Pre-program Tips

To prepare for the program, arrange for a conference room. I like to have the tables in a U-shaped arrangement. Flip charts and marker pens are ideal. Instead of a flip chart you can use a computer and LCD projector to capture the comments of the participants. Using the computer you can print out their comments easily, but I think that participants prefer the flip chart method. Arrange for seven hours of category I continuing medical education (CME) credit. Assemble 2-pocket folders for each participant containing an agenda for the day, a Course Evaluation form, the CME certificate, and possibly a brochure about other programs that you might be offering in the near future. Copies of readings and three case scenarios should be given to the participants at appropriate times during the program and therefore not inserted into the 2-pocket folder before the program. Bring a copy of the book (Remen, R.N.: Kitchen Table Wisdom, Riverhead Books, NY 1996). Mark the story pp. 169 – 172 for reading to the participants. Begin praying for the participants as soon as you know about your program plans. If you do not pray, meditate keeping the participants in mind and visualize wellbeing and wholeness for them.

Two Categories of Physicians to Consider

Physicians generally find Spirit in Medicine useful, but there are two categories of physicians for whom it has special value. First are physicians who are burned out or burning out. Physicians today are under assault. They invested many years to develop their skills, often at great personal cost. Now their work is under growing legal and bureaucratic scrutiny, and they find their incomes, their respect in society, and their job satisfaction deteriorating. When you see them in the clinic, their symptoms are varied. Some show fatigue, lassitude, coolness, and aloofness. Others fail to control anger. Yet others become dominating and abusive as they try to bolster a flagging self-esteem and regain a feeling of control. The second category is physicians’ groups that are newly formed, growing very quickly, or experiencing group dysfunction.

Bringing Physicians to the Conversation

Recruiting styles vary. I worked from a list of the staff physicians and called them explaining the costs and goals. I reported the comments of previous participants in Spirit in Medicine. Using an invitation list helped me insure that I also contacted physicians beyond my personal acquaintances. The medical staff was large. My early attitude was frustration at the low response rates and the need to make so many calls. I soon discovered that those calls were valuable, that there were physicians who needed to talk about practice issues, hospital relations, divorces and children on drugs. Some physicians will resist your invitations, but invite anyway and repeatedly. Several physicians participated only after declining as many as five invitations. A dictum in pharmacy sales is that a physician needs to hear about a new product an average of 29 times before prescribing behavior changes. What does that mean for your recruiting calls? As the word gets out about the quality of Spirit in Medicine, recruiting will become easier.

Recruiting

Physicians are busy. The first challenge with Spirit in Medicine is to persuade physicians to attend. Try to facilitate the program with 6 – 15 participants. An average of three physicians will fail to attend even though they registered. If you recruit 18 and all of them attend, the program will still work well, but adjust the schedule to allow a little extra time for each segment. Brochures, fliers, e-mail announcements and posters improve the physicians’ awareness of the program, but about 0.1% of them register in response. About one in five physicians commit to attend when they receive a personal invitation from you or the hospital’s chief executive officer. Therefore, plan on making 90 personal invitation fill your first program.

Recruiting

Physicians are busy. The first challenge with Spirit in Medicine is to persuade physicians to attend. Try to facilitate the program with 6 – 15 participants. An average of three physicians will fail to attend even though they registered. If you recruit 18 and all of them attend, the program will still work well, but adjust the schedule to allow a little extra time for each segment. Brochures, fliers, e-mail announcements and posters improve the physicians’ awareness of the program, but about 0.1% of them register in response. About one in five physicians commit to attend when they receive a personal invitation from you or the hospital’s chief executive officer. Therefore, plan on making 90 personal invitation fill your first program.

Spirit in Medicine

Spirit in Medicine is an excellent program to use as a first step for the new physician champion. You acquire group facilitation skills, learn group dynamics and learn what enlivens and deflates your physician colleagues. Physicians begin to trust you and your physician care initiative when they realize that they are getting something useful from your program. Spirit in Medicine was originally called Medicine in Search of Meaning and distills some of the concepts from a book by its creator (Bazan, B., Medicine in Search of Meaning, Caritas Communications, 1999). At St. Vincent Hospital I renamed the program because our local physicians resisted the “touchy-feely” name, and the rate of registrations improved. I modified a few other features for our local audience. I learned to facilitate the program from Dan Dwyar. I recommend participating in the program first. Next, lead parts of the program with a mentor before working independently.

