Starting Reflection

We begin by showing a video entitled: “A Woman Bent Double”. (Available from St. Vincent Seton Cove, 2425 Dugan St., Indianapolis IN 46260.) This reflection sets the tone of the conference by highlighting health issues in the context of a sacred encounter. That tone allows the participant to look for the sacred in the remainder of the program. If you do not have the video, read this passage with an unhurried pace: Luke 13: 10 – 17 “On a Sabbath Jesus was teaching in one of the synagogues, and a woman was there who had been crippled by a spirit for eighteen years. She was bent over and could not straighten up at all. When Jesus saw her, he called her forward and said to her, ‘Woman, you are set free from your infirmity.’ Then, he put his hands on her, and immediately she straightened up and praised God. Indignant because Jesus had healed on the Sabbath, the synagogue ruler said to the people, ‘There are six days for work. So come and be healed on those days, not on the Sabbath.’ The Lord answered him, ‘You hypocrites! Doesn't each of you on the Sabbath untie his ox or donkey from the stall and lead it out to give it water? Then should not this woman, a daughter of Abraham, whom Satan has kept bound for eighteen long years, be set free on the Sabbath day from what bound her?’ When he said this, all his opponents were humiliated, but the people were delighted with all the wonderful things he was doing.” I will include some reflection questions with my next post. Meanwhile, have a blessed Christmas.

Participant comfort

Because physicians do not stream in on time, allow 15 minutes for them to gather, make name tags and find a seat. Good dialogue occurs best in a safe, comfortable setting. Time spent orienting the participants to the facility, the agenda and their conference materials contribute to the general comfort level. The physician champion should orient the participants since he or she will be better known. The physician champion introduces the Chief Facilitator. From that point until the end, the Chief Facilitator serves as master of ceremonies and facilitates sessions of dialogue that involve the entire group.

Schedule of events

Here is an example of a program that we entitled: Spirituality & Disease Management for MD’s (4:30 p.m. – 8:45 p.m.) Rationale: To help physicians serve the spiritual needs of patients, families and staff. 4:30 p.m. – Participants Gather 4:45 p.m. – Physician Champion: Welcome 4:50 p.m. – Chief Facilitator: Opening Reflection – Video: “A Woman Bent Double” 5:00 p.m. – Quality Administrator: Patient Satisfaction 5:10 p.m. – Physician Champion: What is “Spirituality?” 5:25 p.m. - Cabbage patch players: Vignette #1 5:50 p.m. – Cabbage patch players: Vignette #2 6:15 p.m. – Chief Facilitator: Blessing & Dinner 6:45 p.m. – Cabbage patch players: Vignette #3 7:10 p.m. - Cabbage patch players: Vignette #4 7:35 p.m. - Chief Facilitator: “A Dying Man’s Journey” 8:15 p.m. – Physician Champion: What are the barriers to serving spiritual needs? 8:35 p.m. – Physician Champion: Closing Prayer 8:45 p.m. – Complete evaluation forms I'll elaborate on some of these entries in my next post.

Pre-conference preparation

The faculty meets thirty minutes before the participants arrive for final instructions and to pray. The faculty consists of an overall Chief Facilitator, two or three actors from the hospital staff and a table discussion facilitator for four to five participants. Include a chaplain and an experienced nurse at each discussion table. It is best if the nurses have participated previously in their staff program. Physicians who have previously participated should facilitate the table discussions. If you have never offered this program, have a special session so the facilitating physicians can experience it in advance. Because physicians facilitate small group discussions infrequently, review the mechanics of facilitation before the participants arrive.

Vignettes & Dialogue

The program was originally entitled “Spirituality and Disease Management”, but “Bedside Spirituality” describes it better. Participants scrutinize critical physician relationships in the hospital, namely the relationships with patients, patient’s families, other health workers, and other physicians. They explore spiritually depleting physician behaviors, namely proselytizing, addictions, staff abuse, and the use of medically futile treatment. Staff members act out short vignettes. Then questions and dialogue bring out stories that teach the best behaviors. Physicians, like most people, tend to modify their behavior toward the group norm. Since physicians rarely have conversations like this, they are not clear on the group norm or even what one or two other physicians are doing. These conversations accomplish much. A seasoned facilitator is a must.

