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Prevalence and Patterns of Physician Referral to Clergy and Pastoral Care Providers
Timothy P. Daaleman, DO;
Bruce Frey, PhD
Arch Fam Med. 1998;7:548-553.
ABSTRACT
Background There is a heightened interest in spiritual and religious interventions in clinical settings, an area marked by unease and lack of training by physicians. A potential resource for generalists is specialty consultation and referral services, although little is known about the prevalence and patterns of involvement of clergy or pastoral professionals in patient care.
Objectives To identify the prevalence and patterns of physician-directed patient referral to or recommended consultation with clergy or pastoral care providers and to describe attitudinal and demographic variables that can predict referring and nonreferring physicians.
Design A mailed anonymous survey.
Setting Family physicians in the United States.
Participants Active members of the American Academy of Family Physicians whose self-designated professional activity is direct patient care. Of the 756 randomly selected physicians for participation in the study, 438 (57.9%) responded.
Main Outcome Measures Physician reporting on their attitudes and referral behaviors, including referral frequency, and conditions or reasons for referral or nonreferral to clergy and pastoral care providers.
Results More than 80% of the physicians reported that they refer or recommend their patients to clergy and pastoral care providers; more than 30% stated that they refer more than 10 times a year. Most physicians (75.5%) chose conditions associated with end-of-life care (ie, bereavement, terminal illness) as reasons for referral. Marital and family counseling were cited by 72.8% of physicians; however, other psychosocial issues, such as depression and mood disorders (38.7%) and substance abuse (19.0%), were less prevalent. Physicians who reported a greater degree of religiosity had a small increased tendency to refer (r=0.39, P<.05) to these providers. In addition, physicians who were in practice for more than 15 years were more likely to refer to clergy (P<.01).
Conclusions Most family physicians accept clergy and pastoral professionals in the care of their patients. In medical settings, the providers of religious and spiritual interventions have a larger and more expanded role than previously reported.
INTRODUCTION
IN A 1993 landmark national survey that depicted the prevalence, costs, and patterns of unconventional medicine in the United States, 25% of the respondents acknowledged using prayer as a treatment modality.1 From a physician perspective, it is unclear what role spiritual and religious interventions and providers have in clinical encounters. Although 72% of physicians are interested in training in prayer, only 33% believe in it as a legitimate medical practice.2 Despite the opacity of these studies, religion and spirituality continue to be major and consistent factors in the lives of most Americans.3 In health care settings, religious and spiritual beliefs4 wield a substantial influence on patient health beliefs, and some may directly affect clinical outcomes.5
Family physicians are perceived as being unqualified or untrained to discuss spiritual and religious issues with patients,6 which may be reflected through diagnostic or therapeutic uncertainty when addressing these issues. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition7 provides some background and direction for the assessment of religious or spiritual problems.8 Although another potential resource for generalists is specialty consultation and referral services, little is known about the prevalence and patterns of involvement of clergy or pastoral professionals in patient care.
One previous study conducted in Great Britain found that general practitioners perceived an important theoretical role for the involvement of clergy in patient care; however, this role was not matched in practice.9 In a study of family and general practitioners conducted in the United States, fewer than half (45%) of respondents reported a usual pattern of referral to clergy when their geriatric patients were in great distress or near death.10 Although limited by sample size, an additional university medical center–based study of physicians found that 49% of physicians made no referrals to chaplain services.11
The heightened interest in spiritual interventions in clinical settings and the unease and lack of training in this area by physicians highlight the importance of developing an understanding of the interactions between physicians and clergy. Pastoral care providers and clergy may benefit from an awareness of expectations and reasons for receiving consultation from physicians. Physicians in turn may gain a greater insight into their own rationale for involving or not involving clergy in the care of their patients.
To address these issues, we studied family physicians nationwide about their experiences with referring patients to clergy and pastoral care providers. We used the terms pastoral care and clergy and the terms religion and spirituality interchangeably for the purposes of the study, although there are differences in how each is defined.12 In addition, we did not distinguish between consultation and referral, despite the spectrum of physician understanding of these terms.13 Our objectives were to identify the prevalence and patterns of physician-directed patient referral or recommended consultation to clergy or pastoral care providers and to describe attitudinal and demographic variables that can predict referring and nonreferring physicians.
