Despite an efficient tuberculosis-control program, nearly a third of new cases of tuberculosis in San Francisco are the result of recent infection. Few of these instances of transmission are identified by conventional contact tracing.

As patients near the end of life, their spiritual and religious concerns may be awakened or intensified. Many physicians, however, feel unskilled and uncomfortable discussing these concerns. This article suggests how physicians might respond when patients or families raise such concerns. First, some patients may explicitly base decisions about life-sustaining interventions on their spiritual or religious beliefs. Physicians need to explore those beliefs to help patients think through their preferences regarding specific interventions. Second, other patients may not bring up spiritual or religious concerns but are troubled by them. Physicians should identify such concerns and listen to them empathetically, without trying to alleviate the patient's spiritual suffering or offering premature reassurance. Third, some patients or families may have religious reasons for insisting on life-sustaining interventions that physicians advise against. The physician should listen and try to understand the patient's viewpoint. Listening respectfully does not require the physician to agree with the patient or misrepresent his or her own views. Patients and families who feel that the physician understands them and cares about them may be more willing to consider the physician's views on prognosis and treatment. By responding to patients' spiritual and religious concerns and needs, physicians may help them find comfort and closure near the end of life.

OBJECTIVE:To investigate patient preferences for a patientcentered or a biomedical communication style. DESIGN: Randomized study.SETTING: Urgent care and ambulatory medicine clinics in an academic medical center. PARTICIPANTS:We recruited 250 English-speaking adult patients, excluding patients whose medical illnesses prevented evaluation of the study intervention.

Prayer and religious ceremonies may help patients near the end of life and their relatives find comfort and discover meaning in their lives. In this paper, we analyze how physicians might respond in two situations regarding prayer and religious ceremonies. First, how should physicians respond when such patients or their families ask physicians to pray for them or with them? Physicians' responses to such requests will depend on their own religious and spiritual beliefs, the congruence of their beliefs with those of the patient and family, and their relationship with the patient. Many physicians may be willing to be present and stand silently while the patient prays. Second, how should physicians respond when such patients and families seek to carry out their religious and spiritual practices in the hospital? Religious ceremonies can provide meaning, hope, and solace to patients and families. Institutional guidelines regarding religious ceremonies should allow as much leeway as is compatible with good care both for the patient for whom the ritual is offered and also for other patients within the facility. Physicians should inquire whether there are religious and spiritual practices that patients and families would like to engage in. However, physicians should be cautious about recommending specific ceremonies or pratices. Physicians can respond to requests and respect patients' spiritual needs in ways that may deepen the therapeutic doctor-patient relationship, without compromising their own religious and spiritual beliefs or professional roles.