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The Problems and Opportunities of Change

I should state right up front that I’m not a person who does change all that well. My default position on almost anything is to stick with what I have, what I’m doing, or what I believe. Staying with the familiar is comfortable. Changing is stressful. Sometimes this characteristic works for me in that I always try to work out issues with where I am rather than change but often it keeps me from realizing and taking advantage of new opportunities and experiences that would enrich my life.

So it is I think with many businesses, organizations and professions. Despite all we know about how our world and society is changing at an increasing pace and that to prosper and even survive in the new world emerging around us calls for at least re-examining if not changing some basic assumptions about how we function professionally, we resist-often to our detriment and to the detriment of the people who benefit from what we do.

I have had only one career in my life- clergyman. And for almost all of that career I have done my work focused on one setting- the acute care hospital and how to minister to people who are sick and suffering. Health care chaplaincy and ministry in general is based on some assumptions that are so fundamental that they are often not even acknowledged or discussed- let alone disputed. Maybe the most basic is that, to be “successful” -which I will translate as being able to help people relieve pain and suffering- one must be in “relationship” with them.  Further, this “relationship” is assumed to be most effective or even only effective if it is face-to-face. It is assumed that to be “helpful’ we as chaplains need to be physically with the person to whom we are ministering. Anyone who wants to be certified as a chaplain must take clinical pastoral education (CPE) that focuses on teaching us how to satisfy this standard. To foster this goal, CPE has required that students be able to meet with a peer group face-to-face and meet in person with a supervisor.

To be clear, I do not want to argue that this model or the assumptions that drive it need to be abandoned. I know that the training I received and my ability to relate deeply to people has helped a lot of patients, caregivers and health care providers. However, it is increasingly clear that this model of training and assumptions about how chaplaincy care needs to be delivered are barriers to both raising the level of training for health care chaplains generally and to the deliver of spiritual care to many, many people in need. There are many people doing spiritual care who want to be trained but cannot do it because they live at a prohibitive distance from a training center, cannot take the time, or cannot afford the tuition.  There are many people who want the services of a chaplain who cannot access one because they are home bound, live in rural areas, or otherwise have no way to go to a chaplain.

But maybe most importantly, these assumptions about how chaplaincy training and how chaplaincy itself “must” be done have never been tested. Do we have any evidence that CPE done remotely with virtual groups would produce less effective chaplains than the current model? No. Do we have any evidence that patients and their caregivers would feel less supported and have their suffering less well addressed by a chaplain who communicated with them over the telephone or even by email or Skype than one who communicated with them in person? No. What we do know is that our long-held and sacred assumptions are keeping many people from receiving care for their spiritual and religious suffering.

All health care disciplines are currently struggling with the pros and cons of delivering care remotely. Chaplaincy is not special in that regard. Many of us went into health care because we want to be with people and relate to people. Delivering care or even being trained over the phone or by Skype simply may not be as fulfilling. However, it seems very evident to me that given the realities of health care in the US and, more importantly, given the fact that our assumptions are barriers to delivering spiritual care to many people, new models have to be tried. The time for remote or virtual CPE has come. The given reasons for not doing this have no evidence to support them. Likewise, the time has come for leveraging emerging technology to deliver spiritual care to many who need it and want it but who won’t receive it any other way. There is no evidence that these delivery systems will produce results inferior to the current model.

Finally, this is all not about us- the chaplains. It is about what best serves those in need. What will be effective in the end? I have no idea. I do know we owe it to those in need of spiritual care to try new methods and models. 


But Who’s Attending to Spiritual Suffering?

The NY Times published a very interesting piece on February 17th  entitled Doctors Strive to Do Less Harm by Inattentive Care. It got my attention immediately because the first word of the article was “suffering” with a period after it.

As I have become more of a student of communication in general and communication in health care in particular, I have realized the truth of something I heard a long time ago that amounts to “you have to use the right word”. Euphemisms have their uses of course in situations where the most descriptive word can be harsh and even brutal. However, more often, the use of “kinder” words is a cover that allows us as health care providers to pretend we have communicated clearly when we have not and thereby to avoid the painful emotions and even whole topics that we would rather not deal with.  Many times in my career as a chaplain I have sat with families who have been told that their loved one “passed away” realizing that the family does not understand that their loved one is dead. 


This article points out correctly that we have long avoided in health care discussing suffering or even admitting that it exists. As the article describes, mention of suffering has often been actively discouraged if not prohibited. We much prefer to discuss pain. Pain is an expected part of health care. For many years during my career, it was accepted that pain just came along with certain conditions. Post-surgical pain, for instance, was long just something that you had to live through at least up to the point that it actively interfered with your surgical recovery. In some situations pain is even to be desired. “No pain, no gain” is the mantra in every gym I’ve ever been in. While we have largely moved on to an understanding that this kind of physical pain should just not be tolerated, recent stories in the news have reminded us that many still believe that physical pain at the end of life is often inevitable when it is not.

