, our study gives only physicians’ perspectives. We are currently studying patients’ perspectives of situations that elicit spiritual questions and of potential barriers to spiritual assessment. We will use themes from our patient and physician qualitative studies to frame questions for a national patient questionnaire regarding physicians’ spiritual assessment.

Conclusions

Physicians differ in their comfort and practice of addressing spiritual issues with patients, but affirm a role for themselves in responding to patients’ spiritual concerns. Perceived barriers, physicians’ role definition, familiarity with factors likely to prompt spiritual questions, and the recognition of principles guiding spiritual discussions form the context for family physicians’ discussions of spiritual issues with patients. This context is important to consider when training medical students and residents in spiritual assessment. Careful attention to this context will also enhance the practicing physician’s skill in providing patient-centered assistance with spiritual health concerns.

Acknowledgments

The authors wish to acknowledge Arej Sawani, who assisted in data collection; Sheri Price, who assisted in manuscript preparation; and Richard Ellis, MD, MPH, Daniel Vinson, MD, MSPH, Steven Zweig, MD, MSPH, and Dale Smith, who reviewed the manuscript and offered editorial suggestions.

An emerging body of research supports the inclusion of spiritual issues in healthcare. Studies have correlated religious commitment with health.^1-3 Many patients affirm the importance of spiritual factors in their lives.^4-5 Recent studies demonstrate that many patients wish to have spirituality considered in their health care, especially during grave illness or emotional crisis.^4-6 How to accomplish this objective is less clear. Although physicians possess spiritual assessment tools,^7-11 broader issues such as physician attitudes, roles, and varied ways of dealing with spirituality have not been widely studied. Understanding this context is crucial if physicians are to include spiritual assessment in patient care.

Two studies of Midwestern family physicians found strong support for addressing patients’ spiritual concerns. In one survey, family physicians in Illinois (n = 210) believed that strong religious convictions positively affect older patients’ mental health (68%) and physical health (42%).¹² These doctors supported physicians’ pursuing spiritual issues at patients’ request (88%) and when patients faced bereavement or impending death (66%). Similarly, Missouri family physicians (n = 231) affirmed that spiritual well-being is an important health component (96%) and that hospitalized patients with spiritual concerns should be referred to chaplains (86%).¹³ A far smaller percentage of these physicians, however, felt they should personally address patients’ spiritual questions (58%).

Despite acknowledging the importance of spiritual issues, the Missouri physicians seldom engaged patients in conversations about death and dying, meditation or quiet reflection, prayer, forgiveness, giving and receiving love, the role of a deity in illness, and the meaning or purpose of illness. They reported such barriers to spiritual discussions as lack of time (71%), inadequate training for taking spiritual histories (59%), and difficulty in identifying patients who want to discuss spiritual issues (56%). The gulf between physicians’ attitudes and practice of spiritual assessment suggests an incomplete understanding of their role in spiritual health.

A study by Craigie and Hobbs¹⁴ of 12 family physicians who are themselves deeply spiritual represents early progress toward understanding this role. These physicians perceived that their spirituality enabled them to experience sacredness in patient encounters, to view medicine as a mission, to maintain centeredness, and to serve as instruments of healing. They described themselves as facilitators and encouragers of patients’ spiritual values and resources. We reasoned that unlike the deeply spiritual respondents in the Craigie and Hobbs study, family physicians in general are likely to have a broad range of attitudes and practices regarding spiritual assessment. We sought to better understand the spectrum of views about the physician’s role in spiritual encounters, to describe family physicians’ approaches to addressing spiritual issues, and to further explore barriers to spiritual discussions and facilitators of these discussions.

Methods

We conducted semistructured interviews¹⁵ with 13 family physicians. Participants assessed their frequency of addressing patients’ spiritual issues and provided demographic information and practice characteristics. Interview topics included spirituality in the doctor-patient relationship, the practice of addressing spiritual issues, and perceived facilitators and barriers to discussing spiritual issues. Interviews were conducted by one of the authors (either A.D.B. or D.H.) or by a research assistant trained in qualitative investigation techniques. Interviews averaged 45 minutes in duration.

To guard against bias in advocating a particular stance toward spiritual assessment, we stressed to respondents that we wanted their honest observations and confirmed their statements throughout the interview. Before analyzing the data, we noted our preconceptions toward spiritual assessment. We consciously sought to avoid these biases while reviewing the data.¹⁶ To further reduce the likelihood of bias, we selected a research team whose members represented multiple academic disciplines and religious backgrounds.

Qualitative research aims to uncover new information and perspectives rather than to draw definitive conclusions from a representative study sample.¹⁷ Study participants were deliberately selected¹⁸ to represent a range of demographic factors (sex, age, religious background), practice types (academic or community practice; urban and rural), and practice regarding physicians’ role in addressing patients’ spiritual issues.

All study participants were board-certified family physicians in Missouri. Three participants were white women; 10 were white men. They ranged in age from 37 to 63 years. Three were in full-time community practice; all others were medical school or residency faculty. All but 1 faculty member reported previous community practice experience. Two participants practice in rural locations; 2 in community health centers; 1 in a metropolitan community practice; 4 in metropolitan community-based residency clinics; and 4 in a metropolitan university-based residency clinic. Subjects’ religious affiliations were Jewish (1), Christian (6), “Unitarian Universalist with Muslim leanings” (1), “Unitarian Universalist with Buddhist leanings” (1), “Unitarian” (2), “none” (1), and agnostic (1).

Interviews took place in participants’ offices. We informed them of the use of audiotapes during the telephone recruitment and obtained verbal consent before audiotaping. An Institutional Review Board approved our study.

Study staff transcribed the interviews verbatim. Investigators verified interview content through comparison with interviewers’ notes and entered the text into Ethnograph,¹⁹ a computer database program designed to organize textual material. Investigators used an iterative process to make an initial template for organizing and coding data.²⁰ Our multiple readings of interviews led to further code revisions until consensus was reached regarding salient issues or themes.^21,22 We solicited respondents’ views of the validity of the final codes and themes and of the accuracy of illustrative quotations.

Results

Six respondents reported regularly addressing spiritual issues with patients. One respondent reported an intermediate level of involvement; 6 reported that they do not regularly address spiritual issues. One physician was opposed to physicians’ addressing spiritual issues with patients.