METHODS
STUDY POPULATION
The study was reviewed and approved by the Human Subjects Committee of the University of Kansas Medical Center, Kansas City, before its initiation. Study subjects were selected from the membership list of the American Academy of Family Physicians (AAFP), Kansas City, Mo. Physicians who were active members of the AAFP (n=44,194) and whose self-designated professional activity was direct patient care were eligible for the study. The requirements for active AAFP membership include family practice residency training, unrestricted licensure, specified continuing medical education, and engagement in the practice, teaching, or administration of family practice or in the practice of emergency medicine.14 By using these criteria, a randomized sample of 756 physicians was obtained from the AAFP.
METHODS AND SURVEY CONTENT
A self-administered, anonymous survey was mailed to all eligible physicians during October 1997. Enclosed with each survey was a preaddressed, stamped, return envelope; a cover letter from the senior investigator explaining the nature of the survey and our affiliation with the University of Kansas Medical Center; and an invitation to participate. Approximately 2 weeks after the initial mailing, all subjects were sent a postcard reminder. Data collection was completed in December 1997.
The survey consisted of 11 fixed-response items, 5 questions that gathered demographic information, and 1 open-ended question that asked for comments. The survey was prefaced with the instruction, "Please circle the answer that most accurately describes your feelings and choices." Four survey questions, which were included to measure under what circumstances, if any, physicians refer or recommend patients to pastoral care providers and clergy, were taken from a previous survey that also studied these issues.9 Two 5-point Likert-scale questions were used to assess physicians' attitudes toward the role of clergy in patient care. One item addressed perceived importance to patients of religion and spirituality, since this has been found to be a significant variable for determining which physicians refer or recommend geriatric patients to clergy.10 The other attitudinal item focused on the contribution of clergy and pastoral care providers to patient care and was designed specifically for this study.
Five questions were included to measure physician religious beliefs and practices. Items were derived from questions developed by the National Opinion Research Center, Chicago, Ill15 and the Index of Core Spiritual Experiences scale.16 The Index of Core Spiritual Experiences scale was developed from the National Opinion Research Center, which is the oldest national survey research facility that is nonprofit and university-affiliated. The 5 questions asked about the frequency of private religious or spiritual practices and the frequency of religious service attendance and assessed subjective or intrinsic religiosity.
The final section of the survey requested data on physician characteristics, such as sex, age, length of practice, primary practice site, and religious denomination. Questions were pretested and revised after pilot testing with a group of eligible physicians at our institution. Physicians from the pilot group were excluded from the sample. Fewer than 5 minutes were needed to complete the survey.
DATA ANALYSIS
After recoding and reverse scoring the items as necessary, descriptive statistics for responses to the clergy referral questions and physician characteristics were calculated. For questions in which respondents could choose more than 1 option, each option was treated as a separate item. Returned surveys that were only partially completed by subjects were included in the data set, and individual items not completed were excluded from analysis.
To compare physicians who refer to clergy with nonreferring physicians, responses to the 6 clergy referral items were summed to create a single score that represented tendency to refer to clergy. The Cronbach  was calculated as a measure of the internal reliability of the resulting measure. Analyses of variance were conducted for age, length of practice, primary practice site, and self-reported religious denomination to compare the tendency to refer to clergy across different demographic variables. A t test was performed using the sex data set. The dependent variable in each of these tests was the total score on the clergy referral scale. A 2-sided P value of less than .05 was considered statistically significant. For any significant result in the analysis of variance, a post hoc means comparison was conducted. All analyses were performed by using the Statistical Package for the Social Sciences, version 7.5 (SPSS, Chicago, Ill).
RESULTS
RESPONSE RATE
Of the 756 surveys that were mailed, 1 was returned as undeliverable. The response rate was 57.9% (438 of 756 physicians); 386 completed surveys were received after the first mailing. The AAFP provided demographic information about the membership, and Table 1 gives the comparison of the characteristics of the study physicians with those of the active membership of the AAFP. All proportions were statistically different from the AAFP population, but only the proportion of respondents at an urban or rural primary practice site was considered meaningfully different. Because of unequal sample sizes and proportions, we did not perform a statistical analysis.
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Table 1. Characteristics of Study Physicians and AAFP-Member Physicians*
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PREVALENCE AND PATTERNS OF REFERRAL TO CLERGY
More than 80% of physicians reported that they refer or recommend their patients to clergy and pastoral care providers. Table 2 lists the frequency of physician-directed referral to clergy during a year. Only 12.6% of the respondents reported that they never refer patients to clergy, while 30.1% reported that they refer more than 10 times during a year.
