Authority from exposing our wounds

With the fast approach of the summer -- a summer where for the first time I will be "flying solo" in leading a group of seminarians and others through the intense full-time experience of learning and ministering to others (as a hospital chaplain) that we call a summer unit of CPE -- I am thinking a lot about where my "power and authority" come from. What is it that gives me the right to stand before these folks and present myself as someone who can aid in their learning?

As someone who might have something to give them? Paul Steinke -- one of the great fonts of wisdom that I have come across in my journey of becoming a chaplaincy and spiritual care educator/supervisor -- today gave me a new and challenging way of thinking about this. In a presentation at a chaplaincy conference at a wonderful retreat center, he said authority comes from telling our own stories to our students. But not just any stories. Stories about our wounds. Stories about out mistakes.

This is some difficult wisdom for me to hear. One of the first things we try to teach many of our beginning students is to not share their own stories with the patients they are ministering to in the hospital. We teach them that sharing their own stories takes the focus of the encounter off the patient, and that they should instead learn to elicit -- and listen to -- the stories of the patients. And we teach them that there is something profoundly healing for the suffering person in having the opportunity to have their story -- especially the story of their suffering (which friends and family often are just not up to hearing) -- heard.

But Steinke challenged me in my own work to grow to the point where I have the confidence to know when I am telling my story to distract from the other person's tale and when I am telling it to help them. He said that chaplaincy supervisors should model this kind of story telling for their students. And it is from that -- not from any title given to us by the hospital or anybody else -- that our most important source of authority, especially the authority to teach, emerges. Another important thing Steinke reminded me of about this is that these kind of stories need to be filled with concrete details and not be told in terms of generalities. It is in the details that something truly important unique comes to be, he said.

While I learned quite a bit from Steinke, today -- much more than I've had time to write about here! -- this is not the first time I've thought about or written about these issues. In December, I wrote about this from the perspective of submission. There, I was more focused on what the student needs to do for learning to happen in CPE (that the student needs to accept at least the authority/possibility of the CPE process teaching them something). . . . . Now, I'm thinking about what I, as the supervisor and teacher, have to do. I have to coax the authority from my students. And telling more of my own stories and struggles is one way to do that. So, one of my goals for this summer will be to start doing more of that with my students.

In that regard, I'd like to express my thanks to one of my students I worked with for the last six months or so. He constantly demanded that I share more of myself and compared me to former teachers who had done that with him. I resisted that as a challenge to my authority and position. But I now see that his challenging of me made me more open to hearing Steinke's message, today.

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Here are some of the stories from Steinke used in his presentation on Power and Authority

• The boy knows the truth, by I. Singer.
  
• The conversion of the Jews, by P. Roth
• The Management of Grief by Bharati Mukherjee
• from The Middleman and Other Stories
• Eudora Welty - The Worn Path
• Found in this collection.

Why I love Hillary

There's a scene in the movie Primary Colors where the Bill Clinton-like main character and his wife have just done an important live television interview together during a presidential campaign. One of the campaign aids is watching it amid a crowd of average folks. He gets an excited call on his cell phone from another campaign aid who asks him, "How'd it play? Wasn't she fantastic?!"

He dryly (and a bit sadly) replies, "Yeah, great. But they'd like to see her hair a little longer."

This is what Hillary Clinton has faced all of her public life. It doesn't matter how much she's accomplished, or what her strength of character is -- someone will always be judging her on whether she is feminine enough. Someone will always feel that somehow she has been "breaking the rules" and that she should have been perhaps more of a mother or just a bit more subservient to her husband. Or maybe that she should have worn dresses more often or that she should have spent more time with her hair in her earlier ears instead of just putting on a simple headband to keep it out of her eyes.

More than anything else, it's Hillary's perseverance in the face of all this that makes her a hero to me. She reminds me of the (largely Jewish) feminists who were heroes to me when I was growing up. People like Bella Abzug , or, more importantly, like my Aunt Bryna, who was such a vital support to me when I was growing up. People who not only said that they, themselves, refused to be limited by the expectations that other people had for them, but who preached to me that I didn't have to be limited to whatever the voices were that were trying to limit me as well. They spoke a narrative of liberation that told me I should have the courage to find my own path.

