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and Holick. Critical revision of the manuscript for impor- Results. Among eligible physicians, the survey response
tant intellectual content: Pietras and Holick. Statistical rate was 63%. The present analysis includes the 1102 phy- analysis: Obayan and Cai. Obtained funding: Obayan and sicians actively involved in patient care. Respondents were Holick. Administrative, technical, and material support: Hol- predominantly male (74%) and came from diverse spe- ick. Study supervision: Pietras and Holick.
cialties, 31% worked at teaching hospitals, 12% worked Financial Disclosure: None reported.
at faith-based hospitals or clinics, and 64% reported car-ing for high numbers of critically ill patients. Of the re- 1. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266-281.
spondents, 10% reported no religious affiliation, 59% re- 2. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vi- ported being Christian, 16% reported being Jewish, and 3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
3. Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency.
14% reported other affiliations; 41% agreed with the state- Lancet. 1998;351(9105):805-806.
4. Chel V, Wijnhoven HA, Smit JH, Ooms M, Lips P. Efficacy of different doses ment, “My whole approach to life is based on my reli- and time intervals of oral vitamin D supplementation with or without cal- gion.” Forty-one percent of the physicians believed it was cium in elderly nursing home residents. Osteoporos Int. 2008;19(5):663-671.
appropriate for them to talk about their own R/S with pa- 5. Holick MF, Biancuzzo RM, Chen TC, et al. Vitamin D2 is as effective as vita- min D3 in maintaining circulating concentrations of 25-hydroxyvitamin D.
tients when the patient asked about it. Fifty percent of the J Clin Endocrinol Metab. 2008;93(3):677-681.
physicians believed it was appropriate for them to pray withpatients when the patient requested it. The physicians re-ported that R/S “often” had a positive impact on their pa-tients (mean [SD] score,2.8[0.5]) and “rarely” had a nega- Physicians’ Experience and Satisfaction
tive impact (mean [SD] score,1.3[0.5]).
With Chaplains: A National Survey
Most physicians (89%) reported experience with chap- lains. Among these, most (90%) reported being satisfied R eligionandspirituality(R/S)areimportantre- orverysatisfiedwithchaplains.Inamultivariatelogis-
sources for coping with serious illnesses, but re- tic regression model, experience with chaplains was as- search indicates that patients’ R/S needs often go sociated with training about R/S in medicine, seeing large unmet.1 Professional chaplains help patients make effec- numbers of critically ill patients, practicing psychiatry tive use of R/S resources in the context of illness,2 but or obstetrics and gynecology, endorsing positive effects one-third of US hospitals do not have chaplains.3 Even of R/S on patients, and believing that it is appropriate to hospitals with chaplaincy programs rarely have suffi- talk with patients about R/S whenever the physician senses cient staff to address the needs of all patients. Given these it would be appropriate (Table). In similar models, higher
constraints, physicians and other clinical staff play criti- levels of satisfaction were associated with practicing medi- cal roles in directing chaplains to patients who will ben- cal or other subspecialties, working in teaching hospi- efit from their services.4 Unfortunately, little is known tals, endorsing positive effects of R/S on patients, and be- about physicians’ experience with and impressions of lieving it is appropriate to pray with patients whenever the physician senses it would be appropriate (Table). Phy- Most physicians have little training to guide referrals sicians from the Northeast and those who endorsed more to chaplains. Some evidence suggests that in the absence negative effects of R/S on patients were less likely to be of such training, physicians’ referral patterns are shaped by their own R/S values and experiences.5,6 Physicians’referrals may also be shaped by their understanding, or Comment. On the whole, physicians appear both expe-
misunderstanding, of chaplains. One study found that rienced and satisfied with chaplains. Factors influenc- physicians with no experience with chaplains feared that ing physicians’ experience and satisfaction included train- chaplains would ignore patients’ concerns and disrespect ing in R/S, practice context, observations of positive and patients’ beliefs.7 Using data from a national survey, we negative effects of R/S on patients, and beliefs about when examined physicians’ self-reported experience and satis- it is appropriate to pray or talk with patients about R/S faction with chaplains. Based on earlier findings, we focused specifically on the relationship between physi- This study asked physicians about “experience with cians’ practice context3 and R/S views5,6 and their experi- chaplains and other pastoral care professionals.” In most ence and satisfaction with chaplains.
