AMBULATORY PEDIATRICS Volume 2, Number 15Copyright q 2002 by Ambulatory Pediatric Association January-February 2002

Faculty and Resident Attitudes About Spirituality and Religion in theProvision of Pediatric Health Care

Benjamin Siegel, MD; Andrew J. Tenenbaum, BA; Amber Jamanka, MPH;Linda Barnes, PhD, MTS, MA; Carol Hubbard, MD, MPH, PhD; Barry Zuckerman, MD

Objective.—To characterize pediatricians’ attitudes toward spirituality/religion (S/R) in relationship to the practice ofpediatrics.

Methods.—Pediatric faculty (n 5 100) and residents (n 5 65) in an urban academic medical center completed aquestionnaire about their attitudes toward and clinical practices related to S/R. Study variables included the strength ofpersonal S/R orientation, attitudes toward S/R, clinicians’ discussion of S/R with patients and families, self-reported S/R behaviors, the medical conditions that warrant discussion of S/R, and attitudes toward praying with patients if askedto do so.

Results.—Sixty-five percent of pediatricians felt that faith plays a role in healing, and 76% reported feeling com-fortable praying with a patient if asked to do so. Ninety-three percent would ask about S/R when discussing a life-threatening illness, and 96% when discussing death and dying. A strong personal S/R orientation was associated withbeliefs that the pediatrician should discuss S/R with the patient (P , .01); beliefs that faith plays a role in healing (P, .01); and feelings that patients would like to discuss S/R with their pediatrician (P , .01), that the doctor-patientrelationship would be strengthened by discussion of S/R (P , .01), and that physicians should call on an S/R leaderfor an illness or death (P , .01). Personal S/R orientation was not related to whether physicians reported that theydiscuss S/R issues with their patients (P 5 .08). Residents were more likely than faculty to state that it is appropriateto pray with patients if asked to do so (P , .05), and compared with pediatricians who were science majors in college,pediatricians who were nonscience majors in college felt more comfortable praying with patients if asked to do so (P, .01).

Conclusions.—In an urban, inner-city, academic medical center, pediatric residents and faculty have an overall positiveattitude toward the integration of S/R into the practice of pediatrics.

KEY WORDS: complementary and alternative medicine; medicine; pediatrics; religion; spirituality

Ambulatory Pediatrics 2002;2:5 10

Physicians who care for adults acknowledge the im-portance of spirituality and religion (S/R) to healthand health care.1,2 Many health care professionals

believe that discussions between clinicians and patientsabout S/R affect physician medical decision making—thatpatients want to talk with physicians about S/R and thatin some cases, patients would like physicians to pray withthem. Although the nature and mechanism of such rela-tionships have not been clearly defined, some research hassought to explore these issues,1–15 but little research hasexamined pediatricians’ attitudes about S/R. Therefore,our aim was to characterize the attitudes and practices ofpediatric faculty and residents toward discussing S/R con-cerns with their patients and family members. We were

From the Department of Pediatrics, Boston Medical Center, Bos-ton University School of Medicine, Boston, Mass (Drs Siegel,Barnes, and Zuckerman); the University of New England Collegeof Osteopathic Medicine, Biddeford, Me (Mr Tenenbaum); the DataCoordinating Center, Boston University School of Public Health,Boston, Mass (Ms Jamanka); and the Division of Developmentaland Behavioral Pediatrics, Maine Medical Center, Portland, ME (DrHubbard).

Address correspondence to Benjamin Siegel, MD, Department ofPediatrics, Boston Medical Center, Maternity 417, 91 E. ConcordSt, Boston, MA 02118 (e-mail: bsiegel@bu.edu).

Received for publication March 1, 2001; accepted October 10,2001.

also interested in identifying whether there were differ-ences in attitudes and practices related to gender, yearssince graduation from medical school, the practice of pri-mary care versus subspecialty pediatrics, faculty versusresidents, and strength of the pediatrician’s personal S/R.The attitudes and practices that we sought to characterizeincluded the frequency of S/R inquiry with patients andfamilies; the appropriateness of such inquiry in varioushealth care situations; the perceived effects of discussingS/R on health care; the perceived appropriateness of pray-ing with patients if asked to do so; and the overall effectof discussing S/R on the doctor-patient relationship. Basedon other studies,1,16–18 we hypothesized that the degree ofS/R orientation of the pediatrician would influence theway in which the pediatrician would value and state thathe/she would integrate S/R concerns into the care of thepatient and family. We also hypothesized that the strengthof personal S/R beliefs, female gender, college major, timesince graduation from medical school, and primary carepractice/orientation would predict the pediatrician’s open-ness to discussing S/R with patients.

