Episcopal Chaplains in Orlando

I have posted before that the Assembly of Episcopal Healthcare Chaplains (AEHC) will be meeting next week in Orlando in conjunction with Spiritual Summit ’09 of the Spiritual Care Collaborative. Let me remind everyone of the scheduled events we can participate in:

• The AEHC Annual Meeting Sunday, Feb. 1, 2009, 1:00-2:00 p.m. This year the meeting will include elections for President-elect, Secretary, and Treasurer. (If anyone would like information on the candidates nominated, email me at the address on my Profile page, and I'll be happy to send it.)
  
• The Episcopal Breakfast Monday, Feb. 2, 2009, 8:00 a.m. This is an event of the Spiritual Summit, sponsored by the Office of the Bishop of Chaplaincies of the Episcopal Church. While not formally an AEHC event, we encourage all members to participate.
  
• The AEHC Reception Monday, Feb. 2, 2009, 6:00-700 p.m. There is a registration fee of $15.00 for this event. You can find the form in the latest Chaplair, or email Treasurer Michael Stewart from the Information page of the AEHC web site.
  

For all of these events, rooms will be announced in the published schedule for the Spiritual Summit.

In addition, AEHC will host a Eucharist on Sunday morning, February 1, at 7:00 a.m. While this will be an Episcopal Eucharist, everyone is welcome to join us. When you register for the Summit in Orlando, look for an announcement of the room on the Message Board.

I hope there will be many Episcopalians and Anglicans among the members of Spiritual Collaborative organizations who will come and join us for these activities. I look forward to meeting many new folks in Orlando.

At Last! My Place Among the Fathers

Well, I don't usually do this; but when I saw this at Haeligweorc, I couldn't resist. (And thanks to Derek.)

You’re St. Justin Martyr! You have a positive and hopeful attitude toward the world. You think that nature, history, and even the pagan philosophers were often guided by God in preparation for the Advent of the Christ. You find “seeds of the Word” in unexpected places. You’re patient and willing to explain the faith to unbelievers. Find out which Church Father you are at The Way of the Fathers!

A Reflection on the Inauguration

Did you catch it today? Did you pay attention and understand? Did you hear what President Obama committed himself to?

It’s important, I think, to consider this. We don’t often think of what the President swears. We’re so aware of the details, the agendas, the many problems small and great that drive our civic and civil government. We’re aware of what has been promised, and what we want to see, whether it’s part of the promise or not. I don’t know that we pay close attention to the commitment itself.

Today, notwithstanding a bit of a slip from the Chief Justice, President Obama committed to this:

I do solemnly swear that I will faithfully execute the office of President of the United States, and will to the best of my ability, preserve, protect and defend the Constitution of the United States.

Note that it is specific: he commits to “preserve, protect and defend the Constitution of the United States.”

I think we don’t think about that enough. It explains a lot, really. He doesn’t commit to defend the people of the United States. That would get us into an awful lot of “us vs. them:” natural-born citizen vs. naturalized; native-born (it’s not the same thing) vs. immigrant; citizen of the states vs. those of commonwealths and protectorates overseas; citizens vs. resident aliens. To begin arguing about who would fit into the people of the United States would divide us, surely and painfully.

Nor does he commit to defend the territory of the United States. That would become quite parochial quite quickly. We might find ourselves recognizing the states and the federal district, but not the Commonwealth of Puerto Rico, or the Protectorates in the Pacific. We might find ourselves becoming insular, in time of crisis ignoring friends and rejecting allies.

He does not commit to defend the interests of the United States. After all, those interests can change year by year and election by election. The phrase might apply to interests shared widely among the people, or focused by narrow interests and political expediency.

No, he commits to protect the Constitution: the foundation of principles that we believe describes our hopes for what it might mean to live together as a free society, across our many divisions, across the time zones of our territory, and across the vagaries of history. It is the Constitution, and not likenesses of race, creed, ethnicity, language, histories, geography, age, or sexuality, that defines this nation, and, when we do right, we who live and serve in it. That is why all our laws and regulations, our political practices and principles, must conform to the Constitution, and not the Constitution to them.

We celebrate this day that another American has sworn to protect and defend the Constitution. We celebrate it because we know that it is only by committing to protect the Constitution that we can be certain he has committed to protect and defend what is best, freest, and most fair for all - for all – of us.

Gathering for Common Mission

This past week, January 12-14, Saint Lukes Episcopal Hospital of Houston, and the Diocese of Texas hosted the first International Episcopal/Anglican Healthcare Ministries Conference. For three days, participants gathered from across the Episcopal Church and beyond to discuss the interests and best practices of Episcopal hospitals in serving their patients and the communities from which they come.

The conference was notable for including not just, or even primarily, chaplains, but also hospital administrators and bishops. I participated as one of the representatives from my health system; but I was pleased that my bishop and the CEO of our central referral hospital were also present.

The conference was truly international and broadly Anglican. In addition to bishops and representatives from the Episcopal dioceses of Puerto Rico and Haiti, there were also participants from the Diocese of Jerusalem; the Anglican Office in Geneva, Switzerland; and the primate and a physician from the Church of South India.