Spirituality and Disease Management

Several members of our mission team noted that a didactic approach often closes the door to spiritual conversation and limits the development of excellent practices. In response selected members of our hospital staff developed a day-long retreat for nursing teams that included ample time for reflection and storytelling. The architects of the program comprised about 15 people including nurses, chaplains, physicians, managers and human resources specialists. Realizing that physicians will act more readily on truths that they discover themselves and on truths that are endorsed by physician colleagues whom they trust, we deleted much of the didactic material from the nurse program; we shortened the retreat by half to make it accessible for physicians. Attendance was best when we held the program between 4:30 p.m. – 8:45 p.m. and included dinner. A safe environment is needed for the dialogue. While cerebral physicians usually talk at the “head” level, this dialogue effectively encourages physician conversations at the “heart” level. Storytelling nearly always brings best practices to the surface.

Bedside Spirituality

What happens at the patient’s bedside is the focus of hospital medicine. Nurses and physicians dominate those events and come with diverse attitudes about what spiritual expressions are appropriate. Most expressions are well-intended. Some will be incompatible with the institution’s mission or style. In no other area can the challenge of modifying physician behavior be greater. How does one foster best practices?

Orientation Overview

The physician champion does not require detailed knowledge of formative theory, but through it the direction of the orientation may be clearer. It starts in appraisal and moves toward spiritual direction. Another way of thinking about this orientation program is that is promotes a confluence of three spiritualities, the physician’s, the patient’s and the hospital’s, where the hospital’s spirituality is expressed in its mission. It is a reminder of why we are here. It is a reminder we need often.

Formative Analysis

This orientation is spiritually formative. Each segment is designed to provide a formative event. Over the course of the orientation the participants can engage in a number of spiritual practices. Each spiritual practice is only briefly experienced but has a rich tradition to explore. The following chart gives an overview with the formative elements that dominate each segment: Formation/Learning Formative Spiritual Segment Objective Event Practice 1 Gather & Breakfast Field Appraisal Conference 2 Hospital History Information Reflection, Reading 3 Meaning of Spirituality Information Journaling, Conference 4 Examining Purpose Resistance Centering, Appraisal Journaling 5 Spirituality Disposition Listening in Health Care Appraisal 6 Personal Care Spiritualizing Reflection Disposition 7 Opportunities Spiritual Spiritual Direction Direction The formative events refer to descriptions in Van Kaam’s formation theory

Providing Mission Opportunities

A third opportunity to offer new physicians is the Physicians Outreach Network. The network is a large group of physicians who work in charity clinics, provide relief services and travel on mission trips. They meet periodically and provide information about mission opportunities. For more details on Physician Outreach Network visit PhysicianFormation.com New physicians would be able to join one of the projects. Physicians might wonder how to fit that in to their schedules or think that family obligations will prevent participation. The participating physicians have successfully dealt with all of those issues, too.

Coaching Doc 2 Doc

The message I like to give physicians during orientation includes a pitch for coaching: When you are in transition it is valuable to have another physician coach you. We have a group of physicians who have been specially trained to provide this service for you. While coaches can be very expensive, these physicians care so much about their colleagues that they donate their time and expertise. We call this program Doc 2 Doc. It is voluntary. If you are interested we would interview briefly to help find you the right coach. You would meet with your coach for an hour every two weeks for about three months. Many new physicians believe that they must work with someone in their own specialty, but it is better to be paired with someone outside your specialty. Many new physicians believe that their new partners will adequately coach them. However, few physicians are trained to coach new physicians, and although partners can be helpful, new physicians may need help with partner relationships.

Learning from Chaplains

Encourage new physicians to make an appointment with one of the hospital chaplains. Spend two hours with the chaplain on rounds. Chaplains approach patients quite differently from us physicians, and we physicians can learn much from even a brief time with them.

Preparing to Heal

If lack of self-care empties our spiritual cup, spiritual practices fill it. During this orientation you had a tiny experience of prayer, spiritual reading, meditation, journaling, and conference. Developing these as daily practices brings you to the bedside prepared to be a healer. In medicine we say we heal when we mean we cure. You are already prepared to cure patients. I invite you also to heal your patients.

Self Care

Spirituality is something we bring to our work. We cannot bring what we do not have; what we bring depends partly on how well we take care of ourselves. So, think about how many hours of nightly sleep you recommend for your patients, and how many hours of sleep you got last night? Do you get regular exercise? How much time did you spend last week recreating or participating in family activities? You are new on the medical staff. This is an excellent time to check any addictive behaviors. Work itself can be addictive; review your schedule. Is your life balanced? If you are using recreational drugs, we can provide confidential help in turning that problem around. Alcohol, tobacco and sex can all be addictive. Now is the time to check your habits.