METHODS

All pediatric staff in the Department of Pediatrics ofthe Boston Medical Center and its affiliated NeighborhoodHealth Centers and the residents in the Boston CombinedResidency in Pediatrics (Boston Medical Center and Chil-

AMBULATORY PEDIATRICS6 Siegel et al

dren’s Hospital of Boston) were sent a survey in the fallof 1998. Two reminders were sent to nonresponders.

The survey instrument (available upon request) focusedon physicians’ approaches to S/R issues in patient carereviewed previously. An understanding about S/R in med-icine was based on previous work.14–17,19–22 We used a def-inition of spirituality described previously9 as ‘‘a beliefsystem focusing on intangible elements that impart vitalityand meaning to life’s events.’’ We defined religion as ‘‘theexpression of faith in, and reverence for, a specific con-ception of ultimate reality; this faith and reverence maybe expressed through understandings of sacred stories,symbols, ethics, devotion, prayer, rituals, mystical quests,and/or reasoned inquiry, which are passed down and re-interpreted over time.’’18 These definitions were explicitin the survey. For the purposes of analysis, the definitionsof spirituality and religion were combined into 1 categoryas done by other investigators.15,16,23 The survey questionswere answered on a 6-point anchored Likert scale onwhich points corresponded to always (.90%), frequently(90%–66%), sometimes (65%–36%), occasionally (35%–10%), rarely (,10%), and never (0%). Likert scale datawere combined when the observations in the cells weretoo few for analysis. For the question ‘‘How strongly re-ligious or spiritually oriented do you consider yourself tobe?’’ the responses ‘‘not at all’’ and ‘‘not very strong’’were combined, while maintaining the other 2 answers(‘‘somewhat strong’’ and ‘‘strong’’) as separate categoriesfor the purpose of analysis. For the questions with 5 ormore choices, we combined the responses into 3 catego-ries of responses: ‘‘never,’’ ‘‘rarely,’’ and ‘‘occasionally’’(0%–35%); ‘‘sometimes’’ (36%–65%); and ‘‘frequently’’and ‘‘always’’ (66%–100%). For all of our analyses, weelected to use a cutoff of ‘‘always, frequently, and some-times’’ (36%–100%) as the level of response consideredto be a positive attitude toward S/R and ‘‘occasionally,rarely, and never’’ (0%–35%) to be a negative attitudetoward S/R. The question addressing whether the clini-cian-patient relationship is strengthened by the discussionof S/R had, and maintained, a Likert scale of 4 points forthe purposes of analysis. For this question, we elected touse responses of ‘‘tremendous’’ to ‘‘somewhat’’ as a pos-itive attitude and responses of ‘‘little’’ to ‘‘not at all’’ asa negative attitude.

Analysis

Data were analyzed using the x2 test and the Fisherexact test (2-tailed).

The following variables were treated as independentvariables: strength of personal S/R beliefs, gender, collegemajor, resident versus staff, primary care versus specialty,and years from graduation of medical school. We inves-tigated the strength of the relationship between the inde-pendent variables above and the attitudes and expressedpractices of pediatricians. We also investigated the degreeof S/R orientation in relation to certain medical conditionsthat would warrant discussion of S/R, graded in degree ofseverity or seriousness of the illness. These conditionswere health maintenance; birth of a baby; giving bad news

in a non–life-threatening illness; psychiatric (emotional)crisis; giving bad news in a life-threatening illness; anddealing with death and dying and life of the deceased.

The Institutional Review Board of the Boston MedicalCenter approved this study.