But suffering is another matter. While we now routinely discuss emotional pain and even, much less often, existential or spiritual pain, discussion of pain still mostly focuses on the physical. However, to discuss suffering as this article points out immediately opens up a whole array of suffering that, since we then know about it, we are obliged to deal with. Many of these sources are, like pain, areas that have long been assumed to be unavoidable in health care. Of course you need to wait, how else can we do it? Of course there is noise in the hospital in the middle of the night, how else can the staff take proper medical care of you? Of course you have to wait for your test results to come back and wait for your provider to call you even though you know that the result may confirm that you have cancer.

So I am thrilled that we finally seem to be reaching the day when these kinds of suffering will not only be acknowledged and spoken about but no longer accepted as an unavoidable consequence of being sick and in a hospital. There is growing appreciation and evidence for the idea that these kinds of suffering, not only affect patient satisfaction scores, but medical outcomes and medical costs as well.

But, as usual, at least one kind of suffering is missing here. That is spiritual or existential suffering (I don’t want to get hung up on the modifier). I think this avoidance arises for much the same reasons that other kinds of suffering have been ignored. We have very little understanding of what “spiritual suffering” looks like or even any sense of how to define it. We have a growing understanding that patients have “spiritual needs” and some growing sense that spiritual suffering as defined by the patient is common, but as yet no real appreciation for how much suffering those needs cause, and even less understanding of how or even if that suffering impacts health outcomes. And finally, even if we do start to describe spiritual suffering, we do not have much idea of how to treat it. Spiritual suffering is rarely assessed and patients generally assume we as health care providers do not want to even hear about it. Any attempts to help patients with spiritual suffering tend to be idiosyncratic to the individual provider and the outcome of even those is rarely documented.

The naming of suffering (using the word) is a great first step. The second may be naming and measuring all the sources of suffering even the ones that we may think are inevitable. The third step is at least working on the premise that no manner of suffering is inevitable and unavoidable. As I mentioned, there was a day in my career that a certain level of physical pain and even a certain level of emotional pain like depression and anxiety when one is sick were thought be unavoidable. We now know better. There are those like Gary Kaplan, CEO at Virginia Mason hospital, who does not accept that making a patient wait for a test is unavoidable.

There are many of us who suspect that spiritual suffering is not only common and has serious impact on quality of life but also can have a big impact on health outcomes and costs. Moreover, we suspect that ameliorating that suffering is not only possible but also straight forward and inexpensive.

So bravo to the authors of this piece in the Times and to those in health care who not only are now willing to acknowledge suffering but find ways to do something about it. It is now up to us who are concerned about spiritual suffering, particularly those of us who are professional chaplains, to keep raising the need to extent this new-found concern to the realm of the spiritual and continue to develop measures to assess for it and help reduce it.



Reflections on the For-Profit/Not-For-Profit Debate

The recent series of articles in the Washington Post on the relative strengths and weakness of for-profit (FP) vs. not-for-profit (NFP) hospice has produced a lot of emotional response and some insight. However, in many people’s opinion, the Post pieces have not been the most objective and have been biased toward presenting FP hospice in a negative light. As is usually the case, bias in a report does not lead to objectivity in the discussion. There are a couple of issues to my mind that have either not surfaced or not been given enough attention.

This is not a new issue in health care. Long term care in a number of states long suffered from unscrupulous operators who took advantage of their relatively defenseless “customers” to make a profit. It should be noted that some of these operators ran FP operations and some ran NFPs. This point is not to excuse those who may take advantage of the dying in the same way but just to point out that this is not something particular to hospice.

Demonizing for-profit health care is simplistic and unhelpful to the debate. There are clearly good and bad actors on both sides.  FPs who are mission driven (and there are many) often provide state of the art care as well as pay off investors. Successful companies in all fields are successful exactly because they both satisfy their customers and reward their investors.  There are many NFP hospitals now owned by FP companies that have not missed a beat in continuing to provide patient-centered care. Yes, NFPs can do fund raising but, put simplistically, fund raising and raising capital are just two different ways to raise cash. Neither one is inherently good or bad. Its what the cash goes for that counts.

Even though chaplaincy is unreimbursed and not clearly a revenue generator or cost saver, I know some for profit hospices which provide the most professional, best trained (and therefore most expensive) chaplaincy and I know some NFPs that provide the cheapest and substandard chaplaincy just so they comply with regulations.  