Much of the time was spent discussing issues we all had in common, both in the United States and beyond. There were also significant differences noted in our contexts, and time was spent considering how hospitals and dioceses might collaborate for better care for all we serve.

This has been an important beginning. Many of us present hoped that there would be future opportunities for discussion and for development of new programs.

Newest at Episcopal Cafe

My newest piece is up today at Episcopal Cafe. It's about the coming shortages - no, the current shortages of physicians and nurses, and how Episcopal institutions are (not so much) involved in training new ones. Take a look, and feel free to comment. Take some time, too, to see the work other folks have posted. I'm in some really good company there.

Performance/Quality Improvement for Chaplains: Measurement (4)

This is the fourth in a series of posts on Performance/Quality Improvement and measurement for Chaplains. If this is of interest, check the "Labels" section in the left column, and choose "PI/QI."

In addition to contacts, time, and interventions, chaplains have looked for opportunities to measure outcomes. That is, chaplains have sought to identify results or consequences of a chaplain’s interaction with a patient, and to measure how often those results might occur, and what actions of a chaplain might contribute.

Measuring outcomes would be the “gold standard” for determining the impact of a chaplain’s work. That would put the profession in concert with other professions in health care. The move toward “evidence-based practice” is established on discovering results and consequences, preferably those offering benefit, for the patient; and then refining practice to increase benefits and avoid injuries.

We might think of two sorts of outcomes that might be measured. The first would be clinical or objective outcomes. That is, outcomes that would themselves be measurable in terms of changes in the patient’s clinical results – lab values, increased function, etc. The various studies trying to measure the outcomes of prayer for patients have been efforts to see clinical changes.

The second sort of outcomes would be subjective, reflecting assessments of either patient or practitioner. This has in fact been the most common area for chaplain research, in that the largest category has been surveying customer satisfaction. That area is significant enough to require a post of its own. However, there have been a number of studies that assessed subjective reactions to the chaplain’s work, and they do have some value.

I think we also need to note that some studies seem to reflect both. Using a standardized instrument or set of questions gives greater consistency to the information gathered, even though the information itself is a subjective self-report. A favorite example might be the Myer-Briggs Type Indicator. It is an instrument many of us know and love. It has been “validated:” that is, it has been used many times over a long period of time, and the quality of the information gathered is consistent over time. Because of the large populations involved over time, the results can be applied to self-reflection and to analysis. At the same time, the information is largely about preferences and/or self-assessment, and so is subjective. Because the data gathering is standardized, the data gathered is more dependable, but still not necessarily objective. My own experience in taking the Myers-Briggs and the related Keirsey Bates Temperment Sorter is that the results change according to my mood, and according to whatever else is going on in my life. So, when life is difficult and I would like more structure, I am more likely to come out more “judging” than “perceiving” in my own results.

As I noted, there have been a number of efforts to quantify outcomes of prayer. More important have been a many studies done to correlate good health outcomes with religiosity and/or a religious lifestyle. Perhaps the most famous name for that research is Harold Koenig, MD, of the Center for Spirituality and Health at Duke University. He and similar researchers have found significant correlations between healthy spirituality and good health.

At the same time, there is criticism of this research. The most significant critique is to note that correlation is not the same as causation. That is, the fact that religious people are less likely to be depressed does not necessarily show that it is being religious that causes the effect. Some critics pointing this out do so because they are looking specifically for a spiritual, i.e. unexplainable, cause. They might, for example, suggest that better health outcomes come to, say, Amish farmers, not because they are religious but because they get more exercise in their daily life. However, they ignore the fact that they get more exercise precisely because their religious discipline shapes their daily life in that direction. While a consideration for any particular study, the aggregate information from multiple studies becomes more suggestive the more it is confirmed. Still, this is an important critique of the prayer studies.

We might also note that such research doesn’t necessarily help chaplains. Most of the correlative research has been done outside health care institutions, and so doesn’t suggest anything one way or another about the work of chaplains. The prayer studies by and large engaged prayer through prayer groups outside the institutions, and so once again didn’t really say anything about the effects of a chaplain’s work.

There have also been studies of the effects of a chaplain’s work, primarily by recording the subjective responses of patients to a chaplain’s support. Once again, much of this has been in the form of customer satisfaction studies, whether by independent researchers or by institutional quality and business research departments. However, some published studies have sought to measure effects at the bedside. One early study that stood out was that of Chaplain Greg Stoddard at Reading Memorial Hospital in Reading, Pennsylvania (“Chaplaincy by Referral: An Effective Model for Evaluating Staffing Needs;” The CareGiver Journal, Volume 10, Number 1, 1993) In Stoddard’s study, patients were evaluated by chaplains and CPE students using the nursing diagnostic categories of Spiritual Concern, Spiritual Distress, and Spiritual Despair. Patients were assessed at first contact and at subsequent visits, and determined to have improved (e.g., Distress to Concern) or gotten worse (e.g., Distress to Despair), based on relevant statements made by patients and families. While the purpose of the study was to evaluate staffing needs, it incorporated some measurement of outcomes of the chaplain’s visit. Once again, the measurement is subjective in both steps: both the patient’s report and the chaplain’s assessment. However, using standard terms and standard measures, significant efforts were made to standardize chaplain responses. In addition, this took place within the clinical setting, at the bedside, and so is more comparable to measurements of clinical outcomes in other disciplines.