Personal Inventory

Spirituality is something we bring to our work. We cannot bring what we do not have; what we bring depends partly on how well we take care of ourselves. Invite new physicians to think about some of the basics: So, think about how many hours of nightly sleep you recommend for your patients, and how many hours of sleep you got last night? Do you get regular exercise? How much time did you spend last week recreating or participating in family activities? You are new on the medical staff. This is an excellent time to check any addictive behaviors. Work itself can be addictive; review your schedule. Is your life balanced? If you are using recreational drugs, we can provide confidential help in turning that problem around. Alcohol, tobacco and sex can all be addictive. Now is the time to check your habits.

Spiritual Healing Restores Purpose

Illness has a shadow side, too. It deforms the spirit of your patients. Its messages are: “I may not be able to work again,” or, “I will be bankrupt from medical expenses,” or, “Who will take care of my children?” These are a few examples of threats that sick people have to their meaning and purpose. Spiritual healing restores purpose, and at its best, restores purpose that transcends life on this planet. For example, Dr. Ira Byok, a pioneer of the hospice movement, told me that he encouraged terminal patients to write thank you notes to their physicians for things like breathing treatments. The physicians received these notes posthumously, were touched by them and found new enthusiasm for treating terminal patients. The patients who wrote these notes found transcendent purpose even in the closing days of their lives.

Patient Spirituality Assessment

When you see patients consider making a spiritual assessment. There are several ways to do this, but a simple, quick and direct method is FICA, now in fairly common useage. This mnemonic will be easy for American readers. To take a spiritual history, ask your patient four questions: F – What is your faith tradition? I – What is important to you? C – Do you have community that supports you? A – How do you want me to address this during your health care? You may find easy opportunities to link your patient with their faith community, but you will certainly discover what spiritual care they desire. For many it will be an important link to their physical healing.

What You Bring to Work

The spirit of medicine can be deformed by our training and by other experiences in practice. What spirit do you bring to the bedside? There is a Sufi parable which illustrates this concept. The story is set at a building site where a great sanctuary is under construction. At the base of this growing structure three men are busy cutting stone. After the stones are cut they are hoisted onto the top of the rising wall by a crane. A passer by approaches one of the stone cutters and asks, “What are you doing?” The stone cutter replies, “Can’t you see? I’m cutting stones.” The passer by walks on a short distance to another cutter and asks, “What are you doing?” The second cutter responds, “I’m working to earn a living for my family. My son will get an education and live a better life.” The passer by asks the third cutter also, and he replies, “I am helping to build a great sanctuary.” All three of the stone cutters were cutting stone. All three brought a different spirituality to their work. In the work of a physician, spirituality is something you bring to the bedside. You cannot expect to be an instrument of spiritual healing for patients if your spiritual cup is empty. You cannot expect to be an instrument of spiritual healing for patients without some simple tools.

Effects of Training

New physicians are fully trained, and the training experience changes them. At this point of examining anew their life direction, they profit by insight about the effects of training. I like to use a didactic method; give them a little “chalk talk”. Here is a sample message for this part of orientation: Our perspective of what is meaningful and significant is deformed by the pressures of culture. The medical training culture is very effective at changing our drive and direction. Dr. Rachael Remen refers to this as the “shadow” of medicine. The practice of medicine has its good side. Most of the practice of medicine is inherently good, but there is a shadow side as well. Dr. Remen noted that the “shadow” of medicine is what prevents you from standing up in grand rounds and saying that medicine is an expression of love for our patient. A freshman medical student might be foolish enough to say that, but our medical schools, our residency training, and our crisp, cool professionalism squeeze those thoughts out of the public forum, and ultimately out of the minds of practitioners. The shadow of medicine is very functional. It focuses on getting things done, but the shadow behaviors can be disturbing. They can be things like browbeating the staff, sounding off to patients, or throwing instruments in the operating room. Frankly, behaviors like that are unacceptable in our hospital. We have a Code of Conduct. Read it. Learn it. Don’t break it.

Actual Spirituality

After physicians have identified what is important. Help them consider this more difficult question invite them to examine their schedule and determine where they spend most of their time. Also, encourage them to examine their bank account to determine where they spend their money, and to think about their dreams and fantasies. These all serve as pointers to the spirituality that they actually live. In other words, these indicate how they try to acquire a sense of purpose and significance in life. Joining a new medical staff is a significant point of transition and therefore a good time to re-examine life direction.