The big issue that I have heard peak its head up but not be seriously addressed is the issue of quality of care. The Washington Post has framed the debate by at least implying that the quantity of care is positively correlated with the quality of care. They strongly imply that spending less nursing time on a patient or not sending a nurse to visit over the last two days of life is substandard care just by virtue of it being less care. This claim invokes a classic US premise that More care is necessarily Better care. It is this premise that is at least partially responsible for the US spending so much on health care but having less than optimal results. We are starting to learn and palliative care is teaching how false this premise can be. Do we know that having a nurse visit in the last two days of life is “better” care? We don’t. Is this even what patients and families want and need? We don’t know. And maybe the “pain” is social or spiritual generating anxiety so maybe the visitor should be the chaplain or the social worker.  We don’t know that either.

I believe that a major reason why quality is not discussed is that quality measures are not used in much of US health care and often we do not even know what a quality measure would be in a given context. We are getting better and some recent findings indicate that less care can even lead to, not only better QOL but to longer life, but we have a long way to go.

The more is better premise is also common in chaplaincy. A lot of us still work on the basis that the more we visit a patient the better without any real evidence for (1) whether the patient even wants this and (2) whether we are accomplishing anything positive. We are nice people and patients like us but do we “help” and what does help mean in this context?

It is on the basis of agreed upon quality measures that hospices ought to be compared. The only question should be does the particular hospice deliver quality care (effective and efficient), not whether it is FP or NFP. We often claim we don’t have time for quality measures and even sometimes imply that we deserve to be trusted because we are good and honorable people in this for the right reasons.  But that is no longer good enough. Our patients deserve better no matter what our business model is.



The New Year for Health Care Chaplaincy

Recently, I’ve been asked in several settings to address the question of the future of health care chaplaincy. In each case, it was either implied or explicitly stated that the question arose from a real fear that professional health care chaplaincy was fundamentally endangered as a component of US health care. I frankly find it very odd when I’m asked the question in this way. Maybe the fact that I’ve worked in health care chaplaincy for close to 40 years gives me a longer view than others, but I’ve never been more optimistic about the future of professional chaplaincy than I am today, and I have never been known as a person who underestimates the downsides of situations.  

But what about all the places where chaplaincy budgets are being cut? And what about the chaplains who can’t find a job? Yes, certainly those exist but it is also true that the line of chaplains crossing the stage at the Association of Professional Chaplains convention to receive their certification grows longer every year. It is true that the business case for including professional chaplaincy grows stronger by the year. I recently did a paper on the state of the science in the efficacy of chaplaincy and had over 70 references. So it is no longer correct to say that there is no case for professional health care chaplaincy.

I am convinced that the road to further successful integration of chaplaincy care in health care in the US is a fairly straightforward one- at least in theory.  (1) It is very clear that palliative care is becoming, not only a fully integrated specialty in health care, but also a part of generalist education for all practitioners. It has now been shown to positively impact health care cost, patient satisfaction, quality of life, readmissions, and even length of life in some illnesses. (2) Every model and set of guidelines for palliative care in the US and internationally includes spiritual care as a required component and most of those include the professional chaplain as the spiritual care lead on the team. (3) As mentioned, the evidence case for the inclusion of spiritual care is quite solid and the case for chaplaincy is significant and growing rapidly. 

I am not suggesting that palliative care is the only path for integrating spiritual care in health care. However, it is one that is certainly going to yield positive results across almost every segment of health care in the US. It is where I am putting my time and energy going forward.

So why is chaplaincy not growing faster than it is and why are chaplaincy budgets cut in some places and chaplaincy positions eliminated?  First, let me be very clear that budget cutting and layoffs happens even to chaplains who have the best training and do all the right things in terms of integrating chaplaincy into their hospitals. Often these kinds of cuts happen in health care institutions whose leadership is still narrowly focused on budget cutting rather than pursuing a strategy in which keeping or even expanding non-revenue producing services like palliative care and chaplaincy can wind up saving more money than they cost. Those are also the institutions that are failing at a great rate.

That all said, as I talk to chaplains and hospital administrators, I often see chaplains having some of the same issues which repeatedly put their positions in jeopardy and often cost them their jobs.

A lack of understanding of the evidence or business case for professional chaplaincy so they can sell chaplaincy to their system. Many chaplains simply do not keep up on the literature in the field and many, unfortunately, still don’t understand that selling chaplaincy is essential to the preservation of spiritual care in their institutions.

A lack of appreciation for the necessity of structuring chaplaincy according to what the institution values rather than according to what the chaplains prefer to do or think is best.  I know many chaplaincy jobs that have been cut, not because the institution did not value spiritual care, but because the chaplains essentially refused to provide care that the institution valued. A common example of this mistake is holding on to the “we have to visit everyone” strategy when the hospital wants chaplaincy resources allocated more strategically- including having a dedicated chaplain for palliative care.  A related issue is some chaplain’s unwillingness to participate fully in institutional quality assurance or cost cutting programs that every other department is participating in.

