Battle for the Soul of Medicine: Chaplains

Chaplains offer time, compassion, and therapeutic communication for patients and hospital staff

“It is easy for me to imagine that the next great division of the world will be between people who wish to live as creatures and people who wish to live as machines.”

-Wendell Berry

There is an ongoing battle for the soul of medicine. I’m guessing you’ve probably noticed. Those of us who wish for heart-centered medical practice or for people to be able to live as creatures are, frankly, getting our asses kicked. Alas, heart-centered medical practice is hard to measure. At some point in the past 50 years, our focus on evidence-based medicine has shifted the culture of medicine such that if you can’t measure it, it doesn’t matter. Imagine applying that to other areas of life. We can’t quantify how a warm hug makes us feel (I mean, I suppose you can apply a Likert scale to just about anything, but that doesn’t mean the numbers will be useful). Does that mean hugs are a waste of time? Perhaps even more detrimental to our cause, heart-centered medicine doesn’t generate revenue on the same scale as “move the meat” medicine.

Saint Catherine of Siena Exchanging Her Heart with Christ by Giovanni di Paolo

There are many examples of this, but recently Massachusetts General Hospital (the hospital associated with Harvard Medical School, so one of the most prestigious and specialized hospitals in the world) decided to lay off many of their chaplains and eliminate their chaplaincy education program altogether. The wonderful Christine Vaughan Davies called my attention to this decision in her important piece about why chaplains are essential. Her article is great. Since then, she informed me that University of Pennsylvania Hospitals made the decision to end its chaplaincy education program. I also learned this has already happened in my neck of the woods. Fairview Hospitals in the Twin Cities cut half of their chaplaincy staff at the end of 2023. I don’t have many contacts in that health system, so I haven’t been able to learn first hand about the impact. I suspect some people may not be persuaded by a chaplain telling you why chaplains are important. So, let me, a cynical ER doctor, tell you why chaplains are important.

Many people question the importance of chaplains in an increasingly secular world. However, I suspect this secularization actually makes chaplains even more important. Many people who come to the hospital don’t have their own clergy to call. However, uncertainty, life-changing diagnoses, and death naturally leave patients and families disoriented. Chaplains now are typically non-denominational, multifaith, or humanist in their approaches. They also bring with them training in counseling. In other words, they are usually the closest thing the hospital has to a therapist. Hospital mental health providers are generally limited to those requiring hospitalization for psychiatric care.

I work in a small, rural hospital. It’s a very different setting than Mass General. We transfer nearly all of our sickest patients to larger hospitals in the Twin Cities. Because of this, the role of the chaplain is a bit different. They are present with families when a loved one dies or when they receive a difficult diagnosis like cancer. However, we don’t take care of critically ill patients here, so their continuous presence at our hospital isn’t as vital. When I started my career, we had a trained chaplain on call. Her name was Julia. She was excellent. I knew her well enough to feel good leaving grieving families in her care. About 8-10 years ago, our hospital switched to volunteer chaplains. The ones I have interacted with are likable and helpful, but I don’t know the extent of their training or skills. I am, perhaps, a bit extra sensitive to the communication skills of chaplains.

When I was in residency, I would sometimes “moonlight”, working in nearby small-town ERs where they benefited because I had more ER experience than most of their providers and I benefited from really putting my decision making skills to the test. One day, I was working at one of these hospitals and a patient came in in cardiac arrest. We performed CPR, but it was unsuccessful and eventually, I pronounced him dead. Later, one of the nurses called me to the room because the patient’s family thought the patient was still alive. As I talked to them and explained the situation, I learned that the chaplain had somehow in his prayer communicated uncertainty about whether the patient was dead. Understandably, the grieving family clung to that hope, so I was left both looking like I didn’t know what I was talking about and having to crush their world one more time. Trained chaplains know the importance of careful, accurate communications in high stakes settings like this.

Though it is difficult to measure what chaplains do, they increase both the efficiency and the efficacy of how hospitals work. As an emergency physician, I take pride in how I deliver bad news. I try my best to be compassionate, well-informed, leave time for any and all questions, and let families know that they did all the right things. I know that I am becoming part of someone’s story forever and I would like my role in the story to suck as little as possible. That said, while I am taking the time to deliver that news well, the queue of people waiting for me in other patient rooms is stacking up. Even for physicians who possess the emotional skills to stay present with grief (which certainly isn’t all or even most of us), there are simply other important demands on our time. Leaving a family in the hands of a skilled chaplain feels good. You know they are being cared for. Leaving a grieving family untended feels heartless. It is a source of moral injury for physicians because there is something at our human core that knows we are not meant to grieve alone.