The themes that emerged from the coded interviews were associated with 5 issues: (1) the appropriate role for physicians in addressing spiritual concerns; (2) situations in which physicians focus on spiritual issues (the nature and setting of these discussions); (3) how physicians address spiritual issues; (4) barriers to addressing spiritual issues; and (5) facilitators of spiritual assessment.

Physician’s role

Physicians who regularly discussed spirituality believed that the scientific evidence linking spirituality and positive health outcomes justified their actions. One study participant stated, “Every physician ought to be dealing with [patients’] spiritual issues. [For example,] how can you justify not talking about spirituality to a patient with depression when you can prove scientifically that strengthening faith commitment helps them? It really comes down to a quality of care issue.”

Some respondents believed that the primacy of spirituality in life provided a justification for addressing spiritual issues with patients. As one stated, “These values . . . get at the core of who you are. I would hope that I would be respectful and supportive” [whether or not I was a physician].

The respondents universally viewed themselves as supportive resources for patients through listening, validating spiritual beliefs, and remaining with patients during times of need. One expressed that healing occurs as physicians and patients connect as people, stating, “I don’t have to be a spiritual master. I can be a human being, trying to connect with another human being. That is a healing experience.”

Although several participants seldom addressed spiritual matters, only one strongly opposed the initiation of such discussions, out of concern about role definition and invasion of patients’ privacy. This participant felt that spiritual matters were “no more in the physician’s domain than questions regarding patients’ finances or their most evil thoughts.”

Nature and setting of discussions

Respondents reported specific patient illnesses and stressors that are likely to prompt spiritual discussions. These included terminal illness; chronic illness; specific conditions, such as heart disease, cancer, or miscarriage; depression, anxiety, or other psychiatric illness; pregnancy; and life stressors, including traumatic illness in the family. Other patient situations associated with spiritual discussions included the presence of symptoms without an explanation (eg, pain, insomnia, anorexia), loss of a bodily function, role change within the family, or an illness that erodes one’s self-concept.

Physician respondents also reported factors that often prompt them to ask spiritual questions. These included intensive care unit admission, new diagnosis of terminal illness, treatment failures, patients’ dissatisfaction with progress of treatment, and discussion of advanced care directives. The respondents who regularly address spiritual issues use screening questions that they tend to ask in response to a patient’s cues or crisis (Table 1).

Some respondents asserted that patients’ spiritual questions arise from their unique reactions to life stress and illness. One physician stated that patients’ questions have “more to do with their view of their illness than what the illness really is.” Spiritual questions commonly asked by patients covered a wide range of spiritual themes (Table 1).

TABLE 1
SELECTED SPIRITUAL QUESTIONS OF PATIENTS AND PHYSICIANS

Manner of addressing spiritual health issues

The physicians in our study believed that in most circumstances, patients should initiate spiritual discussions. One said, “It’s one of those areas where you need a small amount of the patient’s permission to get started and a lot more of the patient’s permission to finish.”

Those who regularly address spiritual issues reported using a variety of techniques and approaches (Table 2). These physicians allow for an inclusive definition of spirituality; they try to normalize spiritual discussions and to integrate spiritual discussions into the ongoing doctor–patient relationship. One said that “bringing [spirituality] to the table” along with other potentially sensitive issues helps patients know “what you’re interested in and gives them the option of deciding to pursue it or not.”

The physicians who address spiritual issues follow principles of spiritual assessment (Table 2). All respondents affirmed that spiritual discussions should be approached with sensitivity and integrity to avoid imposing their own belief systems on their patients. One said, “I can’t even describe how negative it [would be] for me to impose my spiritual beliefs on [my] patients.” Another respondent agreed, but also described a tension between faith-based and profession-based thoughts: “[Discussing one’s faith with a patient risks being] an abuse of power; yet if a patient dies tonight and I haven’t shared the Good News that I have . . . I’m neglecting something that’s very important. . . . How do we do this . . . with both gentleness toward the patient and reverence toward God?”

Respondents expressed divergent viewpoints concerning routine spiritual history taking. Although some considered this to be an essential skill, those who seldom addressed spiritual issues found it less pressing and more time consuming than medical concerns. None reported the routine use of currently available spiritual assessment tools. A respondent opposed to initiating spiritual discussions noted a Judeo-Christian bias in these tools, calling their use “cultural imperialism.”

TABLE 2
PHYSICIANS’ APPROACHES TO ADDRESSING SPIRITUAL ISSUES

Barriers to spiritual assessment

Our respondents noted significant barriers, including physician barriers, mutual physician–patient barriers, physician-perceived patient barriers, and situational barriers (Table 3). An example of a physician–patient barrier is the mutual feeling that neither wants to raise issues of spirituality for fear of alienating or causing discomfort in the other.

TABLE 3
SELECTED BARRIERS TO SPIRITUAL DISCUSSIONS AND FACILITATORS OF THEM

Facilitators of spiritual discussions

Respondents noted that characteristics facilitating patients’ discussions of sexuality and other sensitive issues also facilitate conversations about spirituality. These characteristics include communicating a willingness to engage in (and having the time for) such discussions and assuring patients that spiritual confidences will be received in a nonjudgmental fashion.

Physicians who are more spiritually inclined may be more likely to address spiritual issues with patients. As one respondent stated, “When I have conversations about spiritual issues, it’s [sic] usually been at my initiation . . . because I’m more concerned about religious sorts of things than many physicians.”

A final theme expressed by respondents is that physicians who model a life characterized by balance and spiritual maturity can facilitate patients’ spiritual growth. One stated, “My patients perceive something about my balance and spiritual strength that makes them believe they can do anything. It allows me to move to the next level with them . . . [by showing them how to foster] that strength in themselves with the help of family, community, and God.” Other facilitators are listed in Table 3.

Discussion

The relationship between religiosity and positive health outcomes does much to justify spiritual assessment.^1-3 Other justifications include enhanced coping in chronic illness states,²³ providing patients with hope in illness-coping and recovery;^24,25 the possibility that neglect of spiritual needs may drive patients away from medical treatment,²⁴ and evidence that some patients desire physicians to raise spiritual issues.^6,25,26

We sought to explore the context of spiritual assessment rather than to further justify such assessments. The context of spiritual assessment refers to the philosophical question of whether physicians should address spiritual questions and to practical questions of how spiritual matters arise, how physicians approach them, and what barriers and facilitators they perceive with regard to discussing spirituality. Our study adds to knowledge about this context in several important ways.