RESULTS

Study Population

Surveys were mailed to 110 pediatric faculty and 98pediatric residents. The response rate for the faculty was90.9% (100/110), while the resident response rate waslower at 66.3% (65/98). Of a total of 165 respondents, 94were women, 118 were science majors in college, and 114had a primary care orientation. Fifty-three percent of thesample had graduated from medical school within the past9 years, 22% between 10 and 19 years previously, and25% at least 20 years previously. There were no signifi-cant differences between residents and faculty in terms ofgender, major in college, or primary care versus specialtyorientation.

S/R Orientation

Of the entire sample, 46% described themselves as ‘‘notat all’’ or ‘‘not very strong’’ in their S/R orientation, while33% reported that they were ‘‘somewhat strong,’’ and21% reported that they were ‘‘strong’’ in their S/R ori-entation. The independent variables did not have an im-pact on the degree of physician S/R orientation; therefore,the degree of S/R orientation was treated as an indepen-dent variable as well.

Pediatricians’ Attitudes and Practices

Thirty-five percent of pediatricians stated that theyshould (always to sometimes, 100%–36%) initiate discus-sions of spirituality, whereas 19% stated that they actuallydo inquire about S/R (Table 1). A majority (65%) notedthe belief that faith plays a role in patient healing. Thirty-eight percent felt that patients would like to discuss S/R,and 45% would contact a spiritual community leader. Six-ty-four percent reported that the clinician-patient interac-tion would be strengthened (tremendous to somewhat vslittle to not at all) by discussions of S/R. Primary care–oriented pediatricians, compared with specialty-orientedpediatricians, were more likely to view the clinician-pa-tient relationship as strengthened by discussions of S/R (P, .05) (data not shown).

Praying With Patients: Appropriateness and FeelingComfortable

A large majority (90%) of all pediatricians stated thatthey thought it appropriate to pray with patients if askedto do so, while 76% would feel comfortable praying withpatients if asked to do so. Pediatricians who had a strongerS/R orientation were more likely to feel comfortable pray-ing with patients if asked (P , .01). Pediatricians whowere nonscience majors in college were also more likelyto feel comfortable praying with patients, if asked, thanthose who were science majors in college (P , .01). Fi-

AMBULATORY PEDIATRICS Spirituality and Religion in Pediatric Health Care 7

TABLE 1. Pediatricians’ Attitudes and Self-Reported Behaviors About Spirituality/Religion*

Pediatricians’Attitudes/Behaviors

Always(.90%)

Frequently(90%–66%)

Sometimes(65%–36%)

Occasionally(35%–10%)

Rarely(,10%)

Never(0%) N

Pediatricians shouldinitiate discussion of S/R 3 (2) 11 (7) 43 (26) 62 (38) 38 (23) 7 (4) 164

Pediatricians do inquireabout S/R 3 (2) 7 (4) 21 (13) 48 (29) 70 (43) 15 (9) 164

Faith plays a role inhealing 5 (3) 45 (28) 55 (34) 41 (25) 15 (9) 2 (1) 163

Pediatricians feel thatpatients would like todiscuss S/R 2 (1) 9 (6) 50 (31) 64 (40) 34 (21) 2 (1) 161

Pediatricians wouldcontact S/R leader 9 (6) 24 (16) 37 (23) 37 (23) 45 (28) 8 (5) 160

Tremen-dously Somewhat Little

Not atall N

Clinician-patient relationshipstrengthened by discussion ofS/R 14 (9) 87 (55) 47 (30) 9 (6) 157

Yes No N

Is it appropriate to pray with a patient of yours if asked to do so? (90) (10) 154Would you ever feel comfortable praying with a patient of yours if

asked to do so? (76) (24) 157

* Values are expressed as No. (%) of pediatric faculty and residents unless otherwise noted. S/R indicates spirituality/religion.

nally, residents were more likely than faculty members tofeel it appropriate to pray with patients if asked. Therewere no differences according to gender, primary care ver-sus specialty care orientation, or years since graduationfrom medical school in feeling it appropriate to pray withpatients (data not shown).