hospitals the pastoral care professional is the chaplain,but in future research this wording should be more spe- Methods. The methods of this national survey have been
cific. In addition, the term chaplain may refer to people reported elsewhere.8 We surveyed 1144 US physicians with diverse training and experience, from clergy who of all specialties younger than 65 years, who were se- volunteer on occasion to board-certified chaplains with lected from the American Medical Association Physi- years of clinical experience.2 Unfortunately, this study cian Masterfile. We examined physicians’ reports of prior could not assess any chaplain-specific factors. Nor did experience with chaplains (yes/no) and satisfaction with we have information about the contexts of physician- chaplains (satisfied/dissatisfied). Predictor variables in- chaplain encounters (eg, around patients who are anx- cluded physician demographics, training about R/S in ious, terminally ill, or who have religious objections to medicine, practice setting, personal R/S, opinions about treatment). Other research4 suggests that physicians value addressing R/S in the clinical setting, and the frequency some chaplain services, such as providing support around (range, 0 “never” to 4 “always”) of observing R/S to have death, more than others. Future studies should exam- 3 different positive and 3 different negative effects on ine the situations in which chaplains and physicians in- teract, the effect of physician training in R/S on such in- (REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 19), OCT 26, 2009 2009 American Medical Association. All rights reserved.
Table. Multivariate Association of Demographics, Practice, and R/S Characteristics of 1102 Physicians With Experience
or Satisfaction With Chaplainsa
Odds Ratio (95% Confidence Interval)
Any Experience With
Satisfied vs
Variable (Reference Group)
Chaplains vs None
Dissatisfied
Any formal training about R/S in medicine (none) Life based on religion (strongly disagree) When appropriate to talk about R/S (never) When appropriate to pray with patients (never) MD experience of impact of R/S on patients Abbreviations: MD, doctor of medicine; Ob-Gyn, obstetrics and gynecology; R/S, religion and spirituality.
a The analyses used case weights to account for the oversampling of specialties and for modest differences in response rates by sex and graduation from a US b In the past year, cared for 20 or more patients with critical and/or life-threatening illness, severe disability or chronic pain, a grave prenatal diagnosis, or an teractions, and the characteristics of interactions that each Author Contributions: Study concept and design: Fitch-
ett, Cadge, and Curlin. Acquisition of data: Curlin. Analy-sis and interpretation of data: Fitchett, Rasinski, and Cadge.
Drafting of the manuscript: Fitchett, Rasinski, and Cadge.
Critical revision of the manuscript for important intellec- tual content: Cadge and Curlin. Statistical analysis: Rasinski. Obtained funding: Curlin.
Financial Disclosure: None reported.
Correspondence: Dr Fitchett, Department of Religion,
Health, and Human Values, Rush University Medical Cen-
ter, 1653 W Congress Pkwy, Chicago, IL 60612 (George
1. Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treat- ment preferences and quality of life. J Clin Oncol. 2007;25(5):555-560.
(REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 19), OCT 26, 2009 2009 American Medical Association. All rights reserved.
2. Association of Professional Chaplains; Association for Clinical Pastoral angiotensin-aldosterone system blockade on major renal Education; Canadian Association for Pastoral Practice and Education; Na- tional Association of Catholic Chaplains; National Association of Jewish Chap-lains. A white paper: professional chaplaincy: its role and importance in In 2008, we reported on the previously unreported syn- healthcare. J Pastoral Care. 2001;55(1):81-97.
drome of late-onset renal failure from angiotensin block- 3. Cadge W, Freese J, Christakis NA. The provision of hospital chaplaincy in the United States: a national overview. South Med J. 2008;101(6):626-630.
ade.3,4 We submit that the potential for iatrogenic renal fail- 4. Galek K, Flannelly KJ, Koenig HG, Fogg SL. Referrals to chaplains: the role ure from ACEI and/or ARB use remains underestimated, of religion and spirituality in healthcare settings. Ment Health Relig Cult. 2007; especially in older patients.3,4 A recent review of the litera- 5. Koenig HG, Bearon LB, Hover M, Travis JL III. Religious perspective of doc- ture has unearthed a growing list of reports implicating iat- tors, nurses, patients, and families. J Pastoral Care. 1991;45(3):254-267.
rogenic renal failure from ACEI and/or ARB use, such as 6. Curlin FA, Odell SV, Lawrence RE, et al. The relationship between psychia- following cardiothoracic surgery, after oral phosphate so- try and religion among US physicians. Psychiatr Serv. 2007;58(9):1193-1198.
7. Hover M, Travis JL III, Koenig HG, Bearon LB. Pastoral research in a hospital dium, and following contrast administration.4 setting: a case study. J Pastoral Care. 1991;46(3):283-290.
We support the use of the various antihypertensive drug 8. Curlin FA, Lantos JD, Roach CJ, Sellergren SA, Chin MH. Religious charac- teristics of US physicians: a national survey. J Gen Intern Med. 2005;20(7): classes for hypertension. Chlorthalidone is an effective and safe first-line agent.1 It is less expensive, and sometimesthis and other diuretics are the only available antihyper-tensive agents available in some third-world settings. For COMMENTS AND OPINIONS
ACEIs and ARBs, we suggest more caution in their use,especially in patients older than 65 years.