Penetrating a Medical Staff

A steady offering of programs can slowly penetrate a medical staff. For example, in the first decade of work at St. Vincent Hospital, there was an average of 56 program registrations yearly. While the penetration may seem slow, 565 registrations were logged in ten years. Numbers do not really tell the story. Some physicians embrace these programs more enthusiastically than others. Some physicians attend several programs; the average number of programs attended by individual physicians was 1.63. I can report no measure of how any program influenced a physician because I used no psychometric testing or social assessments. Nevertheless, there is a halo effect within the workplace that radiates from spiritually mature physicians to other physicians, staff, patients and families.

The Value of Programs

Programs generally bring physicians into contact with you and with your retreat center or meeting place. Programs present an opportunity to build relationships and trust. Physicians have an opportunity to raise spiritual and work-related questions. All the while the medical staff becomes increasingly aware that someone cares about the wellbeing of the physicians. Programs allow you to teach leadership, conflict management, meeting facilitation, faith-sharing and how to maintain life balance. Programs create opportunities for dialogue. Dialogue reduces physicians’ isolation from one another and helps them realize that others have the same successes and frustrations. Programs can be used to restore joy in the practice of medicine and to embed the mission, vision, and values of the hospital.

Debriefing The Dying Man's Journey

This film speaks to the physician’s heart. Consequently there is usually a protracted silence after it is shown. The Chief Facilitator is wise to let the participants break the silence and avoid the temptation to make personal observations or ask guiding questions as in the preceding vignettes. Have tissues available. As this conversation winds down, you may choose to have the physician champion lead the closing segment of the program. Use a flip chart and ask the group as a whole to identify the barriers we experience in serving the spiritual needs of patients. Invite the participants to consider one at a time what barriers they see for families, nurses, support staff, other physicians and hospital administrators. Encourage them to write down one thing that they will put into action. A variation on the action step is to have them self address a postal card and write the action plan on it. Drop all postal cards in the mail between two and three weeks after the conference. Offer a closing prayer. Have participants complete the course evaluations.

Observations of a Dying Patient

Tom covered many important thoughts in this recording. Here are a few so that you can understand how the video recording fits into this program: It was important for Tom to know his prognosis. He was glad that medically futile options were not offered. His first priority was to invite family and close friends to be with him. He believed that the most dangerous thing was to become isolated. Letters from friends and family affirmed that he had done a good job in life. Receiving help from his children reassured him that they will be OK. Pain is a problem, but hospice gives him just what he needs, not more or less. Suffering overlaps with pain and is evil. Suffering is being in pain and being isolated. You lose a little bit of yourself at a time until you have nothing. The battle is to have as much time as possible, to die well and move into the mystery. Physicians wear this armor under the scrubs. We put on too much armor. Physicians fail to take care of themselves and practice personal denial. Some physicians are on a crusade against disease and can’t let go. They often say: “We lost one today.” You didn’t lose one. You just came to the end of your work with one. Death is not like the dramatic portrayal of agony that we see in the movies. You sleep more. You are less present. Patients take a breath every once in awhile. You sit, watch and wonder if this one is it.

Extraordinary Response

After working with us for two more years, Tom learned that he had a terminal cancer. A common response to that news would be to go home and withdraw from personal contacts. Tom’s response was anything but common. Instead, Tom marched down the hallway to the media services department and asked them to make a video recording of his death. Some 1800 hours of recording was edited to 20 minutes of the most poignant, insightful commentary on the experience of dying. The film, A Dying Man’s Journey, debuted at the Heartland Film Festival, and is a part of our program, too. Should you choose to use it, it is available from St. Vincent Seton Cove, 2425 Dugan St., Indianapolis IN 46260.

Attitudes & World View

In contrast to the previous large group dialogue, rather than moving to the next segment before the conversation is exhausted as you will for the first three vignettes, let each participant have the opportunity to state his or her personal commitment. After their comment point out that we learned and will continue to learn about bedside spirituality from the relationships we have in the hospital. Another component of bedside spirituality relates to our attitude and our world view. Those who are dying can have great wisdom in this arena, but rarely do we pause to hear their thoughts. The story of Rev. Tom Stoll can help us. Tom came to St. Vincent hospital after working for 20 years in parish ministry with the Episcopal Church. He enrolled as a chaplain intern and was assigned to our surgery and recovery departments. Over the eighteen months of his internship the atmosphere in the operating rooms slowly changed. Episodes of anger and foul language became less frequent. He talked with individuals, prayed with patients and organized a prayer group for the staff that met early, before the day’s operations began. He was very popular. When he completed his training, the hospital hired him immediately to continue his work. We will continue Tom's story next time.