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Table 2. Physician-Reported Referral to Clergy*
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Table 3 gives the indications or reasons for clergy referral. Approximately 75% of physicians chose conditions and diagnoses associated with end-of-life care (ie, terminal illness, bereavement) as reasons for referral. Marital and family counseling were cited by 72.8% of physicians; however, other psychosocial issues, such as depression and mood disorders (38.7%) and substance abuse (19.0%), were less prevalent. Table 4 lists reasons that physicians do not refer to clergy. The belief that "patients will self-refer anyway," was noted by 13.3% of physicians as the major reason for nonreferral.
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Table 3. Physician-Reported Indications for Clergy Referral (n=437)*
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Table 4. Physician-Reported Reasons for Nonreferral to Clergy (n=427)*
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CLERGY REFERRAL SCALE
One response to the question asking reasons for nonreferral did not correlate well with other clergy referral items. The low percentage of respondents (38.2%) who chose the response, "I do refer or recommend to clergy," suggested that many physicians did not respond at all to this item, even if they do actually refer in practice. This item was not included in the referral to clergy scale. In addition, after an initial internal consistency analysis, we found that the overall reliability of the scale could be improved by removing the item that represented the "other condition" response option under the question that asked for conditions or diagnoses for referral. These slight revisions resulted in a Cronbach for this scale of .82, indicating adequate reliability. The mean score of this scale was 17.91 (SD, 4.30), with a range of scores from 7 to 25.
RELATION OF TENDENCY TO REFER AND LEVEL OF RELIGIOUS BELIEF
Total scores on the clergy referral scale were correlated with total scores on a scale of religiosity. High religiosity scores indicated strong intrinsic religious belief and frequent practice of private and corporate religious and spiritual behaviors (=.87). The Pearson product moment correlation between the 2 sets of scores was .39 (P=.01), indicating a small to moderate positive correlation.
DIFFERENCES IN TENDENCY TO REFER TO CLERGY
Among the demographic variables we assessed (ie, age, sex, primary practice site, self-reported religious denomination, and length of practice), only the length of practice demonstrated significant differences in tendency to refer to clergy. Physicians in practice from 16 to 25 years scored significantly higher than other physicians within this category (Table 5). However, a post hoc analysis with Bonferroni controls found that this group of physicians did not differ significantly from any of the other 3 categories of length of practice. We then collapsed the 4 length-of-practice groups into 2 groups: those practicing 15 years or less and those practicing 16 years or more. A t test showed a significant difference between these groups, with physicians who were in practice longer having a greater tendency to refer to clergy (Table 5).
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Table 5. Length of Physician Practice and Tendency to Refer to Clergy
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COMMENT
Whether viewed as an alternative practice or as an integrative and complementary adjunct to conventional medical care, the role of spiritual and religious providers of care in clinical practice remains largely unexplored. Our results suggest that these providers may have a larger and more expanded role in clinical care than previously reported. More than 80% of the physicians in the present study referred or recommended consultation with clergy, with most (59.3%) referring more than 4 times a year. When queried in a different fashion, only 12.6% of physicians reported that they never refer to clergy in a given year (Table 2).
The call for research to further understand the consultation and referral process has been placed within the context of 4 domains: (1) describing the pattern of consultation and referral, (2) understanding the components of the consultation and referral decision, (3) describing the costs and outcomes of consultation and referral, and (4) developing better strategies for consultation and referral.13 Our purpose in this study focused on the first of these domains and was 2-fold: (1) to identify the prevalence and patterns of physician-directed patient referral to or recommended consultation with clergy or pastoral care providers and (2) to describe attitudinal and demographic variables that can predict referring and nonreferring physicians.
Jones9 studied British general practitioners and defined 4 groups of clergy referrers: 43% were nonreferrers; 44% were occasional referrers (1-6 cases per year); 9% were regular referrers (7-12 cases per year); and 4% were frequent referrers (more than 13 cases per year). In 2 studies conducted in the United States, Koenig et al10-11 found that fewer than one half of physicians (45% and 49%) reported a usual pattern of clergy referral for their patients or initiated a referral to clergy services. Each of these studies was limited by a nonrandom study population and a sampling method that recruited subjects from a similar geographic area, which may limit the generalizability to other physician populations.