Physician S/R Orientation and PracticePediatricians who considered themselves as being spir-

itual or religious were more likely to believe that a cli-nician should initiate discussions of S/R with their patients(Table 2). For example, 60% of pediatricians who had astrong S/R orientation would sometimes to always (36%–100%) initiate discussion of S/R compared with 15% ofpediatricians who did not have a strong S/R orientation(P , .01). There were no differences (P 5 .08) betweenthe strength of S/R orientation and the frequency withwhich pediatricians reported that they do inquire about S/R issues with their patients. Pediatricians who had littleor no self-reported S/R orientation were less likely to be-lieve that faith plays a role in patient healing, were lesslikely to initiate discussions about S/R with their patients,and were less likely to feel that patients would like todiscuss S/R issues, compared with pediatricians who hada strong S/R orientation. Eighty-two percent of pediatri-cians who had strong self-reported S/R orientation felt thatregularly discussing S/R with patients would strengthenthe clinician-patient relationship. Those with little to noself-reported S/R orientation were less likely to call an S/R leader from the hospital or community about their pa-tients.

S/R Concerns With Specific Medical ConditionsWe assessed the degree of self-reported S/R orientation

of the physicians in relation to their identification of

which medical conditions would warrant discussions withtheir patients and patients’ family members about S/Rconcerns. Specifically, we chose health conditions thatwere graded in severity from those that were not highlymorbid to the most serious conditions concerning a patientor parent.

For health maintenance, birth of a baby, emotional(psychiatric) crisis, and non–life-threatening illness, phy-sicians who had a strong S/R orientation were more likelyto discuss S/R concerns about nonserious to moderatelyserious health conditions compared with pediatricianswith a lesser degree of S/R orientation (data not shown).However, when the health conditions were very severe(giving bad news in a life-threatening illness and dealingwith death and dying and life of the deceased), almost allpediatricians, regardless of spiritual or religious orienta-tion, reported that they would engage in discussions of S/R (Figure). In fact, 93% of pediatricians said that givingbad news or discussing a life-threatening illness wouldwarrant discussions of S/R, and 96% said that issues ofdeath and dying and life of the deceased would warrantdiscussions of S/R, independent of their personal S/R ori-entation. Thus, there were no differences (P . .05), be-tween pediatricians’ S/R orientation and their attitude thathigh-severity conditions would warrant addressing S/Rconcerns (data not shown).

DISCUSSION

We found a positive attitude toward S/R in a pediatricfaculty and resident group in an urban northeastern academicmedical center. Nearly 90% of the physicians believed thatfaith plays some role in patient healing, and an equal numberfelt that it was appropriate to pray with patients when askedto do so. A majority (76%) felt that they would feel com-

AMBULATORY PEDIATRICS8 Siegel et al

TABLE 2. Relationship Between Physician Self-Defined Strength of S/R Orientation and the Dependent Variables*

Physician Strength of S/R Orientation

Not at All/Not Very

StrongSomewhat

Strong Strong N P Value

How frequently should physician initiate discussion of S/R? 164 ,.01

Never to occasionally 63 (85) 30 (55) 14 (40)SometimesFrequently to always

8 (11)3 (4)

19 (34)6 (11)

16 (46)5 (14)

How frequently do you inquire about S/R? 164 (.08)

Never to occasionallySometimesFrequently to always

66 (89)6 (8)2 (3)

42 (76)9 (16)4 (7)

24 (69)7 (20)4 (11)

How often does faith play a role in patient healing? 163 ,.01

Never to occasionallySometimesFrequently to always

37 (50)24 (32)13 (18)

16 (29)20 (36)19 (35)

4 (12)12 (35)18 (53)

Physicians feel patients would like to discuss S/R? 161 ,.01

Never to occasionallySometimesFrequently to always

54 (75)16 (22)2 (3)

33 (61)15 (28)6 (11)

13 (37)19 (54)3 (9)

Patient-clinician interaction strengthened by discussing S/R? 157 ,.01

NoneLittleSomewhatTremendously

7 (10)26 (37)37 (52)1 (1)

2 (4)16 (31)30 (58)4 (8)

1 (3)5 (15)

19 (56)9 (26)

Frequency of calling an S/R leader? 160 ,.01

Never to occasionallySometimesFrequently to always

52 (73)12 (17)7 (10)

30 (56)12 (22)12 (22)

8 (23)12 (34)15 (43)

* Values are expressed as No. (%) of pediatric faculty and residents unless otherwise noted. Frequencies are defined as follows: never tooccasionally, 0%–35%; sometimes, 36%–65%; and frequently to always, 66%–100%. S/R indicates spirituality/religion.