We found variance of opinion concerning the physician’s role in spiritual assessment. Respondents reporting infrequent spiritual assessment expressed the view that spiritual issues have lower priority than other medical concerns. Yet those who regularly address spiritual issues justified this with scientific evidence associating spirituality and health. They also proposed a justification not found in previous studies: that spirituality is central to life and therefore important for its own sake rather than simply as a means to a medical end. These findings support and augment previously cited justifications for physicians assisting patients with spiritual health issues.^1-3,6,24-26

Our study results add to the list of categories that prompt discussions of spiritual issues. Respondents affirmed a role for physicians in discussing end-of-life issues and advanced care directives, as in previous studies.^27-29 In addition, they observed that patients’ spiritual questions arise from their unique responses to chronic illness, terminal illness, and life stressors. They identified 2 new categories prompting spiritual discussions: unexplained symptoms and treatment failure.

All respondents affirmed a role for physicians in supporting patients who initiate spiritual discussions. As in a previous study,¹⁴ they viewed themselves as facilitators and encouragers of patients’ spiritual values and as resources rather than as spiritual counselors. The most reticent physicians believed in responding to patients’ questions rather than initiating discussions, an approach that may fail to identify spiritual issues. All respondents supported a patient-centered approach to spiritual assessment in which physicians act with integrity and take care not to abuse their position.

Many physicians saw value in spiritual history taking, though none reported routine use of spiritual assessment tools. The potential Judeo-Christian bias in assessment questions noted by one respondent highlights the need to use culturally sensitive, generic assessment tools³⁰ and to work toward further development of such tools.

We identified new barriers to spiritual assessment, including a physician’s upbringing and culture, lack of spiritual inclination or awareness, resistance to exposing personal beliefs, and belief that spiritual discussions will not influence patients’ illnesses or lives. Respondents also postulated patient barriers, including fears that their physician might judge them for their spiritual views or consider their raising spiritual questions inappropriate.

We identified facilitators of spiritual discussions, such as communicating a willingness to have these discussions. One respondent noted that physicians whose lives are characterized by spiritual maturity might serve as agents of patients’ spiritual growth, consistent with a previous study’s themes of caregiver spirituality and physician vocation and mission.¹⁴

Limitations

Because qualitative research aims to uncover new perspectives rather than to make generalizable assessments, our findings may not apply to all physicians or to all family physicians. Although our respondents did not represent all major world religions, ethnic groups, and cultures, they did offer a diversity of spiritual and religious perspectives. Finally, our study gives only physicians’ perspectives. We are currently studying patients’ perspectives of situations that elicit spiritual questions and of potential barriers to spiritual assessment. We will use themes from our patient and physician qualitative studies to frame questions for a national patient questionnaire regarding physicians’ spiritual assessment.

Conclusions

Physicians differ in their comfort and practice of addressing spiritual issues with patients, but affirm a role for themselves in responding to patients’ spiritual concerns. Perceived barriers, physicians’ role definition, familiarity with factors likely to prompt spiritual questions, and the recognition of principles guiding spiritual discussions form the context for family physicians’ discussions of spiritual issues with patients. This context is important to consider when training medical students and residents in spiritual assessment. Careful attention to this context will also enhance the practicing physician’s skill in providing patient-centered assistance with spiritual health concerns.

Acknowledgments

The authors wish to acknowledge Arej Sawani, who assisted in data collection; Sheri Price, who assisted in manuscript preparation; and Richard Ellis, MD, MPH, Daniel Vinson, MD, MSPH, Steven Zweig, MD, MSPH, and Dale Smith, who reviewed the manuscript and offered editorial suggestions.

An emerging body of research supports the inclusion of spiritual issues in healthcare. Studies have correlated religious commitment with health.^1-3 Many patients affirm the importance of spiritual factors in their lives.^4-5 Recent studies demonstrate that many patients wish to have spirituality considered in their health care, especially during grave illness or emotional crisis.^4-6 How to accomplish this objective is less clear. Although physicians possess spiritual assessment tools,^7-11 broader issues such as physician attitudes, roles, and varied ways of dealing with spirituality have not been widely studied. Understanding this context is crucial if physicians are to include spiritual assessment in patient care.

Two studies of Midwestern family physicians found strong support for addressing patients’ spiritual concerns. In one survey, family physicians in Illinois (n = 210) believed that strong religious convictions positively affect older patients’ mental health (68%) and physical health (42%).¹² These doctors supported physicians’ pursuing spiritual issues at patients’ request (88%) and when patients faced bereavement or impending death (66%). Similarly, Missouri family physicians (n = 231) affirmed that spiritual well-being is an important health component (96%) and that hospitalized patients with spiritual concerns should be referred to chaplains (86%).¹³ A far smaller percentage of these physicians, however, felt they should personally address patients’ spiritual questions (58%).

Despite acknowledging the importance of spiritual issues, the Missouri physicians seldom engaged patients in conversations about death and dying, meditation or quiet reflection, prayer, forgiveness, giving and receiving love, the role of a deity in illness, and the meaning or purpose of illness. They reported such barriers to spiritual discussions as lack of time (71%), inadequate training for taking spiritual histories (59%), and difficulty in identifying patients who want to discuss spiritual issues (56%). The gulf between physicians’ attitudes and practice of spiritual assessment suggests an incomplete understanding of their role in spiritual health.

A study by Craigie and Hobbs¹⁴ of 12 family physicians who are themselves deeply spiritual represents early progress toward understanding this role. These physicians perceived that their spirituality enabled them to experience sacredness in patient encounters, to view medicine as a mission, to maintain centeredness, and to serve as instruments of healing. They described themselves as facilitators and encouragers of patients’ spiritual values and resources. We reasoned that unlike the deeply spiritual respondents in the Craigie and Hobbs study, family physicians in general are likely to have a broad range of attitudes and practices regarding spiritual assessment. We sought to better understand the spectrum of views about the physician’s role in spiritual encounters, to describe family physicians’ approaches to addressing spiritual issues, and to further explore barriers to spiritual discussions and facilitators of these discussions.

