(Part 1)
[Before presenting this manuscript as a Grand Rounds lecture for the faculty and residents of an Obstetrics and Gynecology Department in Phoenix (October 2001), I profiled for those in attendance my experience and training in three ways. First, I explained my three overlapping ‘on-the-field experiences’ (as distinguished from an ‘ethicist’ role) over the previous eight years – i.e., (1) as project coordinator and evaluator with an intervention project at the University of Miami for 125 cocaine-abusing women who had prematurely delivered cocaine-exposed babies (1993-97), (2) as residency coordinator and ethics educator while on faculty with the Ob/Gyn Department at Louisiana State University in New Orleans (1992-97), and (3) as a member of the executive leadership team for Dayspring Family Health Center (a not-for-profit community health center serving medically un(der)insured individuals/families in three poverty-ridden Appalachia counties of eastern Tennessee and Kentucky) (1994-2007). Second, I referenced professional experience (e.g., participating as an adjunct faculty member with Michigan State University’s Center for Ethics and Humanities in the Life Sciences in the development of a curriculum for addressing spirituality in medical education) and personal experience (e.g., my first wife’s fourteen-year struggle against her deterioration and eventual death in 1987 due to multiple sclerosis) in which the lecture’s reflections/observations were rooted. Finally, I mentioned the impetus to compose the thoughts later/fully developed in the lecture that came from preparing several months previous to the lecture to participate with a Vanderbilt University team in the creation of an educational video for hospital employees re assessing patients’ spiritual needs.]
1. When to consider a patient’s spiritual needs:
1.1 For the past few years, the senior physician – David McRay, MD -- at the Appalachia community health center where I work and I have been meeting weekly to review his most perplexing and burdening patient encounters – something of an ethics and spirituality approach to rounds. A few months ago, we discussed this case:
It was a busy Wednesday afternoon. The patient was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and his nurse entered the room. David got her into a supine position, covered with a sheet up to her blouse. The nurse turned down the light. As David began raising the blouse for the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought . . . surgery . . . perhaps a previous c-section. Once he saw the scars, he thought . . . accident . . . perhaps a burn. He asked, “In a car accident or . . .?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. The patient asked, “Can you tell the race of the baby by ultrasound?” David had never been asked this question. He found in her chart that she came so late in the pregnancy for prenatal care because she had been on the road with truck drivers. And she had been with IV drug users during the pregnancy. As we reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I didn’t know how to respond. She would never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.
When the patient said “many scars”, she was making a figurative as well as a literal comment. Simply put, she was saying, “My story is broken. Can you help me fix it.”
1.2 Imagine you and your medical team are looking down a hospital or clinic hallway with patients in most of the rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. They are not present together in the hospital as a community. What does matter to each patient ultimately is her particular spirituality. However, you and your medical team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Embracing such a definition of and approach to spirituality is no simple task.
1.3 Most hospitals and clinics exist to respond to patients’ physical needs (in the context of psycho-social circumstances) and, therefore, are centered by empirical language and perspective. Empirical language is the ‘first language’ of health care settings. With symptoms, with injuries, with diseases, . . . – patients come (or are brought) anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.
1.4 Patients hope that entering a hospital or a clinic will be no more than a pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often superficial, acute, and/or benign. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by your choice) on the periphery. By ‘periphery’ I mean that you do remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications – which, for our physicians at the Appalachia community health center where I am working, are detected many times every day – put the caregiver in the tough position of deciding whether s/he has the time and emotional capacity to determine if indeed there is a deeper ‘wound’. And the circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, a spiritual language/perspective should be more centrally and intimately present as you and your medical team attend to the patient’s needs.
1. When to consider a patient’s spiritual needs:
1.1 For the past few years, the senior physician – David McRay, MD -- at the Appalachia community health center where I work and I have been meeting weekly to review his most perplexing and burdening patient encounters – something of an ethics and spirituality approach to rounds. A few months ago, we discussed this case:
It was a busy Wednesday afternoon. The patient was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and his nurse entered the room. David got her into a supine position, covered with a sheet up to her blouse. The nurse turned down the light. As David began raising the blouse for the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought . . . surgery . . . perhaps a previous c-section. Once he saw the scars, he thought . . . accident . . . perhaps a burn. He asked, “In a car accident or . . .?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. The patient asked, “Can you tell the race of the baby by ultrasound?” David had never been asked this question. He found in her chart that she came so late in the pregnancy for prenatal care because she had been on the road with truck drivers. And she had been with IV drug users during the pregnancy. As we reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I didn’t know how to respond. She would never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.
When the patient said “many scars”, she was making a figurative as well as a literal comment. Simply put, she was saying, “My story is broken. Can you help me fix it.”
1.2 Imagine you and your medical team are looking down a hospital or clinic hallway with patients in most of the rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. They are not present together in the hospital as a community. What does matter to each patient ultimately is her particular spirituality. However, you and your medical team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Embracing such a definition of and approach to spirituality is no simple task.
1.3 Most hospitals and clinics exist to respond to patients’ physical needs (in the context of psycho-social circumstances) and, therefore, are centered by empirical language and perspective. Empirical language is the ‘first language’ of health care settings. With symptoms, with injuries, with diseases, . . . – patients come (or are brought) anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.
1.4 Patients hope that entering a hospital or a clinic will be no more than a pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often superficial, acute, and/or benign. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by your choice) on the periphery. By ‘periphery’ I mean that you do remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications – which, for our physicians at the Appalachia community health center where I am working, are detected many times every day – put the caregiver in the tough position of deciding whether s/he has the time and emotional capacity to determine if indeed there is a deeper ‘wound’. And the circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, a spiritual language/perspective should be more centrally and intimately present as you and your medical team attend to the patient’s needs.