fortable praying with patients when asked to do so. Therewas a persistent relationship between a pediatrician’s per-sonal strong S/R orientation and positive attitudes towardintegrating S/R into the provision of health care. However,there was a discrepancy between the attitude that it is ap-propriate for the pediatrician to initiate a discussion of S/R(35%) and the self-reported behavior of actually inquiringabout S/R (19%). The degree of pediatricians’ S/R orienta-tion predicted a positive attitude toward the idea that dis-cussing S/R would strengthen the physician-patient relation-ship and that there would be a greater likelihood of physi-cians requesting involvement of an S/R leader in patientcare. There were no differences in gender, college major(science vs nonscience major), resident or staff status, andyears since graduation from medical school in relation to thedegree of pediatricians’ self-defined S/R orientation. The sig-nificant findings related to the independent variables sug-gested that primary care physicians and residents orientedtoward primary care were more likely to state that the phy-sician-patient interaction would be strengthened with a dis-cussion of S/R than were those physicians who were spe-cialty oriented. Residents, compared with faculty, were morelikely to feel that it was appropriate to pray with patients ifasked to do so. Finally, physicians who were nonsciencemajors in college were more likely to report feeling com-

fortable praying with patients, if asked to do so, than werephysicians who were science majors in college.

Considerable data suggest that some adult patients wantphysicians to inquire about their S/R beliefs in relation-ship to their health and illness experiences.9–11,24 Pediatricresearch on S/R is limited and is often embedded in stud-ies of complementary and alternative medicine (CAM).The relationship between CAM and S/R is poorly defined.One study25 of hospitalized adolescent patients noted thatthe intensity of S/R needs in adolescents (age, 11–19years) increases in proportion to the severity of the illness.In a study of alternative therapies used by parents of chil-dren with and without cancer,26 prayer was used as a com-plementary treatment by 64% of parents whose childrenhad cancer and 40% of parents whose children did nothave cancer. In a recent report from Taiwan,27 40% ofchildren with cancer were involved with temple worshipor shamanism. A single paper28 in the pediatric literaturereported on pediatricians’ experience with and attitudestoward CAM. In this study, S/R issues were consideredpart of CAM. Pediatricians believed that 84% of patientswere using some form of CAM, parents or patients initi-ated 85% of discussions of CAM, and 50% of pediatri-cians would consider referring patients for CAM. The re-port also noted that female pediatricians and younger pe-

AMBULATORY PEDIATRICS Spirituality and Religion in Pediatric Health Care 9

Percentage of pediatricians answering yes to the question, ‘‘Would these medical conditions warrant asking about spirituality or religiousconcerns?’’

diatricians are more likely to discuss CAM with their pa-tients. This report included ‘‘prayer healing’’ as part ofthe CAM therapies: 11.2% of pediatricians use prayerhealing in their personal lives, 4.6% referred their patientsfor prayer healing, 35.9% felt that prayer healing may beeffective, and 11% wanted to learn more about prayerhealing in continuing medical education courses.

Although the subject of S/R issues is less likely to occurwith well-child care (usually S/R issues are embedded inmedical care when there is a particular health problem),there was a defined increment in the degree of importanceof S/R with the severity of the health condition. For thoseconditions of extreme severity, such as a life-threateningillness or death, almost all of the responding pediatricians,regardless of their S/R orientation, would address issuesof S/R. Most pediatricians felt that it was appropriate topray with patients if asked to do so, although those pe-diatricians with a greater S/R orientation reported beingmore comfortable praying with patients.

The American Academy of Pediatrics Committee onBioethics29 has recognized the important role religionplays in the lives of many children or adults. While theethical perspective places the health of the child first, thecommittee recommends that pediatricians ‘‘show sensitiv-ity to and flexibility toward religious beliefs and practicesof families.’’ Furthermore, the same committee and theCommittee on Hospital Care in a joint statement on Pal-liative Care for Children30 noted the importance of ‘‘spir-itual support for both patients and siblings,’’ the encour-

agement of families carrying out ‘‘important family, re-ligious and/or cultural rituals,’’ and the importance of in-cluding ‘‘religious advisors’’ in the process of health care.