Confrontation

Vignette #4 considers physician impairment and physician to physician relationships: Actors: Confronting physician (Larry), impaired physician (David) Scene: Larry and David are in the surgeon’s locker room. David has a towel over his shoulder. Larry: Hey Dave. Have you got a minute? David: Yeah, sure Larry. What’s up? Larry: Uh, Dave, this isn’t an easy subject for me to bring up, but I know you are using drugs. David: Whoa Larry! Where did that come from? Nothing could be further from the truth. Larry: That case we just finished. I agree it was difficult, but you were jumpy as a cat on coals. David: That was just it. The case was a bear. Six hours into the case… the clotting factors were depleted. Everything just bled and bled and bled. It was very frustrating. Of course, I was jumpy. Larry extends his hand with a capsule in his palm: Dave, this fell out of your pocket in the locker room last week. I took it to our hospital pharmacist. She tells me it's a type of meth-amphetamine. What are you thinking? Dave in defensive posture: Nah! That pill could belong to anyone. Larry: Cut the crap, Dave. I'm your friend, but I have to go to the Medical Director if you don’t come clean. David: OK, I take them once in awhile. It’s not like I’m addicted or anything. You know the divorce and all. I don’t sleep at night. Then I have to be alert here at work. You know the ridiculous hours we put in here. You’ve got to cut me some slack. Keep it quiet, and I’ll clean up my act. Action freezes to signal the end of the vignette. Questions for the small groups: How can you respond to an impaired physician? What are the characteristics of a stressed physician? What prevents us from offering help? How do you recognize the right time to approach another physician? To what extent are we responsible for our fellow physicians? Can you think of a successful intervention? Without disclosing identities, can you say why it worked well. Questions for the large group: What was the most important concept that you discovered during your conversation? Can you name one thing that you will do personally to help your colleagues?

Staff Abuse

Vignette #3 examines staff abuse and physician to staff relationships: Actor: Nurse Scene: The nurse is on the telephone. Nurse: Yes, and could you send over the Amoxicillin for 408. 410’s IV’s were changed to D5 and half normal saline with 30 milliequivalents of potassium chloride. Yeah…same rate. Nurse hangs up. She speaks to herself: Oopsie! The 2 a.m. sugar on 411 wasn’t called to the doc. Let’s see. Who’s her doc. (She consults her notes.) Oh Jeez, not him. Maybe I could call his partner instead. Maybe he won’t come in today until AFTER the shift change, and I can just let this one slide. Maybe the sugar is OK and it won’t matter that it was called two hours late. (She again consults her notes.) That’s not going to fly. The sugar was 63. This is nuts. I’ve got to call him. Nurse dials the phone and pauses as phone rings: Oh, hello, Dr. Whinnery. Sorry to wake you. I meant to call earlier with Mr. McKnight’s 2 a.m. blood sugar, but we've been swamped tonight with several admissions, staffing is low, one nurse went home sick, there were several codes, and one patient went into DT's. Nurse winces and pulls phone suddenly away from her ear then freezes momentarily to mark the end of the vignette. Some questions to stimulate small group discussion for the third vignette are: What’s happening for the nurse? What does she need? What does the physician need? How can they supply each other’s needs? How can a physician determine what the underlying issues are for the nurse? Is the physician responsible to detect those issues? Can you cite a similar situation that was handled well? Some questions for the larger group discussion: On our staff today how do you see physicians serving the needs of nurses and staff? In an ideal medical staff how would physicians serve the support staff? What would it take to reach the ideal?

Appropriate Faith Conversations

Vignette #2 explores proselytizing and physician to patient relationships: Actors: Physician and patient Scene: Patient sits in chair with blanket to simulate a patient in bed. The physician is making note in the patient’s chart. Patient: I am so happy that my heart attack was mild, and thank you for doing my open heart surgery so quickly. I feel like I've been given a second chance in life. I'm so grateful. Physician: God has given you that second chance. He has something in mind for you. Do you have a personal relationship with the Lord? Do you have a church home? Patient: Well, I haven’t been much of a church-goer. You know. Sometimes at Easter I’ll take the family. Maybe it would be a good thing. I’m not really not sure. Physician: Our church has a wonderful course called "Getting to know God in the New Millennium". . . I'll leave some literature for you and your family. For now let's go to God on bended knee and with a humble heart for the gratitude which we all feel at this moment. Patient: Doc, you’re gonna have to help me out of bed. I've just had open-heart surgery. The actors freeze momentarily to mark the end of the vignette. Some questions to stimulate small group discussion for the second vignette are: What did you think of this physician’s remarks? What would you do differently? Is it ever appropriate to share your faith with a patient? When is it appropriate to share your faith or beliefs? How do you do it? What are the signs and symptoms of spiritual distress? What are some good openings? Are you aware of publications about this? (Ref Prayer is good medicine by Larry Dossey as a reference.) Some questions to stimulate large group discussion for the second vignette are: What did you talk about most in your groups? What surprised you during your conversations? How will you change your practices? While the participants are fully engaged and before the dialogue is fully completed, move to dinner. The conversations will often continue informally over the meal. Resume the program after the meal. Allow about 45 minutes for dining.