In choosing between Hillary and Obama, I think this is what most people are relying on -- which narrative of liberation speaks most loudly to them. Obama certainly has an inspiring one, one that speaks loudly to many Americans. But Hillary's is the one that resonates more with the struggles -- and accomplishments -- of my own life. I can remember as a young teen taking one of those standardized tests that are supposed to tell you what you are best suited to do. When it came back telling me I should become a computer programmer it felt like a punch in the gut. Like a death sentence.

I don't mean to denigrate the profession of computer programing or of other information technology (IT) professionals. My father was a proud software engineer and I've done quite a bit of IT work in my time, both for work and for fun. But that test was labeling me. It was telling me the "kitchen" where its designers thought a person like me belonged -- a place where being among people was not important. And that's not what I wanted for myself. I didn't want to me a computer programmer or an accountant. I wanted to be a part of transforming the world. I wanted to be about helping other people find their own paths to liberation. It's that call that led me to become first a journalist, later a rabbi and now a special kind of rabbi who is part of helping other people find their path to helping others (I work in a hospital as a clinical pastoral educator training others how to be chaplains and spiritual caregivers).

Hillary, like many great women of her generation, has also refused to be defined by other's expectations -- by the limits that the society in which she has born have imposed on her. It has been anything but an easy struggle for her. She has had to endure whithering criticism -- really hatred -- throughout it .She has had to make painful compromises she clearly did not want to make -- changing her last name, dropping the headband. And, perhaps most inspiring to me, she's had to overcome what many would consider a fatal disability for a politician -- a lack of the natural skill at communicating a charismatic warmth that is so much a part of her husband's success. She's a part of that great generation of American women who taught us how to throw off our chains. It would warm my heart to no end to see one of theirs finally make it to the highest office in the land.

It's time for a change. It's time for a liberation.

Is it the miracles (a Thanksgiving question)?

I have to admit I have never given much thought to the meaning of Thanksgiving. I have thought of it primarily as an opportunity for folks to get together with their families, which is something that can be the source of all kinds of meaningful stuff. But does the holiday itself have some kind of meaning? Is that meaning rooted in the story that's told about the holiday, like the way the meaning of Passover is deeply rooted in the story of the Israelites' redemption from bondage in Egypt?

The below prayer from Rav Zalman would seem to suggest that the meaning of Thanksgiving is indeed rooted in that traditional story. The prayer is written to be included in the "about the miracles" section of traditional Birkat HaMazon, or 'blessing of the food' that is said after meals. The insertion into the "about the miracles" section (which is where we traditionally make insertions on Hanukah and Purim) in and of itself suggests that what we are thankful for on Thanksgiving has something do to with miracles given to us by the Divine. And the content of the insertion suggests the miracle has something to do with the traditional story about Thanksgiving I was told as a kid where poor settlers were helped by Native Americans.

I wonder, however, do we still tell our kids that story? Is there something in there that might be offensive to Native Americans? Do we really want to uphold that traditional story when we celebrate Thanksgiving, or is it about something else for us now? I'm not sure I'm comfortable with this blessing.

But this year, I'm just glad that tomorrow I will have the opportunity -- God willing -- to see my Mom and my Sister and her kids. I hope you will have the opportunity to be with people you care about, too.

Happy Thanksgiving!

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Rav Zalman's "About the Miracles" blessing for Thanksgiving

(click on image to see full size)

"What critically ill person needs above all is to be understood"

That was the line that jumped out at me when I was listening tonight to Fresh Air's Terry Gross read from Anatole Broyard's book Intoxicated by my illness. I transcribed the whole quote (see below), which strikes me as a particularly powerful and succinct expression of how the visitor with the best of intentions can actually alienate an ill person. And the quote also states wonderfully what it is that an ill person often actually needs. Here's the whole quote (which Broyard wrote about his experience with terminal prostate cancer):

All my friends are wits, but now that I'm sick I'm treated to the spectacle of watching them wear different faces. They come to see me and instead of being ironical and making jokes, they're terribly serious. They look at me with a kind of grotesque lovingness in their faces. They touch me, they feel my pulse almost. They're trying to give me strength and I'm trying to shove it off. The dying man has to decide how tactful he wants to be. What a critically ill person needs above all is to be understood.