Methods

We conducted semistructured interviews¹⁵ with 13 family physicians. Participants assessed their frequency of addressing patients’ spiritual issues and provided demographic information and practice characteristics. Interview topics included spirituality in the doctor-patient relationship, the practice of addressing spiritual issues, and perceived facilitators and barriers to discussing spiritual issues. Interviews were conducted by one of the authors (either A.D.B. or D.H.) or by a research assistant trained in qualitative investigation techniques. Interviews averaged 45 minutes in duration.

To guard against bias in advocating a particular stance toward spiritual assessment, we stressed to respondents that we wanted their honest observations and confirmed their statements throughout the interview. Before analyzing the data, we noted our preconceptions toward spiritual assessment. We consciously sought to avoid these biases while reviewing the data.¹⁶ To further reduce the likelihood of bias, we selected a research team whose members represented multiple academic disciplines and religious backgrounds.

Qualitative research aims to uncover new information and perspectives rather than to draw definitive conclusions from a representative study sample.¹⁷ Study participants were deliberately selected¹⁸ to represent a range of demographic factors (sex, age, religious background), practice types (academic or community practice; urban and rural), and practice regarding physicians’ role in addressing patients’ spiritual issues.

All study participants were board-certified family physicians in Missouri. Three participants were white women; 10 were white men. They ranged in age from 37 to 63 years. Three were in full-time community practice; all others were medical school or residency faculty. All but 1 faculty member reported previous community practice experience. Two participants practice in rural locations; 2 in community health centers; 1 in a metropolitan community practice; 4 in metropolitan community-based residency clinics; and 4 in a metropolitan university-based residency clinic. Subjects’ religious affiliations were Jewish (1), Christian (6), “Unitarian Universalist with Muslim leanings” (1), “Unitarian Universalist with Buddhist leanings” (1), “Unitarian” (2), “none” (1), and agnostic (1).

Interviews took place in participants’ offices. We informed them of the use of audiotapes during the telephone recruitment and obtained verbal consent before audiotaping. An Institutional Review Board approved our study.

Study staff transcribed the interviews verbatim. Investigators verified interview content through comparison with interviewers’ notes and entered the text into Ethnograph,¹⁹ a computer database program designed to organize textual material. Investigators used an iterative process to make an initial template for organizing and coding data.²⁰ Our multiple readings of interviews led to further code revisions until consensus was reached regarding salient issues or themes.^21,22 We solicited respondents’ views of the validity of the final codes and themes and of the accuracy of illustrative quotations.

Results

Six respondents reported regularly addressing spiritual issues with patients. One respondent reported an intermediate level of involvement; 6 reported that they do not regularly address spiritual issues. One physician was opposed to physicians’ addressing spiritual issues with patients.

The themes that emerged from the coded interviews were associated with 5 issues: (1) the appropriate role for physicians in addressing spiritual concerns; (2) situations in which physicians focus on spiritual issues (the nature and setting of these discussions); (3) how physicians address spiritual issues; (4) barriers to addressing spiritual issues; and (5) facilitators of spiritual assessment.

Physician’s role

Physicians who regularly discussed spirituality believed that the scientific evidence linking spirituality and positive health outcomes justified their actions. One study participant stated, “Every physician ought to be dealing with [patients’] spiritual issues. [For example,] how can you justify not talking about spirituality to a patient with depression when you can prove scientifically that strengthening faith commitment helps them? It really comes down to a quality of care issue.”

Some respondents believed that the primacy of spirituality in life provided a justification for addressing spiritual issues with patients. As one stated, “These values . . . get at the core of who you are. I would hope that I would be respectful and supportive” [whether or not I was a physician].

The respondents universally viewed themselves as supportive resources for patients through listening, validating spiritual beliefs, and remaining with patients during times of need. One expressed that healing occurs as physicians and patients connect as people, stating, “I don’t have to be a spiritual master. I can be a human being, trying to connect with another human being. That is a healing experience.”

Although several participants seldom addressed spiritual matters, only one strongly opposed the initiation of such discussions, out of concern about role definition and invasion of patients’ privacy. This participant felt that spiritual matters were “no more in the physician’s domain than questions regarding patients’ finances or their most evil thoughts.”

Nature and setting of discussions

Respondents reported specific patient illnesses and stressors that are likely to prompt spiritual discussions. These included terminal illness; chronic illness; specific conditions, such as heart disease, cancer, or miscarriage; depression, anxiety, or other psychiatric illness; pregnancy; and life stressors, including traumatic illness in the family. Other patient situations associated with spiritual discussions included the presence of symptoms without an explanation (eg, pain, insomnia, anorexia), loss of a bodily function, role change within the family, or an illness that erodes one’s self-concept.

Physician respondents also reported factors that often prompt them to ask spiritual questions. These included intensive care unit admission, new diagnosis of terminal illness, treatment failures, patients’ dissatisfaction with progress of treatment, and discussion of advanced care directives. The respondents who regularly address spiritual issues use screening questions that they tend to ask in response to a patient’s cues or crisis (Table 1).

Some respondents asserted that patients’ spiritual questions arise from their unique reactions to life stress and illness. One physician stated that patients’ questions have “more to do with their view of their illness than what the illness really is.” Spiritual questions commonly asked by patients covered a wide range of spiritual themes (Table 1).

TABLE 1
SELECTED SPIRITUAL QUESTIONS OF PATIENTS AND PHYSICIANS

Manner of addressing spiritual health issues

The physicians in our study believed that in most circumstances, patients should initiate spiritual discussions. One said, “It’s one of those areas where you need a small amount of the patient’s permission to get started and a lot more of the patient’s permission to finish.”

Those who regularly address spiritual issues reported using a variety of techniques and approaches (Table 2). These physicians allow for an inclusive definition of spirituality; they try to normalize spiritual discussions and to integrate spiritual discussions into the ongoing doctor–patient relationship. One said that “bringing [spirituality] to the table” along with other potentially sensitive issues helps patients know “what you’re interested in and gives them the option of deciding to pursue it or not.”