Macaulay A. C. Onuigbo, MD, MSc, FWACP, FASN ALLHAT Findings Revisited in the Context
Correspondence: Dr Onuigbo, Department of Nephrol-
of Subsequent Analyses, Other Trials,
ogy, Midelfort Clinic, Mayo Health System, 1221 Whipple and Meta-analyses
St, Eau Claire, WI 54702 (onuigbo.macaulay@mayo.edu).
I readwithinterestandcuriositytherecentrevisita- 1.WrightJTJr,ProbstfieldJL,CushmanWC,etal;ALLHATCollaborativeRe-
tion of the Antihypertensive and Lipid-Lowering search Group. ALLHAT findings revisited in the context of subsequent analy- Treatment to Prevent Heart Attack Trial (ALLHAT) ses, other trials, and meta-analyses. Arch Intern Med. 2009;169(9):832-842.
2. Yusuf S, Teo KK, Pogue J, et al; ONTARGET Investigators. Telmisartan, ramipril, trial by Wright et al.1 They concluded that current evi- or both in patients at high risk for vascular events. N Engl J Med. 2008;358 dence confirmed that neither ␣-blockers, angiotensin- converting enzyme inhibitors (ACEIs), nor calcium chan- 3. Onuigbo MAC. Reno-prevention vs reno-protection: a critical re-appraisal of the evidence-base from the large RAAS blockade trials after ONTARGET—a nel blockers (CCBs), surpass thiazide-type diuretics (at an call for more circumspection. QJM. 2009;102(3):155-167.
appropriate dosage) as initial therapy for reduction of car- 4. Onuigbo MAC. Analytical review of the evidence for renoprotection by renin- diovascular or renal risk.1 We cannot agree more, espe- angiotensin-aldosterone system blockade in chronic kidney disease—a callfor caution. Nephron Clin Pract. 2009;113(2):c63-c70.
cially in light of recent trials including the ONTARGET 5. Suissa S, Hutchinson T, Brophy JM, Kezouh A. ACE-inhibitor use and the trial2 and new insights into plausible benefits of cardio- long-term risk of renal failure in diabetes. Kidney Int. 2006;69(5):913-919.
6. Mann JF, Schmieder RE, McQueen M, et al; ONTARGET investigators. Re- protection and renoprotection using different antihyper- nal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, con- We were surprised that the ALLHAT revisitation did trolled trial. Lancet. 2008;372(9638):547-553.
not go further than just this statement1(p834): Thus, compared with diuretic-based treatment, CCB- and ACE- In reply
inhibitor based therapies failed to demonstrate superiority in the We appreciate the favorable comments by Dr Onuigbo on prevention of CVD [cardiovascular disease] or ESRD [end-stage this latest ALLHAT publication.1 We were also impressed renal disease] in participants with DM [diabetes mellitus].
by the very positive findings in thiazide-treated patients. Indeed, the ALLHAT data showed that among those with ALLHAT was designed to determine whether α-blockers, diabetes, more patients in the lisinopril group progressed ACEIs, or CCBs were superior to thiazide-type diuretics (pre- to ESRD compared with the chlorthalidone group (25 of scribed at an appropriate dosage) as initial therapy for re- 1563 vs 26 of 2755 [relative risk, 1.74; 95% confidence duction of cardiovascular or renal outcomes.1 While poten- interval (CI), 1.00-3.01; P=.05]).4 Besides, Suissa et al,5 tially understated, we believe that our overall conclusion that in a population-based historical cohort analysis of 6102 the thiazide-type diuretic was not surpassed is consistent with Canadian patients with diabetes, demonstrated an in- creased rate ratio of ESRD of 4.2 (95% CI, 2.0-9.0) after 3 Regarding kidney failure, Dr Onuigbo is correct that the years or longer of ACEI therapy compared with diuretics, ACEI was not more effective than the diuretic in preventing ␤-blockers, and CCBs. The Ongoing Telmisartan Alone ESRD in any ALLHAT subgroup, even in patients with dia- and in Combination with Ramipril Global Endpoint Trial betes (and in nonblacks, in whom the blood pressure differ- (ONTARGET) report has raised further doubts of reno- ence between treatment groups was <1 mm Hg). Owing to protection with ACEIs and/or ARBs, more so with com- lack of space, renal outcomes were not discussed in detail, bination ACEI/ARB.2 Also, the ONTARGET authors, in a but they have been published.2 In fact, diabetic participants post hoc analysis published in The Lancet, concluded that with an estimated glomerular filtration rate of 60 to 89 mL/ proteinuria reduction by itself cannot be taken as a de- min per 1.73 m2, showed borderline higher risk of ESRD with finitive marker of improved renal function and that the the ACEI use (relative risk [RR], 1.74; 95% CI, 1.00-3.01). benefits of any treatment, including combination renin- However, this was not seen in all diabetic participants (RR, (REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 19), OCT 26, 2009 2009 American Medical Association. All rights reserved.

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