The U.S. has become home to a burgeoning religious diversity as immigrants from all over the world have brought their religious traditions to take root in American soil. Doctors are dealing with an equally diverse patient population. Patient-doctor interaction is time-limited and bounded by the doctor's areas of specialty and expertise. Despite these limits there is an opportunity to improve healthcare delivery by increasing awareness of the patient's religious frameworks and resources and how these may affect a prospective treatment plan.

The key word here is "increasing" because this awareness is a process, not a final achievement. No doctor can be expected to be versed in all of the many religious traditions found in the U.S. Of course, knowledge is helpful, particularly a broad familiarity with the practices that may be part of a given religious tradition strongly represented among one's patients. Within each tradition, however, there are many differences; there is no easy blueprint to follow. Still, awareness of the religious orientation of the patient may be beneficial to the patient-doctor interaction.

It may be useful for the doctor to be aware of all the patient's healing resources. At the recent conference on religious healing in urban America, Karen Holliday offered examples of those in the Santería tradition who utilize local botánicas—stores selling herbs, remedies, and religious paraphernalia—and rely on their padrinos (godfathers) for guidance and healing. One Catholic woman turned to a local botánica, where meeting with the dueño (owner) gave her hope and agency after her biomedical physician had prescribed an operation that she did not understand and could not afford. In this case, she was reaching for religious resources outside of her tradition. Perhaps if the physician had been aware of the form of religious healing to which the patient was turning, he could have built trust by acknowledging those resources, as well as by addressing her lack of financial resources.

Religious pluralism requires more than tolerance of religious diversity. For a truly pluralistic society there is the opportunity and necessity for active engagement and participation. In medical practice, issues of pluralism appear especially in three areas. Cultural competence, complementary and alternative medicine, and spirituality and religion have been recognized in recent years as significant issues for physicians, receiving attention at numerous conferences and in journals. In reality, these three areas may be very closely linked for patients. They are also important in light of the World Health Organization's definition of health as "a state of complete physical, mental and social well-being."

The quantifiable ways in which prayer, ritual offerings, shamanic practice, or a visit to the local botánica may help in a healing crisis are not at issue here. What is at issue is the awareness that these alternative approaches may represent a patient's primary approach to healing. Awareness of this possibility may allow for better communication and better establishment of a medical treatment plan. Simply acknowledging and respecting the patient's sources of support can be important, particularly if the patient brings them to the doctor's attention. The doctor's open listening posture may make such potentially relevant disclosures more likely.

Such an open posture probably requires that doctors have examined their own religious orientation and acknowledged the diversity present among their patients. There is no avoiding the particularity of individuals' relationship to their religious tradition, which may be governed by cultural norms (or opposition to norms), by degree of acculturation, or by rejection of tradition. In general, though, it is wise to assume that patients may have religious and spiritual concerns in relation to their illness. If asked, they are often willing to teach their physician about these concerns and how they fit into a broader religious/spiritual worldview. "Respectful curiosity" may be a guiding attribute for interacting with patients.

In his article entitled "Illness Meaning and Illness Behavior," Arthur Kleinman proposes that one begin by asking about the patient's and the family's understanding of the illness under consideration. What do they see as the causes, the names, the primary problem, the course, and the desired forms of treatment? What do they most fear about this illness and its treatment? How has it affected their family, work, school, recreational, and personal life? Within these broader questions, one may find issues of religious meaning and spiritual crisis.

In some cases, these issues may not be explicitly stated at first. Therefore, the broader skill—as in all effective medical care—involves developing the capacity to listen differently, in a way that is personally respectful, clinically insightful, and aimed at understanding rather than agreement or disagreement. It may also be important to ask about the different things the patient and family have done to treat the problem, including religious/spiritual therapies and support, and to listen openly. Nor does the process need to be complicated. One colleague has found it extremely helpful in his clinical practice simply to ask, "What do we need to do to heal the whole person?" From there, one may want to consult with and/or make referrals to chaplains or other spiritual/religious caregivers. It is a good idea to build ongoing relationships with available chaplaincy services and local consultants in different traditions. One can also refer to a patient-preferred spiritual care provider.

The current cultural and religious diversity found in many patient populations is a challenge even to chaplains who are trained as religious/spiritual counselors. However, chaplains may be a wonderful resource if a doctor recognizes that there are religious issues that may affect healthcare delivery. Many chaplains are learning about other traditions, and some call upon contacts from various traditions. Many hospitals make use of volunteers from different religious communities to offer a broader base of religious resources for patients.

The Pluralism Project offers resources for religious pluralism on the Web at http://www.pluralism.org. Among these is a directory of religious centers, which may be helpful to patients who are not in their own communities for treatment. The directory also provides web sites and other contact information for doctors who think increased exposure to different religious practices can inform their medical proficiency. The second edition of the CD-ROM On Common Ground: World Religions in America, offering insight into fifteen world religions in their American context, will be available this winter, and the CD and web site will host a wealth of links for each religious tradition.

Ongoing education is required of us all in our changing world. Doctors are already required to be life-long learners to stay abreast of changing medical practice. The Boston Healing Landscape Project, through the Department of Pediatrics at Boston University School of Medicine, aims to develop models to integrate information about religious healing practices into medical education across the levels of that ongoing education, from medical school to doctors' rounds. The objective is to begin a process of transforming physician self-understanding and the patient-doctor relationship.

It is unreasonable to expect doctors to be versed in every religion and every culture's particular understanding of illness and healing. Nevertheless, religiously grounded, cross-cultural understandings of health and intervention inform optimal patient practice. Focused attention to these issues can enhance the listening skills that are integral to patient-centered care.