This study has a number of limitations. This study wascompleted in a northeastern, inner-city, urban and academicmedical center with a long history of a commitment to thesocial, political, and environmental concerns of children, andit probably draws faculty and residents with a similar ori-entation. Pediatricians choosing to be in this environmentmay be more open to cultural, spiritual, and religious di-mensions of child care than pediatricians in nonacademic ornon–inner-city practice programs. This sample does not rep-resent the population of pediatricians and residents nation-ally, preventing any generalizations to other pediatricians orpediatric residents. Surveys such as the current one onlysuggest attitudes and self-reported behaviors and do not cap-ture actual behaviors. We did not explore the special devel-opmental understanding of children at various ages31 in re-lationship to the pediatrician’s discussion of S/R. We did notdifferentiate between the pediatrician’s discussion of S/Rwith children and/or with their parents. Since the questionsthat we were asking are similar to the questions used in othersurveys, we felt that these questions were valid ones. Thesurvey was anonymous, which added to the strength of thevalidity of the questions. A potential threat to validity is thequestion of social desirability. To what degree do physiciansfeel they should engage with patients in discussions of S/R,and are there aspects of the culture of the department thatinfluence that attitude? Anonymity protects against cultural

AMBULATORY PEDIATRICS10 Siegel et al

influences of the department, but we can never be certainthat this factor is not operative.

Significant questions arise from this study. What do pa-tients and parents want from pediatricians with regard toincorporating S/R into clinical practice? How is the qual-ity of health care and the clinician-patient-family relation-ship affected by engaging in these discussions? What arethe implications for education at the undergraduate, resi-dency, or continuing education levels? What are thebroader health policy issues relative to S/R and the prac-tice of medicine? How are ethical issues related to S/R?A recent article32 raised the question of the roles that cli-nicians play in engaging in discussions about S/R andprescribing religious activities and suggested that physi-cians should not engage in S/R issues but should refer toclergy. Thus, the role of the role of health professionalsand the relationship of physicians and hospital chaplainsand other religious professionals in addressing the care ofpatients and their family members need to be further un-derstood and clarified.

Spirituality and religion intersect with medicine at thejuncture of suffering.33 We were struck by the very posi-tive attitude of many pediatricians at our institution to-ward incorporating S/R issues into the discourse of med-icine. We are currently developing curricular materials andexploring research into the specific S/R concerns of ourdiverse patient population to better inform us of our pa-tients’ and families’ perspectives and to incorporate thisinformation into our health care practices. The questionof the variability of physicians’ attitudes toward S/R andtheir incorporation of S/R in their everyday practice aswell as the implications in terms of healing, health, andmental health outcomes need further exploration.

ACKNOWLEDGMENTSThis research was supported by the Department of Pediatrics Bos-

ton Medical Center General Fund. We are grateful for the reviewand editorial assistance of Dr Howard Bauchner.

REFERENCES1. Matthews DA, McCullough ME, Larson, DB, et al. Religious com-

mitment and health status: a review of the research and implicationsfor family medicine. Arch Fam Med. 1998;7:118–124.

2. Craigie FC, Larson DB, Liu IY. References to religion in theJournal of Family Practice: dimensions and valence of spiri-tuality. J Fam Pract. 1990;30:477–479.

3. Pressman P, Lyons JS, Larson DB, Strain JJ. Religious belief,depression, and ambulation status in elderly women with brokenhips. Am J Psychiatry. 1990;147:758–760.

4. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping anddepression among elderly, hospitalized medically ill men. Am JPsychiatry. 1992;149:1693–1700.

5. Koenig HG, George LK, Peterson BL. Religiosity and remissionof depression in medically ill older patients. Am J Psychiatry.1998;155:536–542.

6. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and med-icine. Lancet. 1999;353:664–667.

7. Levin JS, Larson DB, Pulchalski CM. Religion and spiritualityin medicine: research and education. JAMA. 1997;278:792–793.

8. Thomason CL, Brody H. Inclusive spirituality. J Fam Pract.1999;48:96–97.

9. Maugans TA, Wadland WC. Religion and family medicine: a sur-vey of physicians and patients. J Fam Pract. 1991;32:210–213.

