Professional Documents
Culture Documents
INTRODUCTION
C
odes of medical ethics have called physicians to care for the
poor for centuries, from the birth of the Hippocratic tradition in
ancient Greece,1 through the middle ages in Europe,2 and into
modern America.3 In spite of such ongoing moral exhortation, many poor
patients and communities continue to be medically underserved.4-9
Physicians have compelling reasons to avoid practicing among the
poor. Physicians who choose to work in underserved settings often forgo
academic opportunities, professional prestige,7 and free time,10 and accept
reduced salaries, diminished control over the work environment,4 and
increased bureaucratic interference.10 These and other extrinsic11,12 and
objective13 workplace characteristics diminish the appeal of underserved
Conflicts of interest: none reported
settings.
Although the poor are underserved, they are not unserved; many phy-
CORRESPONDING AUTHOR sicians choose to practice in underserved settings. Those who do tend to
Farr Curlin, MD identify intrinsic and intangible rewards of their work, such as making a
Department of Medicine difference in society, having a positive impact on the lives of patients who
Section of General Internal Medicine are otherwise marginalized, and living in a way congruent with their per-
University of Chicago
5841 S Maryland Ave
sonal hopes and aspirations.10,14 These subjective rewards express ways in
Chicago, IL 60637 which physicians may relate to their work among the underserved more as
fcurlin@uchicago.edu a calling than as a job.12,13
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The concept of calling is currently used in the them to indicate whether they practiced in any of sev-
work literature to refer broadly to work done with a eral typical safety net settings (free clinic, community
sense of inner direction and aimed at improving the health center or migrant health center, public or county
world.13,15 In the words of Bellah,16 a calling “constitutes hospital, or other rural health center).
a practical ideal of activity and character that makes a Primary predictor variables included measures of
person’s work morally inseparable from his or her life.” physicians’ religious characteristics. Intrinsic religios-
Although a calling can be either religious or secular ity—the extent to which individuals embrace their
in orientation, religious factors may be particularly religion as the “master motive” that guides and gives
influential in calling physicians to practice among the meaning to their life25 —was measured as agreement or
underserved because Christian,17 Buddhist,18 Hindu,19 disagreement with 2 statements: “I try hard to carry
Jewish,20 and Muslim21 scriptures all call the faithful to my religious beliefs over into all my other dealings in
serve the poor. life,” and “My whole approach to life is based on my
Previous studies have noted that physicians choose religion.” Both statements are derived from Hoge’s
to practice among the underserved because of their Intrinsic Religious Motivation Scale26 and have been
hopes, aspirations, beliefs, personal values, and basic validated extensively in prior research.26-28 Intrinsic
orientations to humanity,10,14 yet no study to date has religiosity was categorized as low if physicians dis-
quantitatively examined associations between physi- agreed with both statements, moderate if they agreed
cians’ religious characteristics and their work among with 1 but not the other, and high if they agreed with
the underserved. In an earlier qualitative study, we both. Organizational,29 or participatory,30 religiosity was
found that clinicians from a sample of faith-based com- measured as physicians’ frequency of attendance at
munity health centers uniformly described their work religious services, categorized as never, once a month
among the underserved as a response to a religious or less, or twice a month or more. Physicians’ religious
sense of calling.22 Building on those findings, this affiliations were categorized as none (included atheist,
study uses data from a national survey of a probability agnostic, and none), Protestant, Catholic, Jewish, or
sample of physicians to examine whether physicians other (included Buddhist, Hindu, Mormon, Muslim,
who are more religious, who conceive of their practice Eastern Orthodox, and other). Additionally, we asked
of medicine as a calling, or both are also more likely to physicians to what extent they agreed with the state-
report caring for the underserved. ment, “My religious beliefs influence my practice of
medicine.”
Many people consider themselves spiritual but
METHODS not religious,23 and there has been a trend toward the
Design and Sampling study of spirituality over religion.31-33 Because there
This study’s methods have been described in detail is still disagreement as to what spirituality means,33,34
elsewhere.23,24 We mailed a confidential, self-admin- we allowed physicians to classify themselves by ask-
istered, 12-page questionnaire to a stratified random ing, “To what extent do you consider yourself a
sample of 2,000 practicing US physicians aged 65 spiritual person?” Spirituality was categorized as high
years or younger, chosen from the American Medi- if physicians answered highly spiritual, moderate if
cal Association Physician Masterfile—a database they answered moderately spiritual, and low if they
intended to include all physicians in the United States. answered slightly or not at all spiritual.
We included modest oversamples of psychiatrists and Because we hypothesized that a sense of calling
several other subspecialties to enhance the power of would be associated with care of the underserved, we
analyses that are not central to this article. Physicians asked physicians to what extent they agreed with the
received up to 3 separate mailings of the questionnaire, statement, “For me, the practice of medicine is a call-
and the third mailing offered $20 for participation. ing.” In addition, because studies suggest that those
This study was approved by the University of Chicago who eventually work in underserved settings are likely
Institutional Review Board. to have begun medical training with that orientation
already in place,8,35,36 we asked physicians to what
Study Instrument extent they agreed with the statement, “The family in
The primary criterion variable was physicians’ responses which I was raised emphasized the importance of serv-
to the question, “Is your patient population considered ing those with fewer resources.”
underserved?” (response options: yes and no). To cross- We examined physician demographics (age, sex,
check the validity of this measure, we also asked physi- ethnicity, region, and foreign medical graduation)
cians to estimate the percentage of their patients who and practice characteristics (primary specialty, board
were uninsured or recipients of Medicaid, and we asked certification, educational loan repayment, and work in
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Note: Totals do not all sum to 1,144 because of partial nonresponse. Percentages do not all sum to 100 because of rounding error.
academic health center) as covariates. Categories for analyses were conducted using the statistical software
all predictor variables are listed in Table 1. Stata/SE 9.0 (Stata Corp, College Station, Tex).
