Sunday, November 12, 2006

Reinventing the wheel -- the power of story

Right before Shabbat on Friday, I put up a post where I mentioned an excellent lecture I attended on Friday.

The lecturer there wonderfully expressed something that has been of a burning concern for me for some time now. He was talking about the issue of spirituality in medicine and about the explosion in recent years of writings and conversation about it. He noted that almost all of this writing and conversation has been by medical personnel -- doctors and nurses -- and _not_ by chaplains. Further, in making their definitions of spirituality, these doctors and nurses almost _never_ cite the works of theologians. Rather, they make up their definitions simply out of their own experience or by citing the works of other doctors writing about spirituality.

"We need to be intentional about being part of this conversation if we want to be part of it," the lecturer said.

I couldn't agree more. We, in the Clinical Pastoral Education movement, in particular, are not doing enough to let people know about the work we are doing. I believe that it is we who are the great experts on Spirituality in Healthcare and on how to bring Spiritual Care to people (and, especially, in how to
train people to properly bring Spiritual Care). But, it seems to me that -- in fact -- we are only rarely seen that way by people outside our discipline. . . . . And, ultimately, I think this is our fault. We are not getting the word out about what we know and have learned. . . . Especially about the (excellent) training techniques we have devised to help people develop the ability to be present for a suffering person. . . . Especially about the training techniques we have developed to help people develop excellent listening skills and the ability to use those to help patients to tell their stories and to thus both feel heard and find profound healing. . . . And so, others are reinventing the proverbial wheel that we could have instead been helping them with.

I first wrote about this in a posting I put on the National Assocation of Jewish Chaplains mailing list in June.
I was at a conference in New York on Illness and Loss that was put on by the Shira Ruskay Center (among other Jewish organizations). The keynote speaker, a physician by the name of Joan Borysenko, gave a presentation on "Spirituality and Healing". At the end, she gave a plug for a Spiritual Direction program she is helping set up . A key question in trying to formulate that program, she said, is trying to find out if there are ways you can "teach presence."

I felt like jumping out of my chair and shouting: "Teaching people how to be _present_ for ill people? That's what we've been doing in CPE for decades!!! Of course, you can teach presence!"

I did not, in fact, jump out of my chair. But I went up and spoke to her afterward, and asked her, What about Clinical Pastoral Education? Do you think we in CPE are not succeeding in teaching people how to develop the ability to be present?"

Her response: "Clinical Pastoral Education? What's that?"


I thought again about some of these issues last Tuesday when I was at the Lutheran Seminary in Gettysburg for a "CPE Day" that was being held there.
I participated in a round table discussion led by Leonard Hummel, the associate professor in Pastoral Theology and Pastoral Care at the Lutheran Theological Seminary in Gettysburg, PA. I learned there for the first time about Dr. Rita Charon and the Narrative Medicine program she has developed at Columbia University (check out this NPR report for a great intro to this).

The keystone of her approach is to ask medical students to keep "Parallel Charts" on their patients. These are in addition to the normal medical chart that is normally kept on each hospital patient. In the parallel chart, the students write a "narrative" describing their experiences with the patients and their understanding of the story the patient tells them. By writing reflectively there, Charon writes in one
article , the physician learns to "more accurately understand what their patients go through and also what they themselves endure in the care of the sick."

Sound familiar? If you have had any experience in CPE it should. It sounds like the whole process of verbatim writing and presentation that we developed nearly 100 years ago now.

In the same article, Charon also writes:

What narrative medicine offers that the others may not be in a position to offer is a disciplined and deep set of conceptual frameworks -- mostly from literary studies, and especially from narratology -- that give us theoretical means to understand whyhow
acts of doctoring are not unlike acts of reading, interpreting, and writing and such things as reading fiction and writing ordinary narrative prose about our patients help to make us better doctors.
Wow, studying a patient's story with the same tools you would study a text. If that doesn't sound like the Anton Boisen's "living human document" I don't know what does! [Boisen was the founder of CPE. He introduced the concept of viewing each patient as a 'living human document,' who could be respected, valued and learned from. Essentially, he asked that the chaplain view each person as a source of the Holy and the source of learning, just as we might view a biblical verse as a source of the Holy and a source of wisdom. This concept of a living human document sits at the core of Clinical Pastoral Education.]