One important thing to understand about chaplains is, as psychiatry professor Robert Klitzman notes, “Frequently, chaplains are the only hospital employees who have the time to talk with patients and families at length to understand patients’ experiences and perspectives in ways that doctors miss, gaining trust and discovering critical information.” This often can have profound impacts on the delivery of care. Dr. Klitzman discussed how chaplains often serve as mediators between families and staff because they are able to gain a deep understanding of the patient’s and family’s perspective. Sometimes families want more aggressive care when the healthcare team thinks it will be futile. Sometimes families want less aggressive care because they know it’s not what their loved one would have wanted. In both situations, the time and skill in understanding multiple perspectives that chaplains bring changes how care is delivered. One particularly powerful example Klitzman provided of the impact of chaplains was this story of a 13 year old boy with cancer and his mother:

Another chaplain helped a 13-year old boy with cancer whose mother travelled around the country seeking a cure. She couldn’t face that he might die. She couldn’t even talk about it. When the doctors asked the chaplain to meet with her, a chaplain told me, this mother literally “put her fingers in her ears and said, ‘La-la-la-la-la. I can’t hear you! … I don’t want to talk about this!’ ”

After long discussions with the chaplain, the mother was eventually able to say to her son, “I’m concerned that the treatment isn’t working.” That comment gave the boy an opening to say, “OK. So, Mommy, when I die, I don’t want flowers because they’re for girls. I want stuffed animals. Then, after the funeral, bring them all to the hospital to give to all the kids.” He had it all planned out, but could never talk about it because she wouldn’t let him. He could see she couldn’t handle it.

Working in a small hospital with volunteer chaplains, one thing I did not know chaplains did (and learned from Christine Vaughn Davies) is that they support healthcare workers. Similar to how they support patients, they lead discussions to support staff after difficult cases and they continue to follow-up in the days, weeks, and months that follow. Many people working in healthcare now are in crisis. It goes far beyond burnout. It is a mix of burnout, moral injury, and trauma. Meditation apps for self-care are meaningless when you have a 12 year old waiting in your ER for days for a hospital bed or you have to tell someone they have metastatic cancer because they were too afraid of going bankrupt to seek care sooner. We are asked to accept these things as they are even as we know they don’t have to be this way.

Because chaplains have become the default mental health providers of hospitals, they are often the ones that help us navigate that. And research shows, their continued supportive presence and follow-up reduces the likelihood that a traumatic event will become PTSD. In fact, healthcare workers with low social support were nearly 6 times more likely to develop PTSD. The reality is that for most of us working in healthcare, the only follow up that happens after a traumatic event, at least at my small hospital, is a physician-led debrief immediately after the event, which is usually more focused on how we performed as a team, not on our feelings. Otherwise, there might be a peer review, which feels like being in trouble for making a mistake, not like ongoing compassionate support. I know larger hospitals see more traumatic cases more often and because of this have better infrastructure for the initial emotional support, but I have never encountered ongoing emotional support offered on a routine basis. It seems that the assumption is that we offered this initial support, so clearly you are fine now. In other words, chaplains’ attunement to the ongoing emotional needs of staff after difficult cases is absolutely vital to healthcare worker mental and emotional health.

Two other predictive factors for the development of PTSD in healthcare workers are the workload that staff face and feeling abandoned or betrayed by leadership. These cuts to the chaplaincy do both. They increase the amount of time physicians and nurses must make available to emotionally support patients without decreasing any other responsibilities. In addition, leadership are making these decisions to cut vital team members who support both patients and staff without having any sort of plan for where alternative support should come from.

Lastly, healthcare organizations give lip service to the “Triple Aim” all the time. The triple aim includes:

• Improving the experience of care

• Improving the health of populations

• Reducing the per capita cost of healthcare

The decision to cut chaplains certainly doesn’t improve the experience of care. I don’t see how worse communication could increase the efficacy of the care provided, so the health of populations would worsen. The only thing this decision helps with is the per capita cost of healthcare. And even that is debatable because often better communication leads to less unnecessary treatment and better outcomes. I don’t know this, but I suspect that the entire chaplaincy department and the chaplaincy education program cost less than the salary of the person who made this decision. In fact, in 2019, the US spent between $600 billion and $1 trillion in healthcare administrative costs. I suspect somewhere in there we could find some money for some chaplains.

If we believe that people are more than the numbers in their medical chart, and I think that most of us still do, then we know that feeling heard and understood matters at least as much as your blood sugar going from 156 to 104. We know that feeling a sense of spiritual and emotional balance matters just like the structural integrity of your meniscus matters. We know that the things that we can’t see on your brain MRI matter just as much as the things we can. Chaplains are the people in hospitals who have the best tools to tend to these unseen realms of our health that are so vital, not only to our wellbeing, but to our very humanity.

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As I wrote this, I found myself wanting to squeeze other topics like AI in here too, but they didn’t fit. If you have a particular area of interest or concern about the soul of medicine, I’d love to hear your ideas and experiences. I suspect this may become an ongoing series.

Last, in case you missed last week, I’m beta-testing my new health coaching services and expanding my paid subscriptions. I’d be delighted to have you join me.