The physicians who address spiritual issues follow principles of spiritual assessment (Table 2). All respondents affirmed that spiritual discussions should be approached with sensitivity and integrity to avoid imposing their own belief systems on their patients. One said, “I can’t even describe how negative it [would be] for me to impose my spiritual beliefs on [my] patients.” Another respondent agreed, but also described a tension between faith-based and profession-based thoughts: “[Discussing one’s faith with a patient risks being] an abuse of power; yet if a patient dies tonight and I haven’t shared the Good News that I have . . . I’m neglecting something that’s very important. . . . How do we do this . . . with both gentleness toward the patient and reverence toward God?”

Respondents expressed divergent viewpoints concerning routine spiritual history taking. Although some considered this to be an essential skill, those who seldom addressed spiritual issues found it less pressing and more time consuming than medical concerns. None reported the routine use of currently available spiritual assessment tools. A respondent opposed to initiating spiritual discussions noted a Judeo-Christian bias in these tools, calling their use “cultural imperialism.”

TABLE 2
PHYSICIANS’ APPROACHES TO ADDRESSING SPIRITUAL ISSUES

Barriers to spiritual assessment

Our respondents noted significant barriers, including physician barriers, mutual physician–patient barriers, physician-perceived patient barriers, and situational barriers (Table 3). An example of a physician–patient barrier is the mutual feeling that neither wants to raise issues of spirituality for fear of alienating or causing discomfort in the other.

TABLE 3
SELECTED BARRIERS TO SPIRITUAL DISCUSSIONS AND FACILITATORS OF THEM

Facilitators of spiritual discussions

Respondents noted that characteristics facilitating patients’ discussions of sexuality and other sensitive issues also facilitate conversations about spirituality. These characteristics include communicating a willingness to engage in (and having the time for) such discussions and assuring patients that spiritual confidences will be received in a nonjudgmental fashion.

Physicians who are more spiritually inclined may be more likely to address spiritual issues with patients. As one respondent stated, “When I have conversations about spiritual issues, it’s [sic] usually been at my initiation . . . because I’m more concerned about religious sorts of things than many physicians.”

A final theme expressed by respondents is that physicians who model a life characterized by balance and spiritual maturity can facilitate patients’ spiritual growth. One stated, “My patients perceive something about my balance and spiritual strength that makes them believe they can do anything. It allows me to move to the next level with them . . . [by showing them how to foster] that strength in themselves with the help of family, community, and God.” Other facilitators are listed in Table 3.

Discussion

The relationship between religiosity and positive health outcomes does much to justify spiritual assessment.^1-3 Other justifications include enhanced coping in chronic illness states,²³ providing patients with hope in illness-coping and recovery;^24,25 the possibility that neglect of spiritual needs may drive patients away from medical treatment,²⁴ and evidence that some patients desire physicians to raise spiritual issues.^6,25,26

We sought to explore the context of spiritual assessment rather than to further justify such assessments. The context of spiritual assessment refers to the philosophical question of whether physicians should address spiritual questions and to practical questions of how spiritual matters arise, how physicians approach them, and what barriers and facilitators they perceive with regard to discussing spirituality. Our study adds to knowledge about this context in several important ways.

We found variance of opinion concerning the physician’s role in spiritual assessment. Respondents reporting infrequent spiritual assessment expressed the view that spiritual issues have lower priority than other medical concerns. Yet those who regularly address spiritual issues justified this with scientific evidence associating spirituality and health. They also proposed a justification not found in previous studies: that spirituality is central to life and therefore important for its own sake rather than simply as a means to a medical end. These findings support and augment previously cited justifications for physicians assisting patients with spiritual health issues.^1-3,6,24-26

Our study results add to the list of categories that prompt discussions of spiritual issues. Respondents affirmed a role for physicians in discussing end-of-life issues and advanced care directives, as in previous studies.^27-29 In addition, they observed that patients’ spiritual questions arise from their unique responses to chronic illness, terminal illness, and life stressors. They identified 2 new categories prompting spiritual discussions: unexplained symptoms and treatment failure.

All respondents affirmed a role for physicians in supporting patients who initiate spiritual discussions. As in a previous study,¹⁴ they viewed themselves as facilitators and encouragers of patients’ spiritual values and as resources rather than as spiritual counselors. The most reticent physicians believed in responding to patients’ questions rather than initiating discussions, an approach that may fail to identify spiritual issues. All respondents supported a patient-centered approach to spiritual assessment in which physicians act with integrity and take care not to abuse their position.

Many physicians saw value in spiritual history taking, though none reported routine use of spiritual assessment tools. The potential Judeo-Christian bias in assessment questions noted by one respondent highlights the need to use culturally sensitive, generic assessment tools³⁰ and to work toward further development of such tools.

We identified new barriers to spiritual assessment, including a physician’s upbringing and culture, lack of spiritual inclination or awareness, resistance to exposing personal beliefs, and belief that spiritual discussions will not influence patients’ illnesses or lives. Respondents also postulated patient barriers, including fears that their physician might judge them for their spiritual views or consider their raising spiritual questions inappropriate.

We identified facilitators of spiritual discussions, such as communicating a willingness to have these discussions. One respondent noted that physicians whose lives are characterized by spiritual maturity might serve as agents of patients’ spiritual growth, consistent with a previous study’s themes of caregiver spirituality and physician vocation and mission.¹⁴

Limitations

Because qualitative research aims to uncover new perspectives rather than to make generalizable assessments, our findings may not apply to all physicians or to all family physicians. Although our respondents did not represent all major world religions, ethnic groups, and cultures, they did offer a diversity of spiritual and religious perspectives. Finally, our study gives only physicians’ perspectives. We are currently studying patients’ perspectives of situations that elicit spiritual questions and of potential barriers to spiritual assessment. We will use themes from our patient and physician qualitative studies to frame questions for a national patient questionnaire regarding physicians’ spiritual assessment.

Conclusions

Physicians differ in their comfort and practice of addressing spiritual issues with patients, but affirm a role for themselves in responding to patients’ spiritual concerns. Perceived barriers, physicians’ role definition, familiarity with factors likely to prompt spiritual questions, and the recognition of principles guiding spiritual discussions form the context for family physicians’ discussions of spiritual issues with patients. This context is important to consider when training medical students and residents in spiritual assessment. Careful attention to this context will also enhance the practicing physician’s skill in providing patient-centered assistance with spiritual health concerns.

