In the March 6th issue of the New England Journal of Medicine, Drs. Timothy Quill and Amy Abernathy (the immediate past president and the current president respectively of the American Academy of Hospice & Palliative Medicine) published a very interesting thought piece entitled “Generalist plus Specialist Palliative Care — Creating a More Sustainable Model”. The piece discusses the pros and cons of providing palliative care by educating all practitioners in palliative care practice vs. providing it through relying on specialists who are called in when palliative care is required.
Their thesis is that we need both educated palliative care generalists and palliative care specialists. Thus, they are proposing that palliative care become like every other medical specialty. That is, every physician is taught something about cardiology, certainly including how to assess and at least preliminarily diagnose cardiac issues. The general internist will also be able to treat some number of these issues, especially in their less severe forms, without referring to a cardiologist. However, at some point for some patients, a referral will be necessary. Part of the debate in US health care is exactly when a referral is actually necessary.
This thesis exactly parallels the provision of spiritual care on at least at two levels. Over the past several years, many of us have been promoting the exact same generalist-specialist model with regard to spiritual care. Dr. Harold Koenig and I published an article on this topic some years ago (Handzo, G. F. & Koenig, H. G. (2004). Spiritual Care: Whose Job is it Anyway? Southern Medical Journal, 97(12), 1242-1244). That is, we need generalists (physicians, nurses, social workers, etc) and specialists (Board Certified Chaplains). The generalists are responsible for screening for spiritual need and making referrals when appropriate. Dr. Christina Puchalski, among others, has posited the concept of “simple” vs. “complex” spiritual interventions. Simple interventions are those that every health care practitioner should be able to do such as reflective listening and compassionate presence.
As chaplains who are the spiritual care specialists on the team, we need to be about educating the generalists and helping them learn about and be comfortable with their role in spiritual care. We have to be sure that we as professional chaplains are trained and committed to fulfill our role as spiritual care specialists on the team. The competencies recently released by the Association of Professional Chaplains for specialty certification in palliative care chaplaincy are a helpful addition in this regard.
The second level has to do with the place for palliative care generalists and palliative specialists within the ranks of professional chaplains. Just like Quill and Abernathy describe in medicine, relying on the palliative specialist is not always possible or best practice. Yes, the large academic medical centers of the world which should have robust palliative care teams should have a chaplain who has advanced certification in palliative care and is attached to that team. However, most hospitals in this country are too small to ever be able to provide that level of palliative care. Further, much (or maybe even all) of what chaplains do routinely could be seen as falling under the rubric of palliative care. Thus every chaplain in health care should be at least a palliative care generalist.
This model for the delivery of spiritual care needs to drive chaplaincy training much more than it currently does. There should be a palliative care component even in basic levels of the training of clinical chaplains just as there is some basic level of training in cardiology in the education of every physician. The learning goals for programs like Clinical Pastoral Education (CPE) need to reflect this growing reality of US health care. We also need more opportunities for specialist spiritual care training. The recently announced collaboration between HealthCare Chaplaincy and the Palliative Care Institute at the California State University-San Marcos (http://www.healthcarechaplaincy.org/palliative-care-chaplaincy.html) and the Summer Institute at the George Washington Institute for Spirituality and Health (www.gwish.org) are great offerings but we need many more opportunities.