Explore purpose

Invite the participants to use their journal again, asking: “Where do you find meaning and purpose in life?” A clarifying questions helps: “What is most important to you?” Use the pattern of journaling followed by dialogue as with the previous question. Answers to these questions come in two categories, connections and accomplishments. The connections refer to things like family, friends, social and political groups. The accomplishments are described differently but are examples of money, power, or prestige. Some participants will answer that faith or God is important and gives meaning to their lives. For some the faith response is about the social connections of their faith community. For others it is about personal faith practices and how they feel about the way that their faith accomplishments measure up. Most people answer this question based on their idea of what should be important in life.

Religion vs Spirituality

Physicians give a variety of answers, emphasizing the misunderstandings we have for each other’s spirituality. Many of the answers will describe spirituality as religion. This answer is the springboard for you to differentiate between spirituality and religion. One is tempted to launch a monologue as soon as one of the participants triggers this idea. Delay until all of the participants have spoken. For the physician champion these are useful definitions of religion and spirituality: Religion is a system of belief, worship, conduct, doctrine and governance to which a group of people adhere. Spirituality is that which gives meaning and purpose to life. In other words, spirituality is not so much something you achieve or a set of rules. It is something you are.

Journals

Telling physicians about spiritual practices is not as inviting as a personal experience. Use journals for this part of orientation. Allow participants a few minutes to consider the question: “What does spirituality mean to you?” Ask them to write their answers. Watch them for indicators that they have finished writing. They ordinarily write for about three minutes. Occasionally, someone will try to write a dissertation. If so, ask if anyone needs another minute; then you can bring the group back together after a brief pause. Let each one comment on the question. Rarely, someone will decline. Do not press them; pressure destroys the crucible of safety that you have labored to create. Journaling is tempting to delete, but it dramatically enriches the ensuing dialogue.

Moments of Reflection

At the conclusion of this reflection allow about 15 – 30 seconds of silence before resuming. This is a good time to let new physicians on the staff know that meetings at your hospital are expected to begin with a reflection or a prayer. Reflections are a time to settle ourselves, recall our purpose and find the context of our work. If they are asked to lead a reflection and panic ensues, they can call for help. There are other opportunities to reflect. For example, stop for a few moments during the Morning Prayer when you hear it broadcast through the hospital. Link reflections or prayers to your habits. For example, reflect or pray when you cleanse your hands before entering the patient’s room or as you dictate the discharge summary.

Immersion

Therefore go and make disciples of all nations, baptizing them in the name of the Father and of the Son and of the Holy Spirit, and teaching them to obey everything I have commanded you. And surely I am with you always, to the very end of the age. (Matt. 28:19–20) This saying is absolutely freighted with significance, but I would like to focus on three key words today. Those words are: baptize, name and command. I am going to start with the word name because it doesn’t refer to a label or a moniker. In the language of the first century Middle East, the word name signified the character of a person. This passage doesn’t use names, pleural, but name, singular. The way this passage reads, all three members of the Holy Trinity have the same name. In other words they have the same character. They are the same in their nature. Now the word “command” in this passage really refers us back to the character of the persons of the Holy Trinity. Jesus’ command is to obey everything I have commanded you, but the character of the Holy Trinity is revealed in the commands of Jesus. We just went over his principal command. He said to love one another. As we think about the way we do health care within faithful institutions, like hospitals and clinics. We need to think about how we teach this love to our physicians, staff and the patients who enter our doors. This passage clarifies how we are to do that, and that brings me around to the word “baptism.” Baptism is a ritual of some denominations. Baptism is practiced in different ways, but the image evoked in this passage is of immersion. I don’t believe that this passage tells us to practice ritual baptism in the care of patients or even each other. I believe, rather, that it tells us to immerse all of the people in our hospitals and clinics with selfless love. Some of those people whom we immerse will also be patients. We talk about having a culture, in America, in the South, in our hospital. We are immersed in our cultures. They may be efficient, or pleasant, or toxic, or businesslike, but this commission of Jesus, sometimes called the great commission, tells us that we are to make our culture loving.

Healer's Attitude

The second saying that I like to use is John 13: 34 – 35 "A new command I give you: Love one another. As I have loved you, so you must love one another. By this everyone will know that you are my disciples, if you love one another." I call this an attitude because love is so often taken as an emotion. This love that Jesus mentions here is not emotion but a matter of will. It is not simply affinity but a profound desire to achieve ultimate good in other souls. It is a desire so profound that it can even evoke personal sacrifice to achieve ultimate good for another person. How would we know exactly what ultimate good would be? From Jesus’ sayings it is clear that his view of ultimate good is to be at one with the will of our creator, and that brings us to the third saying that defines the goal of our healing work and our healing attitude.