The misunderstanding that completing four units of Clinical Pastoral Education and even being board certified fully qualifies a chaplain to function successfully in today’s health care environment. With a few exceptions, while CPE programs generally train chaplains to function well at the beside, very few train in a number of other areas essential today. Successful chaplaincy today requires the ability to function in an interdisciplinary environment, to communicate well with other disciplines both verbally and in writing, and to make documentable contributions to the carrying out of the institution’s mission and strategic plan.  All of this content and more should be taught in CPE and required in certification and that very does not often happen.

I am very enthusiastic about the future of professional chaplaincy’s role in health care. It is certainly more central and more accepted and understood than at any time during my career. I see more and more chaplaincy colleagues stepping up to practice chaplaincy in the ways our current health care system demands. I look forward to the time soon when the barriers above will be relics of the past and all patients will receive the spiritual care they deserve and need.



Getting the Evidence for Health Care Chaplaincy

A common refrain from many of my health care chaplain colleagues in response to any new study, case report, or consensus document on health care is “why weren’t chaplain’s mentioned?” or the variant, “why wasn’t spiritual care mentioned?”  Favorite targets recently are any reports on the recently released Institute of Medicine (IOM) document, Dying in America. Now, granted, if any report on any phase of health care should prominently include a discussion of spiritual care and chaplaincy care it should be a report on how people die and how that process could be improved. However, much of the commentary on these reports in general, and the IOM report in particular, highlight several issues that often characterize these responses.

The implication of some of the chaplain commentary is that because chaplaincy was not mentioned in a given presentation or not mentioned prominently, there must not have been anyone with chaplain experience on the panel (untrue in this case) and there is no real mention of chaplaincy in the report. In fact, if all the mentions of chaplaincy in this report are cut and pasted to a single document, that document is 12 pages long in 12-point type (thanks Brian Hughes).  The lesson here is we need to be sure to do our homework before we comment. To be clear, I have been known to shoot from the hip with the best of them, but we chaplains need to recognize that it doesn’t help our credibility to not read and think before we speak. To assume we have been left out yet again is, thankfully, increasingly incorrect. And, in the case of this document, that assumption does a significant disservice to a good number of people on this panel who absolutely believe in spiritual care and chaplaincy care.

The commentary also often belies a lack of understanding of how some of these processes work. In the case of the IOM and other bodies including the National Quality Forum (NQF), the credibility of their reports is based on their strict adherence to a policy of not including anything that is not supported by evidence. In other words, like it or not, these are processes based on science. It is a very simple equation. No evidence = no mention. On the individual level it means no experience or history doing good science in this field = no seat at the table. Again, to comment without a full awareness of this fact suggests that we chaplains don’t do our homework and therefore lack credibility.  Fortunately, what constitutes evidence is broader that many of us usually understand which is why there is so much in the IOM report about chaplaincy.

But finally, my irritation with all of this is that virtually every comment I see about issues like this from chaplains stops with the complaining. We all know we are underrepresented at these tables. The commentary almost always stops short of adding “and here is what I plan to do to help make sure this eventually doesn’t happen” or “here’s what I am doing or plan to do to help develop the evidence.” Kristin Baird, a leader in patient experience consulting has often said something like, What have you done this week to improve patient experience? The chaplaincy equivalent is, What have you done this week to develop/disseminate the evidence for the efficacy of chaplaincy?  This is something every professional chaplain should be doing in some form. The first step is to know what the evidence is. This is a matter of reading including at minimum the J of Health Care Chaplaincy, the J of Pain and Symptom Management (borrow a copy from your local palliative care doc or RN), PlainViews, and the blogs PalliMed and GeriPal that are free on line. Then we all need to do a much better job of writing. It can be as little as a 2-3 line comment on PalliMed, or an article for PlainViews or a piece for the hospital newsletter which discusses some new study supporting spiritual care. And we need to speak up and educate our teams about what the literature says and what the standards are and support quality improvement and research projects that help extend this evidence.

And while we may not lead research projects, we need to go out of our way to participate in them when we have the opportunity. Recently I heard from two chaplain colleagues who have gone out of their way to write a research protocol testing an online support structure for chaplains and get it approved by their IRB which is no easy task, only to have trouble getting our colleagues to volunteer to participate.

A request to all chaplains. Please from now on refrain from writing anything about chaplains not being included in something. We already know that and the reason why which is that chaplains have not attended sufficiently to developing the evidence and the best practice that support our inclusion.  So instead of writing or talking about what is not happening, we all need to spend that time finding ways to develop and disseminate the evidence and integrate it into our practice and tell each other about it in writing. And I would ask everyone to hold me to that standard as well.