Medical Futility and Relating to Patient Families

Vignette #1 deals with medical futility and the physician’s relationship to the patient’s family: Actors: Nurse, Family Member, Physician Scene: Family Member, Mrs. Crane, is seated. The nurse enters. Mrs. Crane stands, eager for news. Nurse: Mrs. Crane? Mrs. Crane nods: Yes. Nurse: Have a seat. I’ve been going over Frank’s situation with the nurse that took care of him last night. It is clear that he will need dialysis because his kidneys are still not working. Water and toxic substances are beginning to build up in his body. He had a repeat brain wave test, an EEG, late yesterday and still there is little activity. As you know Frank has not regained consciousness since his operation two weeks ago, and there has been no change overnight. The prognosis is not good. Mrs. Crane wipes her eye and tries to keep her composure: We aren’t surprised. We all talked yesterday. You know…about Frank. He really fought the good fight. We all wanted to hear something else…a miracle, I guess, but we all knew that the end was near when Frank came into hospital. Physician enters: Good morning Miss Flynn, Mrs. Crane. Nurse Flynn: Good morning Doctor. I was just updating Mrs. Crane on her husband’s condition, that his kidneys are failing and that his repeat EEG shows minimal activity. Mrs. Crane and the family understand that Frank is at the end of his life. Physician: Oh! Oh! Wait a minute. Let’s not give up just yet. There are still things we can do to try to save him. Admittedly, his life will not be like it was before, but it’s not over. We can start dialysis. We can continue to support his breathing with the respirator. He will need a tracheostomy in the next two or three days. I just wrote orders for total parenteral nutrition so that he doesn’t starve. The situation is not hopeless. Mrs. Crane: My husband didn’t want this. None of the family wants this for him. Can you just keep him comfortable? Physician: I know all of these tubes and treatments are frightening but they help him stay alive. Look, just trust me that more can be done. The actors freeze momentarily to mark the end of the vignette. Some questions to stimulate about 10 minutes of small group discussion for the first vignette are: What are the issues for the family member? What are the issues for the physician? Underlying motivation and belief about each of their decision making processes? What does the family member need? What is behind the difference in approach of the physician compared to the nurse? What did you agree with or disagree with regarding the physician’s response? Some questions to stimulate about 10 minutes of discussion by all participants about the first vignette are: What was the most important theme for your discussion group? What made it so important? Whose opinions should dominate medical decision making? Why? How should care-givers respond when there is a disparity in treatment goals? Best practices will come out of these dialogues. Writing the best practices on a flip chart keeps the ideas in front of the participants.

Have a Good Time

The segment entitled “What is Spirituality?” allows the Physician Champion to reiterate the differences between spirituality and religion. I also introduce the concept of the Spiritual Formation Field as conceived by Van Kaam. This sets the stage for understanding the following clinical vignettes as a part of the formation field. As you prepare the program, a few inquiries will turn up 3 – 4 amateur actors on the staff. The vignettes run no longer than 3 minutes and stop in mid-action with key unresolved issues. The table facilitators begin a dialogue about the issues. Because our program began with cardiovascular physicians, our whimsical acting troupe called themselves The Cabbage Patch Players. It is important to have a good time.

Linking to Patient Satisfaction

Choose an administrator for the next segment who is knowledgeable about patient satisfaction and who is trusted by the medical staff to tell the background of the program. Give data about patient satisfaction and tell what features of care are important in creating satisfaction. Remind the participants of some basic behaviors that foster satisfaction: • Let the patient know who you are. • Sit close to the patient. • Ask the patient what they want to accomplish and what they understand about their illness. • Touch the patient appropriately. When we began this program we discovered that about 75% of patients wanted their physicians to address their spiritual and emotional needs. By contrast, only 2% reported that their physician had actually done so. Tell descriptive stories about how one or two respected physicians have demonstrated spiritually fulfilling behaviors in the hospital.

Reflection Questions for the preceding scripture

Ask the participants these reflection questions leaving 15 – 20 seconds between each. Do not ask them to respond verbally, but if someone spontaneously volunteers, encourage their comment: What would it mean to be bent so that you could not straighten? What would it be like to walk, or bathe, or look out at the countryside? Where are you in this story? Are you the woman? Have you lived with infirmity? Are you the healer? Do you relieve distress? When you touch are you healing or are you healed? Are you the synagogue ruler? Are the rules important to you? Are you one of the people, delighted by the miracle? Are you Satan? Do you bind and control?