Acknowledgments

The authors wish to acknowledge Arej Sawani, who assisted in data collection; Sheri Price, who assisted in manuscript preparation; and Richard Ellis, MD, MPH, Daniel Vinson, MD, MSPH, Steven Zweig, MD, MSPH, and Dale Smith, who reviewed the manuscript and offered editorial suggestions.

BACKGROUND: Acute treatments for cluster headaches include oxygen, ergotamine derivatives, and intranasal or subcutaneous sumatriptan. Although up to 95% of acute cluster headache patients treated with subcutaneous sumatriptan experience pain relief within 15 minutes,¹ the route of administration and restrictions on recommended daily dosage may limit patient use of this therapy. Oxygen is effective as abortive therapy but is frequently unavailable in settings where acute cluster headaches are experienced. Rectal and oral ergotamine derivatives have poor bioavailability, and all ergot alkaloids have a high incidence of adverse effects. Oral zolmitriptan is efficacious in the acute treatment of migraine headache. However, no previous studies have evaluated the efficacy of oral triptans in the treatment of cluster headaches.

POPULATION STUDIED: The authors of this study included patients aged 18 to 65 years who were recruited from multiple specialty referral centers in Canada, the United Kingdom, and Sweden. All subjects had an established diagnosis of chronic or episodic cluster headache, described as headaches typically lasting 45 minutes or longer that were distinguishable from other types of episodic headaches, and had tolerated previous treatment with a 5-hydroxytryptamine (5-HT) agonist, such as sumatriptan or ergotamine. The study excluded patients with a history of basilar, ophthalmoplegic, or hemiplegic migraine, and those with risk factors contraindicating the use of 5-HT agonists.

STUDY DESIGN AND VALIDITY: This randomized double-blinded placebo-controlled crossover study compared 5-mg and 10-mg doses of zolmitriptan with placebo for the acute treatment of cluster headaches. Headache intensity was rated on a diary card with a 5-point severity scale (no, mild, moderate, severe, or very severe pain); only headaches of moderate to very severe intensity were treated. Subjects were required to take the study medication within 10 minutes of headache onset, were not permitted to take escape medications, such as oxygen or analgesics, within 30 minutes of taking study medications, and were not permitted to institute prophylactic treatment during the study period. Subjects whose cluster headache period ended before treatment or who had fewer than 3 headaches before the end of the study period were excluded from the analysis. Those who failed to comply with the strict requirements for medication use were noted, but were still included in the intention-to-treat analysis. This is a well-designed study, with no major threats to validity. Patients were selected from referral centers and thus may differ from cluster headache sufferers in a primary care clinic population.

OUTCOMES MEASURED: The primary outcome was headache improvement at 30 minutes, defined as a reduction in headache intensity of 2 or more points on the 5-point scale. Secondary treatment outcomes included the proportion of subjects experiencing any headache relief at 15 and 30 minutes, experiencing headache relief at any time, using escape medication 30 to 180 minutes after treatment, having mild or no pain 30 minutes after treatment, and obtaining relief of associated symptoms. Subjects in each study arm were also asked to indicate their preferred treatment.

RESULTS: Different treatment responses were found for episodic and chronic cluster headache subgroups (the latter patients had attacks for more than a year without remission). Chronic cluster headache subjects showed no statistically significant treatment response to zolmitriptan. Compared with placebo, a greater proportion of episodic cluster headache sufferers experienced a 2-point reduction in headache intensity after taking 10 mg of zolmitriptan (47% vs 29%). Six patients would need to be treated with this dose for 1 patient to improve this much (number needed to treat [NNT]=6). Use of 10 mg zolmitriptan was also associated with statistically significant improvement in all of the secondary outcomes. Patients treated with 5 mg zolmitriptan had improvement in only 3 secondary outcomes: headache relief at any time (NNT=6), lower likelihood of escape medication use (NNT=5), and mild or no pain at 30 minutes (NNT=7). Zolmitriptan was associated with a significantly greater incidence of medication-related adverse effects (number needed to harm=5 for the 10-mg dose). The most frequently described adverse effects were paresthesia, heaviness, asthenia, nausea, dizziness, and (nonchest) tightness. No medication-related events led to withdrawal from the study. Forty-five percent of subjects preferred the 10-mg dose compared with 29% who preferred the 5-mg dose, and 26% the placebo.

BACKGROUND: Acute treatments for cluster headaches include oxygen, ergotamine derivatives, and intranasal or subcutaneous sumatriptan. Although up to 95% of acute cluster headache patients treated with subcutaneous sumatriptan experience pain relief within 15 minutes,¹ the route of administration and restrictions on recommended daily dosage may limit patient use of this therapy. Oxygen is effective as abortive therapy but is frequently unavailable in settings where acute cluster headaches are experienced. Rectal and oral ergotamine derivatives have poor bioavailability, and all ergot alkaloids have a high incidence of adverse effects. Oral zolmitriptan is efficacious in the acute treatment of migraine headache. However, no previous studies have evaluated the efficacy of oral triptans in the treatment of cluster headaches.

POPULATION STUDIED: The authors of this study included patients aged 18 to 65 years who were recruited from multiple specialty referral centers in Canada, the United Kingdom, and Sweden. All subjects had an established diagnosis of chronic or episodic cluster headache, described as headaches typically lasting 45 minutes or longer that were distinguishable from other types of episodic headaches, and had tolerated previous treatment with a 5-hydroxytryptamine (5-HT) agonist, such as sumatriptan or ergotamine. The study excluded patients with a history of basilar, ophthalmoplegic, or hemiplegic migraine, and those with risk factors contraindicating the use of 5-HT agonists.