I intend to get this book. It sounds like will be an excellent part of literature readings for CPE students, especially after reading the very positive annotation it was given at the Litmed database.

The interview, by the way, was actually with Broyard's daughter, Bliss Broyard, and comes from the 9/27/07 podcast (at about 18:50).

Literary Resources

Some resources for literary CPE:

• Alan Abrams' study questions on Kafka's Metamorphosis
• Alan Abrams' study questions on Tolstoy's The Death of Ivan Ilyich
• Literature, Arts & Medicine Database (http://litmed.med.nyu.edu)
• Abayye blog entries on the power of story
• Other resources that I -- and other educators and CPE supervisors -- have found particularly helpful
• Anton Chekhov's Gusev
• Edwin Friedman's Friedman's Fables
• Becket's Waiting for Godot
  

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Getting out of the way (and the illness narratives)

One of the first things we try and teach our new chaplains is not to say, "I understand exactly what you are saying, let me tell you when the same thing happened to me . . ." and then going on to tell the patient their own story.

Students really have trouble understanding this -- "don't we want to establish common ground with our patients," they ask? "Doesn't this establish rapport?"

The problem is that we're jumping to conclusions when we do this. We're assuming we understand what the patient is going through before we even have the slightest conception of his or her experience. We're taking the focus off the patient and putting it on us. We're telling our story by preventing the patients from telling theirs.

My supervisor shared with me an excellent short article by a San Francisco doctor that explains this problem wonderfully by talking about the "Illness Narratives". The Illness Narratives (Restitution, Chaos and Quest) were described by sociologist Arthur W. Frank (see his The Wounded Storyteller: Body, Illness, and Ethics; for a brief, but excellent, description of these three narratives, see the short article, above).

The author of the article takes a great quote from Frank's book that well describes much of my understanding of how pastoral care can heal:

"Serious illness is a loss of the destination and map that had previously guided the ill person's life: ill people have to learn to think differently. They learn by hearing themselves tell their stories, absorbing others' reactions and experiencing their stories being shared".

This is what we try and train our student chaplains to do instead of sharing their own stories with patients -- inquire into the patient's experience. Get out of the way and let them to tell their story. Don't try and fix their problem. Instead, try and understand their experience. . . and open the door for the suffering person to take the next step: the step to the learning and self-transformation that has the potential to make them into a person who has regained control over their life, even if they have tragically lost any control over what their body is doing.

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By the way: Speaking of people who miss the patient's story by telling their own (in a ill-conceived effort to establish rapport), the Archives of Internal Medicine recently published a study saying many doctors are doing just that. The New York Times headlined its story about the study: Study Says Chatty Doctors Forget Patients

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I'm a Wiki, you're a Wiki . . . .

. . . . wouldn't you like to edit Wikipedia, too?

Tonight I did! Yes, as hard as it might be to get your head around, the pages on that amazing free Internet encyclopedia can be edited by anybody . . . even a chaplain. :)

My latest contribution (my second effort at editing a Wikipedia page) was to add a site I just found to the "external links" part of Wikipedia's page on Humanistic Medicine.

The site I added -- the Literature, Arts & Medicine Database -- is really pretty amazing. I came across it while trolling the Web for info about a Chekhov story we are using to spark discussion in our chaplain summer interns' reading seminar. The database is full of texts and comments on literature, film and art meant exactly to be used for this purpose -- that is, to help folks (mostly medical students) use literature and art to help sensitize themselves to the full reality of the patient experience (and not just think of patients as bunch of diagnoses and numbers).

The entries are listed by categories. For example, if you want to teach a session on Death and Dying, you can just go to that category in the database and find dozens of suggestions to use of relevant films and short stories -- including comments on exactly how you can use each!

I'll be interested to see if my addition stays up on the Wikipedia page. From what I understand, there is a small army of serious Wikipedia edtitors who kind of police the site, making sure changes fit the standards of the encyclopedia (I, myself, wonder if the site I added might be better suited to the Narrative Medicine page) . . . We'll see if my entry makes the grade! :)

Psalm 88 -- going to the bottom in order to get back up

I've written here before about the possiblity of using great literature to help people (whether they be chaplains or doctors) develop a greater sensitivity to just what it is that hospital patients experience and need. This summer I'm actually putting this into effect myself by leading some literary study sessions with our summer chaplain interns.