Analysis
Case weights37 were assigned and included in analyses RESULTS
to account for the sampling strategy and modest differ- Survey Response
ences in response rate by sex and foreign medical grad- Of the 2,000 potential respondents, an estimated 9%
uation. We first generated estimated proportions for were ineligible because their addresses were incorrect
each survey item. We then used the χ2 test to examine or they were deceased. Among eligible physicians,
the association between each predictor and the cri- our response rate was 63% (1,144/1,820). (Details of
terion variable. Finally, we used multivariate logistic response rate estimation24 and physicians’ religious char-
regression analysis to examine whether associations acteristics23 have been provided elsewhere.) Respondent
persisted after controlling for other covariates. These characteristics are listed in Table 1.
analyses were conducted for the full study population Foreign medical graduates were less likely to
and then repeated for the subpopulations of primary respond than US medical graduates (54% vs 65%,
care physicians (general internists, general pediatri- P <.01), and men were slightly less likely to respond
cians, and family physicians) and family physicians. All than women (61% vs 67%, P = .03). These differences
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tests. These values are followed by multivariate odds ratios (ORs) with 95% confidence intervals (95% physicians met 1 of these 2 criteria), we
CIs), which are by survey design adjusted logistic regression tests that control for age, sex, ethnicity, found the same patterns of association
region, foreign medical graduation, board certification, loan repayment, and working in an academic
medical center (test for sex also controls for religious characteristics and intrinsic motivations). as are shown in Table 2, although the
* The n values do not all sum to 374 because of partial nonresponse. only association that reached statistical
† P <.05. significance was that with spirituality.
Although measures of general reli-
the underserved were reported by psychiatrists (40%), giosity were not associated with practice among the
and the lowest were reported by medical subspecial- underserved, physicians who were more religious by
ists (21%). Yet, in multivariate analyses, no significant any measure were substantially more likely to report
differences persisted between family physicians and that their families emphasized service to the poor and
physicians from any other specialty. that for them the practice of medicine was a calling
With respect to religious characteristics, physi- (Table 4). Combining religious characteristics and mea-
cians who were more likely to practice in underserved sures of motivation had little effect on practice among
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a calling (regardless of their patient population) may medicine, and should give preference to applicants who
suggest that the term calling has such religious over- consider themselves very spiritual, who either have no
tones that religious physicians are much more likely religion or strongly agree that the religion they have
than secular physicians to think of it as describing influences their practice of medicine, or who agree that
themselves. Or it may be that for religious physicians, their families of origin emphasized service to the poor.
the vocational meaning of medical practice comes At this point, no one knows whether policies to
from caring for the sick, whether rich or poor, or from select medical students based on these or any other
interacting with patients regarding matters of the soul. characteristics would actually increase the supply of
In support of the latter hypothesis, we found recently physicians to underserved populations. To begin to
that religious physicians are much more likely to report answer such questions, future research should include a
praying with patients and talking with patients about longitudinal study (from medical school matriculation
religious and spiritual concerns.24 to postgraduate practice) of a large cohort of entering
This study has several limitations, the most impor- medical students, measuring religious characteris-
tant of which is that the criterion variable is a subjec- tics, intrinsic motivations, and variables known to be
tive, self-reported measure. Although the percentage associated with practice among the underserved. By
of physicians in our study who said their patient popu- measuring pertinent social and demographic variables
lations are underserved (26%) is comparable to findings at several points in time, such a study would provide
in other studies,40,41 our results could be biased if phy- insights into how physicians’ religious and spiritual
sicians’ religious characteristics lead them to be more commitments, sense of calling, and other social and
or less likely to describe a given patient population as demographic factors interact over the course of medi-
underserved, or if they lead them to overestimate or cal training to lead some, but not others, to practice
underestimate the percentage of their patients who among the underserved.
are uninsured or recipients of Medicaid. In addition, To read or post commentaries in response to this article, see it
although we did not find much evidence for bias in online at http://www.annfammed.org/cgi/content/full/5/4/353.
response to the overall study, it is theoretically pos-
sible that those who care for the underserved were less Key words: Religion; spirituality; medically underserved area; poverty;
access to health care; barriers; community health care; public health
likely to respond to the study because of their heavy
workload. If so, and if those physicians’ religious char- Submitted June 12, 2006; submitted, revised, December 1, 2006;
acteristics differed from those of respondents, such accepted December 8, 2006.
biases could confound our findings. The study further-
Funding support: This publication was made possible by grant fund-
more is not able to distinguish those who deliberately
ing from the Greenwall Foundation, New York, NY (The Integration of
choose to practice among the underserved from those Religion and Spirituality in Patient Care among US Physicians: A Three-
who merely end up there for other reasons, nor does Part Study) and via the Robert Wood Johnson Clinical Scholars Program
it capture many other ways in which physicians may (Drs Curlin, Chin, and Lantos). Dr Curlin is supported by NCCAM grant
care for the poor. We did not ask physicians what per- K23/AT002749.
centage of their work was charity care, whether they Disclaimer: The study’s contents are solely the responsibility of the
volunteered or worked part time in underserved set- authors and do not necessarily represent the official views of the fund-
tings, or whether they had traveled to other countries ing agencies.
to provide medical care to the poor. It is possible that
Acknowledgments: We are grateful for the assistance of Chad Roach
religious physicians differed from nonreligious physi-
and Sarah H. Sellergren with survey administration and data processing.
cians on one or more of these measures.
Notwithstanding these limitations, this study does
point to possible implications for medical educators, References
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