STUDY DESIGN AND VALIDITY: This randomized double-blinded placebo-controlled crossover study compared 5-mg and 10-mg doses of zolmitriptan with placebo for the acute treatment of cluster headaches. Headache intensity was rated on a diary card with a 5-point severity scale (no, mild, moderate, severe, or very severe pain); only headaches of moderate to very severe intensity were treated. Subjects were required to take the study medication within 10 minutes of headache onset, were not permitted to take escape medications, such as oxygen or analgesics, within 30 minutes of taking study medications, and were not permitted to institute prophylactic treatment during the study period. Subjects whose cluster headache period ended before treatment or who had fewer than 3 headaches before the end of the study period were excluded from the analysis. Those who failed to comply with the strict requirements for medication use were noted, but were still included in the intention-to-treat analysis. This is a well-designed study, with no major threats to validity. Patients were selected from referral centers and thus may differ from cluster headache sufferers in a primary care clinic population.

OUTCOMES MEASURED: The primary outcome was headache improvement at 30 minutes, defined as a reduction in headache intensity of 2 or more points on the 5-point scale. Secondary treatment outcomes included the proportion of subjects experiencing any headache relief at 15 and 30 minutes, experiencing headache relief at any time, using escape medication 30 to 180 minutes after treatment, having mild or no pain 30 minutes after treatment, and obtaining relief of associated symptoms. Subjects in each study arm were also asked to indicate their preferred treatment.

RESULTS: Different treatment responses were found for episodic and chronic cluster headache subgroups (the latter patients had attacks for more than a year without remission). Chronic cluster headache subjects showed no statistically significant treatment response to zolmitriptan. Compared with placebo, a greater proportion of episodic cluster headache sufferers experienced a 2-point reduction in headache intensity after taking 10 mg of zolmitriptan (47% vs 29%). Six patients would need to be treated with this dose for 1 patient to improve this much (number needed to treat [NNT]=6). Use of 10 mg zolmitriptan was also associated with statistically significant improvement in all of the secondary outcomes. Patients treated with 5 mg zolmitriptan had improvement in only 3 secondary outcomes: headache relief at any time (NNT=6), lower likelihood of escape medication use (NNT=5), and mild or no pain at 30 minutes (NNT=7). Zolmitriptan was associated with a significantly greater incidence of medication-related adverse effects (number needed to harm=5 for the 10-mg dose). The most frequently described adverse effects were paresthesia, heaviness, asthenia, nausea, dizziness, and (nonchest) tightness. No medication-related events led to withdrawal from the study. Forty-five percent of subjects preferred the 10-mg dose compared with 29% who preferred the 5-mg dose, and 26% the placebo.

BACKGROUND: Acute treatments for cluster headaches include oxygen, ergotamine derivatives, and intranasal or subcutaneous sumatriptan. Although up to 95% of acute cluster headache patients treated with subcutaneous sumatriptan experience pain relief within 15 minutes,¹ the route of administration and restrictions on recommended daily dosage may limit patient use of this therapy. Oxygen is effective as abortive therapy but is frequently unavailable in settings where acute cluster headaches are experienced. Rectal and oral ergotamine derivatives have poor bioavailability, and all ergot alkaloids have a high incidence of adverse effects. Oral zolmitriptan is efficacious in the acute treatment of migraine headache. However, no previous studies have evaluated the efficacy of oral triptans in the treatment of cluster headaches.

POPULATION STUDIED: The authors of this study included patients aged 18 to 65 years who were recruited from multiple specialty referral centers in Canada, the United Kingdom, and Sweden. All subjects had an established diagnosis of chronic or episodic cluster headache, described as headaches typically lasting 45 minutes or longer that were distinguishable from other types of episodic headaches, and had tolerated previous treatment with a 5-hydroxytryptamine (5-HT) agonist, such as sumatriptan or ergotamine. The study excluded patients with a history of basilar, ophthalmoplegic, or hemiplegic migraine, and those with risk factors contraindicating the use of 5-HT agonists.

STUDY DESIGN AND VALIDITY: This randomized double-blinded placebo-controlled crossover study compared 5-mg and 10-mg doses of zolmitriptan with placebo for the acute treatment of cluster headaches. Headache intensity was rated on a diary card with a 5-point severity scale (no, mild, moderate, severe, or very severe pain); only headaches of moderate to very severe intensity were treated. Subjects were required to take the study medication within 10 minutes of headache onset, were not permitted to take escape medications, such as oxygen or analgesics, within 30 minutes of taking study medications, and were not permitted to institute prophylactic treatment during the study period. Subjects whose cluster headache period ended before treatment or who had fewer than 3 headaches before the end of the study period were excluded from the analysis. Those who failed to comply with the strict requirements for medication use were noted, but were still included in the intention-to-treat analysis. This is a well-designed study, with no major threats to validity. Patients were selected from referral centers and thus may differ from cluster headache sufferers in a primary care clinic population.

OUTCOMES MEASURED: The primary outcome was headache improvement at 30 minutes, defined as a reduction in headache intensity of 2 or more points on the 5-point scale. Secondary treatment outcomes included the proportion of subjects experiencing any headache relief at 15 and 30 minutes, experiencing headache relief at any time, using escape medication 30 to 180 minutes after treatment, having mild or no pain 30 minutes after treatment, and obtaining relief of associated symptoms. Subjects in each study arm were also asked to indicate their preferred treatment.

RESULTS: Different treatment responses were found for episodic and chronic cluster headache subgroups (the latter patients had attacks for more than a year without remission). Chronic cluster headache subjects showed no statistically significant treatment response to zolmitriptan. Compared with placebo, a greater proportion of episodic cluster headache sufferers experienced a 2-point reduction in headache intensity after taking 10 mg of zolmitriptan (47% vs 29%). Six patients would need to be treated with this dose for 1 patient to improve this much (number needed to treat [NNT]=6). Use of 10 mg zolmitriptan was also associated with statistically significant improvement in all of the secondary outcomes. Patients treated with 5 mg zolmitriptan had improvement in only 3 secondary outcomes: headache relief at any time (NNT=6), lower likelihood of escape medication use (NNT=5), and mild or no pain at 30 minutes (NNT=7). Zolmitriptan was associated with a significantly greater incidence of medication-related adverse effects (number needed to harm=5 for the 10-mg dose). The most frequently described adverse effects were paresthesia, heaviness, asthenia, nausea, dizziness, and (nonchest) tightness. No medication-related events led to withdrawal from the study. Forty-five percent of subjects preferred the 10-mg dose compared with 29% who preferred the 5-mg dose, and 26% the placebo.