Physicians consult and refer patients for several reasons: for diagnosis, treatment, or both; for patient, relative, or referring physician reassurance; for specific examinations or specialty procedures; and for medicolegal reasons.13 With the exception of marital and family counseling, we preferentially selected patient conditions or diagnoses rather than specific therapeutics as potential indications and reasons for referral, since patients are more likely to have seen a consultant if the referral was for advice on management of a problem, rather than for a specified treatment.17 In our study and the study by Jones,9 end-of-life care was the leading condition cited as a reason for clergy referral. Whether the prevalence of physician-directed clergy referral actually occurs in clinical practice remains unclear, since studies involving end-of-life care are largely silent on this topic.18
Approximately 73% of physicians listed marital and family counseling as a condition for referral to clergy, although fewer than half chose other psychosocial conditions (ie, depression and mood disorders, substance abuse) commonly seen in a primary care practice. This selection by physicians of religious or spiritual providers for family and marriage problems parallels patient-reported preferences. Most patients opt for religious counseling for domestic problems and nonreligious counseling for mental illness and addictive disorders.19
Almost two thirds (64.3%) of physicians in our survey cited religious or spiritual problems as a condition for referral. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition7 lists religious or spiritual problem as a V code (V62.89), or a condition that may be a focus of clinical attention. End-of-life care and family and marital counseling are frequently distressing experiences that can involve an unstable religious or spiritual state. The high response to each of these conditions suggests a recognition of additional and overlapping diagnoses. Perhaps physicians expressed a greater sensitivity to value-laden and culturally laden experiences by acknowledging a referral to clergy. Another explanation is that physicians may have responded to an overt patient request to address their spiritual and religious needs during the clinical encounter.
To identify physicians who refer to clergy from nonreferring physicians, we developed a scale that incorporated physician attitudes and behaviors. The measure was a reliable instrument (= .82), which enabled us to study physician characteristics more accurately. Physician religiosity had a small to moderately positive correlation with a tendency to refer to clergy. This finding is congruent with that of Koenig and colleagues11 who found that physicians with less religiosity referred patients to pastoral care services less often than other physicians. Among the demographic variables, only the length of practice was statistically significant for identifying referring physicians (Table 5), a finding reported in another study on the consultation and referral patterns of family physicians.20 Physicians in practice for 16 years or longer scored higher on our scale of tendency to refer. Age, primary practice site, sex, and self-reported religious denomination were not significant variables.
Our study had several limitations. There is generally no formal documentation of the referral process to clergy and pastoral care providers in clinical practice, in contrast to the documentation of other types of consultation and referral in primary care.13 This drawback, in addition to the absence of claims data, markedly hampers research in this area. Logs maintained by clergy21 remain a source of data, but they are limited to institutionally based physicians and patients. Owing to the lack of these sources of data, it is difficult to validate whether our study measured actual behavior (ie, referral) or an attitude toward referring. The lack of physician economic and administrative incentives or prohibitions tied to clergy referral led us to believe that our findings reflect referral behavior, as well as attitude.
A higher proportion of our study population reported a rural primary practice site than did the general AAFP membership. Rural physicians may not have the same access as their more urban colleagues to social work and mental health professionals in their communities. In such settings, clergy and pastoral care providers may be viewed as the primary available resource in these ancillary fields. Although the higher proportion of rural practitioners could have accounted for the reported referral rates and reasons for referral in our study, the primary practice site was not found to be a significant variable in identifying a tendency to refer.
Good item construction from established measures, pilot testing and scale refinement, and a high coefficient support the reliability and validity of our instrument scales. Although our response rate of 57.9% was modest, it is comparable with other survey studies of clinicians in active clinical practice.22-23 The sample population was family physicians, and the generalizability of these findings to other specialties is unclear.
We found that 80.2% of physicians refer patients to clergy and pastoral care providers, with a majority (59.3%) referring more than 4 times a year. End-of-life care and marital and family counseling were cited as the major conditions for referral. More religious physicians and physicians in practice for 16 years or more tended to refer more than did other physicians. Directions for future research include studying specialty differences and the clinical decision-making process for clergy referral. There is also great promise and usefulness in outcomes-based studies, which can explore the effect of these providers on such areas as patient satisfaction, cost of care, and changes in general health and functional status.
AUTHOR INFORMATION
Accepted for publication July 10, 1998.
Dr Daaleman is a Robert Wood Johnson Generalist Physician Faculty Scholar (Career Development Award).
We thank Cynda A. Johnson, MD, Jasjit S. Ahluwalia, MD, MPH, MS, and Ken Kallail, PhD for their review of the manuscript.
Reprints: Timothy P. Daaleman, DO, Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160-7370 (e-mail: tdaalema{at}kumc.edu).
From the Department of Family Medicine (Dr Daaleman) and the Office of Primary Care (Dr Frey), University of Kansas Medical Center School of Medicine, Kansas City.
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