At the seminary in Gettysburg, Professor
Hummel talked about a "five minute protocol" for doctors to interview patients about their lives and that this commitment of such a short period of time had yielded great gains for patients. . . . Looking at my notes, I can't recall whether that protocol is Charon's or if it is in a book I'm excited about seeing (we ordered it at the hospital). It's called Spiritual Transformation and Healing: Anthropological, Theological, Neuroscientific, and Clinical Perspectives. Professor Hummel co-wrote a chapter in there.

Here is part of what the publisher's blurb says about it:

Joan D. Koss-Chioino and Philip Hefner's new volume is unique in exploring the meaning of spiritual transformation and healing with new research from a scientific perspective. An intedisciplinary group of contributors-anthropological, psychological, medical, theological, and biological scientists-investigate the role of religious communities and healing practitioners, with spiritual transformation as their medium of healing. Individual authors evaluate the meaning of spiritual transformations and the consequences for those who experience it . . . .


In reading about Narrative Medicine, I was reminded also of a great lecture I heard at the hospital here late last month by Dr. Ira Byock, an expert on Palliative Care who heads up the palliative care program at the Dartmouth Hitchcock Medical Center. Residents and other doctors at the hospital were extremely interested in talking with him at a small group session after the lecture. One doctor described to him a case about a young woman with a serious cancer who was very concerned about trying to maintain her physical appearance.

After the doctor described the case along with an extensive description of the patient's symptoms and the treatments offered, Byock responded, "you haven't told me very much about her as a person." He added that her suffering was likely not only from the afflicted body parts, but was from something broader.

He also talked about the importance of someone listening to the patient and hearing her story. He said that the problem that blocks this process is that patients are visited by members of the medical care team who "make people uncomfortable because they have their own
agenda . . . and checklists that can block the forming of relationship. . . It is ultimately about being fully present."

All I can say is, "Amen, brother." This is what I believe CPE has always been about. About advocating for the medical care team to treat a patient as a
person. About learning how to put our agendas aside when we enter a room so we can be fully present and open to forming a relationship with the patient. These are very hard things to learn how to do. We spend a great deal of time and energy in CPE helping people to build these important skills.

The questions is, as one of the doctors asked Byock at the session, why have
doctors become the ones who are in charge of this? Why are doctors becoming the experts on spirituality with patients, and with issues relating to how patients can best deal with their own deaths? Haven't people had cultural ways of dealing with this through the ages? Why are doctors getting so involved in this now?


Of course, I have to admit that I very much like the work of some of these doctors! One book I bought not long ago that I really liked was Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine
by Dr. Barry Bub. He makes a very compelling case that a commitment of only five minutes or so by a physician to learn about a patient can make a world of difference.

What I especially like about Bub is how seriously he takes the issue of listening. Most people think listening is the easiest thing you could do -- you just sit there and listen!

But, as Bub points out, psychotherapists and chaplains go through extensive training to develop their listening skills. This is for a reason. Listening well is actually quite difficult. But, it can also be learned.

Bub -- and I really admire him for this -- went and got himself training both in the therapy field and in the chaplaincy field. I believe he did a unit of CPE at the
Healthcare Chaplaincy in New York.

Another doctor who has written on these issues (and done quite well selling her books!) is
Rachel Remen. Besides spending a few minutes with one of her books in a bookstore once, I haven't had a chance to read her stuff. But, she writes in the form of stories -- very short narratives -- in her Kitchen Table Wisdom -- Stories that Heal.


I've only started to think about these issues. I'm not sure where it's leading me. . . . . But it seems important!! :)

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