BACKGROUND: An estimated 175,000 Americans have a pulmonary embolism (PE) each year. Pulmonary angiography is the accepted gold standard for diagnosing PE, but it is invasive, expensive, and causes cardiopulmonary complications in 3% to 4% of patients. A ventilation-perfusion (V/Q) scan is less invasive, but also less accurate. Used in combination with clinical assessment, it fails to find 20% of PEs.¹ Recent studies evaluating the use of spiral computed tomography (CT) have reported favorable results in diagnosing PE. However, the role of CT for this use is not yet fully defined.

POPULATION STUDIED: In this systematic review, neither specific patient characteristics nor exclusion criteria were mentioned. Enrollment criteria were described as inconsistent.

STUDY DESIGN AND VALIDITY: The authors conducted a systematic review of the literature evaluating the use of spiral CT in diagnosing PE. They searched MEDLINE and Current Contents through July 1998 and reviewed pertinent references. Eleven articles met their preset inclusion criteria. The articles were rated by using a set of 11 basic methodologic standards for addressing diagnostic test research. None of the 11 studies met all of the criteria; only 5 studies met 5 or more criteria. All studies compared CT with either pulmonary angiography or another reference standard (high-probability V/Q scan plus high clinical suspicion) to confirm the diagnosis of PE. The studies were not methodologically similar enough to perform a meta-analysis.

OUTCOMES MEASURED: The primary outcome was the presence of a PE.

RESULTS: Compared with the gold standard of pulmonary angiography, the sensitivity of spiral CT ranged from 64% to 93%. If a PE is present, the probability of a positive CT scan is 64% to 93%. That means up to one third of PEs could be missed. The reported specificity ranged from 89% to 100%, which corresponds to a false-positive rate of 0% to 11%. These results are similar to those of another recent systematic review in which the authors reported a sensitivity range of 53% to 100% and a specificity range of 81% to 100%.¹ Nine of the studies differentiated between large central and small subsegmental vessel embolism. When stratified by site, the sensitivity for spiral CT was much higher for central vessel PE (83% to 100%) than for subsegmental vessel PE (29%).

BACKGROUND: An estimated 175,000 Americans have a pulmonary embolism (PE) each year. Pulmonary angiography is the accepted gold standard for diagnosing PE, but it is invasive, expensive, and causes cardiopulmonary complications in 3% to 4% of patients. A ventilation-perfusion (V/Q) scan is less invasive, but also less accurate. Used in combination with clinical assessment, it fails to find 20% of PEs.¹ Recent studies evaluating the use of spiral computed tomography (CT) have reported favorable results in diagnosing PE. However, the role of CT for this use is not yet fully defined.

POPULATION STUDIED: In this systematic review, neither specific patient characteristics nor exclusion criteria were mentioned. Enrollment criteria were described as inconsistent.

STUDY DESIGN AND VALIDITY: The authors conducted a systematic review of the literature evaluating the use of spiral CT in diagnosing PE. They searched MEDLINE and Current Contents through July 1998 and reviewed pertinent references. Eleven articles met their preset inclusion criteria. The articles were rated by using a set of 11 basic methodologic standards for addressing diagnostic test research. None of the 11 studies met all of the criteria; only 5 studies met 5 or more criteria. All studies compared CT with either pulmonary angiography or another reference standard (high-probability V/Q scan plus high clinical suspicion) to confirm the diagnosis of PE. The studies were not methodologically similar enough to perform a meta-analysis.

OUTCOMES MEASURED: The primary outcome was the presence of a PE.

RESULTS: Compared with the gold standard of pulmonary angiography, the sensitivity of spiral CT ranged from 64% to 93%. If a PE is present, the probability of a positive CT scan is 64% to 93%. That means up to one third of PEs could be missed. The reported specificity ranged from 89% to 100%, which corresponds to a false-positive rate of 0% to 11%. These results are similar to those of another recent systematic review in which the authors reported a sensitivity range of 53% to 100% and a specificity range of 81% to 100%.¹ Nine of the studies differentiated between large central and small subsegmental vessel embolism. When stratified by site, the sensitivity for spiral CT was much higher for central vessel PE (83% to 100%) than for subsegmental vessel PE (29%).

BACKGROUND: An estimated 175,000 Americans have a pulmonary embolism (PE) each year. Pulmonary angiography is the accepted gold standard for diagnosing PE, but it is invasive, expensive, and causes cardiopulmonary complications in 3% to 4% of patients. A ventilation-perfusion (V/Q) scan is less invasive, but also less accurate. Used in combination with clinical assessment, it fails to find 20% of PEs.¹ Recent studies evaluating the use of spiral computed tomography (CT) have reported favorable results in diagnosing PE. However, the role of CT for this use is not yet fully defined.

POPULATION STUDIED: In this systematic review, neither specific patient characteristics nor exclusion criteria were mentioned. Enrollment criteria were described as inconsistent.

STUDY DESIGN AND VALIDITY: The authors conducted a systematic review of the literature evaluating the use of spiral CT in diagnosing PE. They searched MEDLINE and Current Contents through July 1998 and reviewed pertinent references. Eleven articles met their preset inclusion criteria. The articles were rated by using a set of 11 basic methodologic standards for addressing diagnostic test research. None of the 11 studies met all of the criteria; only 5 studies met 5 or more criteria. All studies compared CT with either pulmonary angiography or another reference standard (high-probability V/Q scan plus high clinical suspicion) to confirm the diagnosis of PE. The studies were not methodologically similar enough to perform a meta-analysis.

OUTCOMES MEASURED: The primary outcome was the presence of a PE.

RESULTS: Compared with the gold standard of pulmonary angiography, the sensitivity of spiral CT ranged from 64% to 93%. If a PE is present, the probability of a positive CT scan is 64% to 93%. That means up to one third of PEs could be missed. The reported specificity ranged from 89% to 100%, which corresponds to a false-positive rate of 0% to 11%. These results are similar to those of another recent systematic review in which the authors reported a sensitivity range of 53% to 100% and a specificity range of 81% to 100%.¹ Nine of the studies differentiated between large central and small subsegmental vessel embolism. When stratified by site, the sensitivity for spiral CT was much higher for central vessel PE (83% to 100%) than for subsegmental vessel PE (29%).