There is the additional difficulty that the outcomes we are most aware of as chaplains are not those used by other disciplines. That is not to say that, like the studies of Koenig et al, we can’t look for such outcomes. They are not, however, those we most value in our own measures of our work. Nor are they within our practice to measure ourselves. That is, we might choose to track how blood pressure or agitation are affected by our work; but the actual measurement will be done by others, and without significant coordination, at their convenience and on their schedule.

Working as chaplains do in a environment of evidence based practice, measuring outcomes could be of great importance, especially in seeing pastoral care departments as necessary rather than as luxuries – useful and desirable, but still luxuries that can be dispensed with in hard times. At the same time, measuring outcomes can be difficult, especially because correlation is not necessarily causation, and because much of the information can be subjective. However, to the extent that we can measure outcomes and can relate those outcomes to patient wellness, it is worth our effort. It contributes to our claim that we are members of the team and important parts of the hospital’s purposes; and it adds to our abilities to communicate with professional colleagues in our institutions.

A New Frontier in the Market for Organs

Well, I suppose I shouldn’t be surprised, but still I was when I heard this report late last night on the BBC World Service. A physician and his wife are divorcing. During the marriage he donated a kidney to save her health – arguably, to save her life. Now that they are divorcing, he wants financial compensation for the kidney.

The reason I shouldn’t be surprised is that there has been an argument out there, largely from folks who believe “the market” is the best way to structure social relations, that the solution to the vast difference between the number of people who might benefit from a donated organ, and the number of organs actually donated, is some sort of incentive other than goodness of heart to encourage folks to donate. You can read here two good discussions of that from the last year here and here.

Of course, a market does exist. In this country, to the small extent we see it, it is a black market because such trade is illegal. However, we know that open and black markets in human organs do exist. They raise significant questions about whether the poor or prisoners, or other populations that in this country we would call “protected,” are in one way or another abused, making decisions without truly being free in their choices.

That a market does exist doesn’t, however, suggest that it should, or that we would as a society benefit if it did. We would, I think, benefit significantly if we were successful in encouraging generosity generally, and a sense of social connectedness; and I think that would support greater donation. However, a market approach does just the opposite. It makes it about how it benefits me, and how that separates me from, and potentially sets me in opposition to, others in my society. As an American, I find that sad. As a Christian I find it utterly untenable.

This case does include a significant corollary: that people don’t know how to give freely. This doctor’s demand for reimbursement for the donated kidney makes clear that he didn’t really make it as a gift. Once given, a gift is gone, beyond my control. There is a risk it won’t be used as I would like. However, if I’ve really given it, if I’ve really let it go to another, I realize I have no more claim. It is essentially his argument that he delegated the kidney to his wife, but only for his own purposes. He may or may not have been explicit about that, even in his own mind. But, his desire for that level of control, and for that sort of compensation, makes clear this was indeed that sort of extension of himself in her, and not a gift to her; all of which may say something about how the divorce came about in the first place.

We have here an attempt to commodify a donated organ, and to do so after the fact of the donation. Morally it’s wrong; but at a much more basic and more human level, it’s just sad.

More on Hospital Economics

On NPR's All Things Considered yesterday afternoon there was this story on one of the less well known effects of the economic crunch on not for profit hospitals. In essence, the credit crunch has seriously affected the ability of not for profit hospitals to issue bonds to raise money to expand facilities and services.

Hospitals see impact from this both directly and indirectly. Directly they see their inability to add or upgrade space, or to add new programs and equipment to better serve and to serve more patients. Because they operate on very slim margins (the "profits" available to keep up with growing needs and inflation), they can't do much expansion based on margin alone. In addition, while needs are growing, reimbursement is shrinking, both because Medicare and other insurers want to cut and because as more people lose jobs, more people come for care without insurance. As a result, margins disappear, and often plans and programs with them.

Indirectly, hospitals see impacts because it's harder to attract physicians or to negotiate with insurers as facilities age. This is part of what I wrote about in this earlier post. Physicians who want the best care for their patients, and employers and insurers who want the most effective resources for their clients (well, I still believe most of them do), want new facilities for their care. Even where that is not a big issue (and that's a rare circumstance), changes in building codes and patient safety regulations require updating and upgrading facilities - facilities that are often cheaper to replace than to repair.

To do either, not for profit institutions have to go for credit, primarily through the bond market. Difficulties there have these direct and indirect effects on the institutions, and so have direct and indirect effects on us and the care we receive.

New Word on Mount Calvary

There's a new news story on Mount Calvary, centered on the survival of the monastery cross. It provides information on the history of the cross, and on considerations for the future of the community. (Hat tip to Episcopal Life for point to this.)