Most of our readings will be from 20th and 19th century literature -- like Tolstoy's The Death of Ivan Ilyich. But last week we started with a much older work of literature -- the book of Psalms.

I got the idea that Psalm 88 might be a particularly appropriate psalm to focus on from Paul Steinke, a very interesting trainer of chaplains who works at Bellevue in New York. Rev. Steinke encourages his chaplain students to read psalms to their patients. But, as one of his former students explained to me, he does not encourage them to read any psalm. In fact, he even discourages them from using the most favorite psalm of chaplains everywhere -- Psalm 23 -- at all.

Steinke's reasoning, as I understand it, is that Psalm 23 is too comforting. Comforting words -- as important as they might be -- are relatively easy to find. What is hard to find -- and what it is that the chaplain might be the only one willing to offer -- is someone who will be willing to join the ill person in their most lonely place, the place where their suffering and despair is the greatest. And joining them there -- being willing to try and break their lonliness there -- may be the most healing thing we can do.

Psalm 88 goes to such a dark and despairing place in the most dramatic of ways. In its mere 19 lines, it expresses a wealth of emotions the suffering person might feel, including that God has abandoned them (verse 6):

I am like the dead who have been released [from life]	בַּמֵּתִים, חָפְשִׁי
like the slain lying in the grave	כְּמוֹ חֲלָלִים, שֹׁכְבֵי קֶבֶר
whom You [God] remember no more;	אֲשֶׁר לֹא זְכַרְתָּם עוֹד
And from Your hand they are cut off.	וְהֵמָּה, מִיָּדְךָ נִגְזָרוּ

The psalm also wonderfully expresses the terrible loneliness of an illness, and even the shame that the victim of the illness can feel at his or her condition (verse 9):

You [God] have estranged my friends from me	הִרְחַקְתָּ מְיֻדָּעַי, מִמֶּנִּי
You have made me an abomination to them;	שַׁתַּנִי תוֹעֵבוֹת לָמוֹ
I am imprisoned, and cannot get out	כָּלֻא, וְלֹא אֵצֵא

The line that says you have made me an abomination -- a toeavah -- to them is particularly powerful to me.

What I also love about this psalm is the lines that reflect what I think is one of the central themes of the entire book and that represent the book's favorite way of asking God for mercy. The Psalms' author believes that our purpose is to praise God -- in song and prayer. And, further, the author believes ferverently that God appreciates these songs. In asking for mercy -- and for more life -- the author seeks to remind God that only the living can offer such song (verses 11-14):

Will the dead rise to give thanks to You, Selah?	אִם-רְפָאִים, יָקוּמוּ יוֹדוּךָ סֶּלָה
Will Your lovingkindness be recounted from the grave?	הַיְסֻפַּר בַּקֶּבֶר חַסְדֶּךָ
Your faithfulness amid destruction?	אֱמוּנָתְךָ, בָּאֲבַדּוֹן
Will Your wonders become known in the darkness?	הֲיִוָּדַע בַּחֹשֶׁךְ פִּלְאֶךָ
And Your righteousness in the land of oblivion?	וְצִדְקָתְךָ, בְּאֶרֶץ נְשִׁיָּה
But I, to you HaShem cry out,	וַאֲנִי, אֵלֶיךָ יְהוָה שִׁוַּעְתִּי
and in the morning	וּבַבֹּקֶר
my prayer to you will be the first thing.	תְּפִלָּתִי תְקַדְּמֶךָּ

In those final words I have put in bold, one of our students saw a fundamental hopefulness in this psalm, in that the author -- for all his feelings of despair -- has not give up on God and continues to pray to God.

I am not sure I see that in the psalm myself, but I was very encouraged to see how intensely the student was engaging the text of the psalm to find things within it that supported his own theology. It was clear that our discussion of the psalm struck the students deeply, and individual students several times during the week referred to something from our discussion while they were describing their work with patients. This connection by students of the literary study with their reflection on clinical work is, of course, precisely the goal of bringing literary study into a Clinical Pastoral Education program. So, I was extremely pleased to see this.