Reflection 1

At this point one of our hospital chaplains provides a reflection. One of our chaplains likes to read these quotes with an instrumental version of “As I Walk Through the Storm” playing in the background, and it seems to work well as the participants reflect on three excerpts from scripture. The first is: Matthew 25: 34 -40 “Then the King will say to those on his right, 'Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.' "Then the righteous will answer him, 'Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?' "The King will reply, 'I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me. I won’t try to dissect all of the details in this passage, but it specifically mentions three concepts that are integral to Christian healing: 1. We must visit the sick. 2. We must supply people’s needs. 3. The creator identifies with sick people. While this passage identifies what we are supposed to do to be healers, the passage for next week tells us what our attitude needs to be.

Broadening Access

I think the message that you give new physicians is important and of course you adjust it for the institution. I give you this example based on the Ascension Health Mission Statement: This mission that you are joining has some other implications for your practice. Note that we serve the poor and vulnerable. For instance, do you accept charity patients? Do you accept Medicaid? Some of you will find the “Catholic” part of this statement troublesome. If you are Roman Catholic, this will be an easy part of your Catholic identity. If you are not, recall that “catholic” simply means “universal” and implies that we serve everyone from prince to pauper. Nevertheless, “Catholic” ministry implies adherence to the Religious and Ethical Directives of the Church. Notice the dedication to “spiritually centered, holistic care”. Holistic is not about nuts and berries. Rather, it is a care with three dimensions: spirit, mind and body. Finally, there is a social advocacy that extends even beyond our medical work. This is the mission you join when you practice here. What drives this healing mission are sayings by Jesus of Nazareth

Mission-Vitality Connnection

The vitality of an institution is in its roots. For instance, the vitality of a tree is in its roots. The entire tree may be cut down, and shoots of new growth can be seen weeks later emerging from the roots. So, the new physician to understand the vitality of St. Vincent Hospital, for example, they must understand its roots. The roots are in the loving ministry of Jesus as healer. These are key words: “loving”, “ministry”, and “healer”. Invite the new physician to spend some time thinking about what those terms imply for thier practice. Invite them to consider how physicians express love at the bedside or at the nurse’s station? Ministry is about serving. How can you best serve those around you, including your family? What does it mean to be a healer?

Hospital as Mission

We think of our hospitals as hospitals but if they are faith-based they are actually a mission, meaning that we are sent here for a special purpose. I practiced in an Ascension Health hospital. Ascension describes its mission this way: “Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care, which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words.” Other hospitals and systems use different descriptions but have a similar focus.

Framework is Important

The next component is to give a brief institutional history. The feedback I received by way of the program evaluations revealed that institutional history was not deeply cherished. I adjusted my presentation in response. I shared this negative feedback with subsequent physicians and emphasized that this story tells why we do health care and why we do it a certain way. Later evaluations disclosed that reframing the story made it the “most helpful” part of orientation on about 25 per cent of the evaluations.

Setting the Stage

As people arrive use soft instrumental music to help them calm themselves. The informal social time over breakfast helps participants feel comfortable in the setting and allows some early networking. Start the orientation on time even if 90 per cent of the participants have not yet arrived; honor the time of the physicians who honored your time. Organize the meeting room with seating around a table and let each person give name, specialty, and group affiliation. Ask, “What appealed to you about practicing at this hospital? What concerns do you have as you start a practice here?” These opening questions help the participants see that their motives and challenges are not that different from the others.

Some Particulars

Have a sign in station so that you can record the names and contact information of the participants. Arrange for food services. At a minimum place an agenda, a small journal and a pen at each participant’s place. With amazing consistency about 40 per cent of new physicians show up without a pen or pencil. Consider providing some other materials like brochures on other programs that you have, especially brochures about mentors and mission work. Have the chaplain supply business cards. Provide a manual or flash drive with the deluge of information that you were tempted to use for the orientation. Finally, have an evaluation form to get program feedback. Much of the orientation depends on how the physician champion relates to the physicians. That feedback proves invaluable.

A Different Kind of Physician Orientation

Physicians have personal conversations during orientation, and therefore the environment must feel safe to them. To achieve the feeling of safety, limit the attendance to new physicians, a hospital chaplain, and you, the physician champion. If the Chief Executive Officer or other administrators want to present something, it should be at the very end.