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In marked contrast to the stated importance that spirituality had come to mean in their personal and professional journey, participants expressed that talking about spirituality was «not easy» and «not very frequent» generally, either with patients or with colleagues. To begin with, participants stated that very little mention of the topic was made in their own training and early professional development.

«There wasn’t a lot of room for that in my medical training... My memory is that of a training focussed exclusively on science, on the great progress of science and how to act in all circumstances with regard to the medical guidelines from the advances in science. I liked that, I am a medical specialist and I like to apply the basics of science..., but on the spiritual side, it’s a total void, sincerely, they taught us absolutely none of that.»

Facilitators

Talking about spirituality seemed facilitated in serious and chronic illness including

mental illness, care of the elderly, end of life care and decision-making, as well as settings such as hospital and home care. In these situations, physicians practiced with a more structured allied health care team where participants mentioned discussing spiritual issues. The following example concerned a palliative care team :

«When patients die, certain patients who we know, they touched us a lot, they stirred us a lot; the death was horrible by its intensity..., we always take time, the following week, in fact the following meeting to stop and say: ‘OK, how did you experience that, like you, how did you feel? What are you left with?’ So I think that we touch on a level which is a bit different and yes it’s important.»

Apart from interdisciplinary team meetings, participants recounted discussing spiritual needs of patients sometimes directly during case transfers and discussions with physician colleagues or with nursing personnel. For instance:

«It has happened to me with nurses when we do joint follow-up and compliance is not there, to talk, to tell the nurse who that patient is, what his or her story is, how I approach him or her, what are my expectations, what her expectations should be and how she should talk to the patient. That, that can happen.»

In the practice settings mentioned above, participants spoke of the more frequent need to inquire about «patient beliefs» in order to take them into account in ethical decision- making. Moreover, some participants told stories of talking to patients more directly about spirituality in a context that even stretched the usual boundaries of patient care. The following extract is from a participant who spoke about spirituality with a suicidal patient:

«I found it slippery a bit, at the time that I did it because I was telling myself: ‘I have to take a risk.’ If she’s not spiritual,... if she sees me as someone who is religious: ‘Well then if you want to haul out God and make me feel guilty’; that will probably not work. The way I approached her, it worked well and after, I told myself: ‘No, deep down there was no risk, all she could have told me is no’,... I would have respected that, I would have taken another path, I think.»

Barriers

Participants evoked several reasons for having difficulty in talking about spirituality. With regards to patients, time was cited as being a major barrier. Taking extra time in order to address spiritual issues with patients caused them to run even later on tight schedules:

«I think that we often neglect it [spirituality] because we lack the time to talk about it. There are so many other additional things for a family physician. There is always something new, that must be done, that must be discussed; lifestyle, blah, bah, blah. For sure, one should take the time to fit in spirituality as well.»

«To date, throughout my career, it has been very much somewhat of a dissatisfaction to say: ‘Well OK, I have to see people, I have to roll.’ Then to always be late, because when I tried to talk to people, well, it made me run late.»

Some participants felt that the level of physician discomfort in talking with patients could be offset if they had addressed somewhat their own spirituality: «I think that to be at ease with them expressing that, first, I think one has to be at ease with the principle.»

Another reported barrier was medical culture that made spirituality a taboo topic of discussion with patients and in medical circles, particularly if associated with religion.

«Oh yes, it’s more intimate, I think, spirituality than psychology. There are already a thousand taboos with regard to psychotherapy and psychology; I think there are even more, there must be at least ten thousand with regard to spirituality. Oh yes, I think that it’s more difficult, oh yes, yes. And if within spirituality, one refers to religion, then it’s really difficult to address…»

«No, never. I think it [spirituality] is a bit taboo. I think it has been so associated with the religious aspect, and you know, religion is not talked about or hardly talked about. It’s rare that I have had such discussions. I don’t even remember having discussions like this with colleagues.»

«I don’t think that it’s in the culture of the medical community to have such exchanges about everyone’s values. I don’t think so.»

Fear of ridicule or anticipation of a negative reaction was often inhibiting: «I was too afraid people would think I was crazy or that I imagined things.»

In this context, participants expressed that talking about spirituality with colleagues was easier on a one to one basis, «depending on the type of relationship that had been established».

«I wouldn’t say the whole team; it’s more like one to one. There are certain colleagues with whom I won’t be able to talk about it one on one or sometimes there will be three of us and we will talk about what we find difficult or easy or beautiful.»

However, participants did recount situations where they had received a positive reaction from colleagues, as when this participant told a story about creating an «oasis of love»

during a team meeting marked by longstanding conflict:

«So I see it as a spiritual principle, so I tried bringing that up: that we try to conceptualize what an oasis of love would look like in our department, how we can help each other, value each other, always see each other through a positive eye, try and avoid bringing negative things one towards the other, and try and note what is positive. So I was able to expose that concept a bit in our team and surprisingly, two people came up to me after to hug me and tell me how they were like, touched.»