I hope we have similar results with our next reading!

---

By the way, my notes are a couple of years old now, but what they indicate is the following (lamenting) psalms are the ones Rev. Steinke was encouraging his students to use (the ones in parenthesis are ones considered not quite as useful as the others):

(30), 38, (41), 88, 90, 130


And here, by the way, is psalm 88

• in Hebrew
• in English (King James version)
  

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Today's hospital meets 19th century Russia . . . and the Bible

There is a fascinating article in the New York Times this week about how one physician uses the great literature of 19th century Russia to teach Harvard undergraduates about the profound impact illness has on people's spirits and psyches. Writes Jerome Goopman (author, also, of the recent, How Doctors Think):

Medicine engages life’s existential mysteries: the miraculous moment of birth, the jarring exit at death, the struggle to find meaning in suffering.

That is, what some might call life's Big Questions -- what is life? what is the meaning of life? why do the good suffer? what is death? -- are the stuff of daily life at the hospital (and are the reason why hospitals are a natural setting for chaplains -- people trained in engaging the big questions!). But, as Groopman points out, the daily grind of hospital work can quickly desensitize people to the grand nature of what is happening around them. And one way to re-sensitize folks is to engage other sources of the big questions. Few in history have more dramatically and directly engaged these questions than the great authors of 19th century Russia, like Tolstoy, Chekov and Dostoevsky, who wrote in an environment where an entire nation was engaging those questions as it stood on the brink of its cataclysmic and incredibly rapid transition from feudalism to Communism.

Not surprisingly, then, one of Tolstoy's works -- his novella, "The Death of Ivan Ilyich" -- stands at the center of Groopman's course. Some clinical pastoral education programs have also used this work as a means to spur discussion among aspiring clergy and chaplains. In an article in the winter 2006 issue of The Journal of Pastoral Care & Counseling, Paul Steinke gives an extensive bibliography, including The Death of Ivan Ilyich, of works he has used in teaching his students. Many others have been doing this kind of work. I wrote here, recently, about a similar course at U Penn. [And here is a syllabus, including a bibliography, for a similar course at U. Colorado.]

But what I really like about Groopman's piece is that he links modern works like Tolstoy's to a very-much-not-modern book that still remains the greatest of all time for engaging the big questions:

Whether read as revealed truth or as a literary work, the Bible is a sourcebook of human psychology and an enduring inspiration for authors trying to capture the drama and dilemmas of medicine.

As Groopman points out, one way to find the Bible's encounter of the big questions is to read modern literature, carefully -- so many references to the Bible are in there if you look for them. Certainly, Tolstoy refers to it, often.

Another thing I liked about Groopman's piece is the sharp critique he makes at the end of some of the most popular "spiritual" New Age success books out, today. Groopman points out that they are full of some very damaging -- and antiquated -- notions about why bad things happen to people; in effect, they blame people for their own misfortune:

Later in the semester we shift to New Age writing, examining the message of books like the surgeon Bernie Siegel’s “Love, Medicine and Miracles” and, new this spring, Rhonda Byrne’s “The Secret,” the runaway best seller that asserts you can solve all your problems, including “eradicating disease,” by correctly aligning your thoughts and aspirations. . . . Both Siegel and “The Secret,” for example, suggest that even cancer arises from anger, resentment and other “negative” emotions. Miraculous cures occur when sick people fix their disease-causing psychology.

Magical thinking is a common malady as we strain to find moral or metaphysical explanations for why, say, some cells mutate and grow abnormally. But there is not a shred of scientific evidence to support the enduring view that patients bring such events on themselves through incorrect thinking. While the Bible contains the seeds of this idea, later religious thinkers like Maimonides, who was deeply influenced by Greek and Roman physicians, drew sharp distinctions between magic and empirical medicine. The New Age writers confuse them anew.

Spirituality for undergraduates

What's the single most healing thing you can offer to a suffering person? Giving them the opportunity to tell their story.

This single important fact has underpinned how we have trained hospital chaplains for many decades now. But, in recent years other professions -- including doctors -- have started to recognize this as well and have started to integrate this fact into their own training curriculums. And, as I learned at the Spirituality in Health Care Education conference last week, even pre-med (or maybe pre-med) undergraduates are getting a taste of this.