10. Daaleman TP, Nease DE. Patient attitudes regarding physicianinquiry into spiritual and religious issues. J Fam Pract. 1994;39:564–568.

11. King DE, Bushwick B. Beliefs and attitudes of hospital inpa-tients about faith healing and prayer. J Fam Pract. 1994;39:349–352.

12. Koenig HG, Bearon LB, Dayringer R. Physician perspectiveson the role of religion in the physician-older patient Relation-ship. J Fam. Pract. 1989;28:441–448.

13. Berman BM, Singh BK, Lao L, et al. Physicians’ attitudes to-ward complementary or alternative medicine: a regional survey.J Am Board Fam Pract. 1995;8:361–366.

14. Ellis M, Vinson D, Ewigman B. Addressing spiritual concernsof patients: family physicians’ attitudes and practices. J FamPract. 1999;48:105–109.

15. Daaleman T, Frey B. Spiritual and religious beliefs and practicesof family physicians: a national survey. J Fam Pract. 1999;48:98–104.

16. Fetzer Institute/National Institute on Aging WorkingGroup. Multidimensional Measurement of Religiousness/Spiri-tuality for Use in Health Research. Kalamazoo, Mich: FetzerInstitute; 1999. Available at: http://www.fetzer.org/resources/FETZERpBOOK.pdf. Accessed February 15, 2001.

17. Ledbetter MF, Smith LA, Fischer JD. An evaluation of the con-struct validity of the Spiritual Well-being Scale: a confirmatoryfactory analytic approach. J Psych Rel. 1991;19:94–102.

18. Cannon D. Six ways of Being Religious: A Framework for Com-parative Studies of Religion. Belmont Mass: Wadsworth PublCo; 1996.

19. Bunker D. Spirituality and the four Jungian personality func-tions. J Psychol Theol. 1991;19:26–34.

20. Degelman D, Lynn D. The development and preliminary vali-dation of the Belief in Divine Intervention Scale. J PsycholTheol. 1995;23:37–44.

21. Genia V. The Spiritual Experience Index: revision and refor-mulation. Rev Religion Res. 1997;38:344–361.

22. Genia V. A psychometric evaluation of the Allport-Ross I/EScales in a religiously heterogeneous sample. J Scientific StudyReligion 1993;32:284–290.

23. Dyson J, Cobb M, Forman D. The meaning of spirituality: aliterature review. J Adv Nurs. 1997;26:1183–1188.

24. Ehman JW, Ott BB, Short TH, et al. Do patients want physiciansto inquire about their spiritual or religious beliefs if they becomegravely ill? Arch Intern Med. 1999;159:1803–1806.

25. Silber TJ, Reilly M. Spiritual and religious concerns of the hos-pitalized adolescent. Adolescence. 1985;77:217–224.

26. Friedman T, Slayton WB, Allen LS, et al. Use of alternativetherapies for children with cancer. Pediatrics. 1997;100:e1–e9.Available at www.pediatrics.org/cgi/content/full/100/6/e1. Ac-cessed February 15, 2001.

27. Yeh CH, Tsai JL, Li W, et al. Use of alternative therapy amongpediatric oncology patients in Taiwan. Pediatr Hematol Oncol.2000;17:55–65.

28. Sikand A, Laken M. Pediatricians’ experience with and attitudestoward complementary/alternative medicine. Arch Pediatr Ado-lesc Med. 1998;152:1059–1064.

29. American Academy of Pediatrics Committee on Bioethics. Reli-gious objections to medical care. Pediatrics. 1997;99:279–281.

30. American Academy of Pediatrics, Committee on Bioethics andCommittee on Hospital Care. Palliative care for children. Pe-diatrics. 2000;106:351–358.

31. Fowler JW. Stages of Faith: The Psychology of Human Devel-opment and the Quest for Meaning. San Francisco, Calif: Harp-er Collins Publ; 1981.

32. Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians pre-scribe religious activities? N Engl J Med. 2000;342:1913–1916.

33. Barnes L, Plotnikoff G, Fox K, Pendleton S. Spirituality, reli-gion, and pediatrics: intersecting worlds of healing. Pediatrics(Journal of the Ambulatory Pediatric Association). 2000;106:899–908.