Professor Elizabeth R. Mackenzie spoke about a freshman writing tutorial class she teaches on healing narratives and humanistic medicine.

When I was an undergraduate at Grinnell College, I took such a freshman writing tutorial (mine was on Eastern European history) and I remember it as one of the most influential and inspiring classes of my entire college career. Dr. Mackenzie's class also sounds like it has the potential to be that exciting for her undergraduates thinking of entering medicine.

They have some eight essays over the course of the semester. The first two sound very exciting:

• 1) Write a first-person illness narrative that ends with a life lesson that can be applied to others.
• As Mackenzie points out, this can be heady stuff for a 18-year old who may have led a somewhat sheltered life and may never have been seriously ill. But she said, for example, an athlete could write about a time he or she got injured; there's a lot of excellent learning for a young person in thinking about how that experience might reflect something general about the human condition and not just their own individual experience.
  
• 2) Collect an illness narrative by interviewing a peer using active listening techniques.
• This helps introduce them to the whole idea of qualitative research, she said.

Here are some of the books she uses:

• Two by highly successful physicians who underwent their own struggles with their own illnesses:
• Rachel Naomi Remen's Kitchen Table Wisdom: Stories That Heal
• Mackenzie said if there's one thing she wanted people to get from her presentation, it was to go out and immediately buy Remen's books. She also likes Remen's My Grandfathers Blessings : Stories of Strength, Refuge, and Belonging
  
• Jody Heymann's Equal Partners: A Physician's Call for a New Spirit of Medicine
• A Life in Medicine: A Literary Anthology
  

Here are some articles she uses as well:

• Telling Stories: The Health Benefits of Narrative, by James W. Pennebaker in Literature and Medicine - Volume 19, Number 1, Spring 2000, pp. 3-18
• Rita Charon's 2001 article in JAMA on narrative medicine.
• Jerome Groopman's A great case, a doctor's account of dealing with his young son's illness and the insensitivity he experienced from physicians.
  
• John Pryor, a trauma surgeon from UPenn kept blog entries while he was in Iraq. Some info on that can be found here.
• An article about basketball star Alonzo Mourning's spiritual awakening while recovering from a kidney transplant.
  

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One fascinating question that was only touched on briefly at the conference was the question of whether medical education should be involved in helping the doctor his or herself to be spiritually healthy. As David Hufford pointed out we would not, for example, make going to the gym part of a student's education on cardiology; we leave it up to the individual student to take care of whatever they might need to do to maintain their own physical health, and do not make it part of their formal learning.

I would agree about that example. But I think spiritual health is fundamentally different than physical health -- a physician in bad spiritual health (one who, for example, is so burned out from seeing death and suffering that they can hardly stand to talk to patients anymore) is one who is going to do damage to his or her patients. In short, I don't see how a physician who is not whole (spiritually), can possibly treat the whole patient (that is, treat the patient as a real person and not just a set of symptoms and diagnoses).

I think that's the point of Mackenzie and Charon and Barry Bub's work -- it's not just about benefit to the patient. It's about benefit to the doctor, and the assumption is that that benefit to the doctor ultimately accrues to the patients as well (who get better treatment, as a result). Bub, I think, would even say that the benefit the patient gets is not just spiritual, but is physical as well. That is, the physician who is whole enough to listen better is going to be able to miss less things and ultimately be able to diagnose and treat more effectively.

Hufford, however, seems very concerned that medical school teaching on spirituality not look soft in any way. For it to be taken seriously by students, he says it is essential that it be required, tested and graded. Just as it would be for a class on cardiology, he says the classroom curriculum needs to focus on real cases and needs to include real research based on real statistics. The content needs to have "clinical utility" he says. In that vein, it is important to point out that, no matter what you may think about the place of spiritual concerns in medicine, a very high percentage of patients make their most serious medical decisions based in part on religious/spiritual concerns; this alone makes it important to train physicians to have some sensitivity to spirituality, he says.

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Another fascinating thing about Mackenzie's course is that she has had her students create and maintain some entries on Wikipedia. She said her students created the narrative medicine entry there, as well as the one on humanistic medicine.

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?"

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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 . . . .

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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?

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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.

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