Friday, July 30, 2010

Worth Reading: A Doctor on a Hard Conversation

I appreciate my readers.  One of my readers, Mark Preece, pointed me to a post at the blog dotCommonweal.  That post was a recommendation and brief comment about an article online at the website of the New Yorker.  The article, titled “Letting Go,” was written by Atul Gawande, a surgeon.  It’s an in depth article, the sort of thing the New Yorker is known for, and it’s worth the time to read.

The subject of the article is, really, the difficulty that physicians have being honest with patients when the patient faces a terminal diagnosis.  As much as anything else, the cause is that the physicians have difficulty being honest with themselves.  Having been educated to think that disease and death are enemies, many physicians are reluctant to stop therapeutic treatment even when there’s no reason to think further therapy will benefit the patient.  They’re also inclined to see a patient’s death as a defeat, and both a personal and professional failure.  But, as Dr. Gawande notes, “Death is the enemy. But the enemy has superior forces. Eventually, it wins.”  Or, as I often say, the mortality rate of being human is 100%

Dr. Gawande does speak well of specialists in palliative care, even as he raises another hindrance.  To really understand a patient’s values and to help the patient understand what is and isn’t possible or statistically reasonable takes a great deal of time.  It certainly doesn’t help that physicians are paid to apply treatments and not to really sit down and talk to a patient.  At the same time, I don’t think lack of reimbursement is the most serious reason that physicians don’t have these conversations, nor does Dr. Gawande.  Rather, it is that most physicians aren’t trained to address the personal, and certainly non-clinical issues that really shape how patients hear information and make decisions.

Dr. Gawande is honest about his own difficulties, and clear, too, in his critique of his profession.  He offers a worthwhile reflection on what makes it hard for doctors to be clear with themselves and their patients when therapeutic medicine has nothing more to offer.     

Thursday, July 29, 2010

I beg your pardon! Resolved

As near as I can tell, Google didn't like my template, and stopped supporting it.  I'm trying one of the new templates, one that I think I can live with, and now I can see my own posts.  Blessedly, I expect that now you can, too!  Thanks so much for reading things here.  I hope you haven't missed too much in the last little while.

I beg your pardon? I beg your pardon!

I don't know whether you're seeing what I'm seeing today.  As I try to look at the blog, no posts are appearing.  I'll try to get stuff back as soon as possible.  If you are seeing my posts, leave a comment here so that I'll know.

Wednesday, July 07, 2010

Some Out-Loud Thinking About Ecclesiology

Yesterday I was reading this post on Thinking Anglicans about the struggles toward ordination of women to the episcopate in the Church of England. This article from Andrew Goddard, linked at the TA post, made a reference to Anglo-Catholics and Anglo-Evangelicals in the Church of England having “different ecclesiologies.”

In responding, I made the comment, “As for Mr. Goddard's analysis: I was struck by the comment that Anglo-Catholics and Anglo-Evangelicals have "different ecclesiologies." Notwithstanding some differences in opinion, how can those with different ecclesiologies claim to be in the same institution?”

One person responded to my question with his own: “Good question -- but aren't you a bit late in asking it, since it has been the case ever since 1559?” (And thank you for that, Mr. Tighe.)

I had some thoughts about that which I posted (I think; the process didn’t seem to function smoothly), but which I also thought I would share here.

Well, late, yes, although I wouldn't have dated it to 1559 so much as after the Tractarians; but perhaps late, yes.

However, I think the "different ecclesiologies" as laid out by Mr. Goddard are more different, more polarized than I experience in the Episcopal Church. My experience is of a theology of episkope that balances functional and charismatic understandings - that is, a vocation to specific functions for which the Spirit provide the person the specific charismatic gifts. Perhaps most folks in the Church of England think (when they think about it at all) much the same, and Mr. Goddard presents the poles for clarification and sake of argument. However, the wider rhetoric, and especially all the talk of "taint," suggests that there are indeed folks in the Church of England embracing the extreme positions.

Perhaps the question isn't why they're still in the Church of England (if not exactly "together"), and not in the Episcopal Church. In the American context, where all ecclesial communities are matters of choice and none is "by law established," the extremes have largely left, forming new communities (and, two points: rhetoric from some notwithstanding, no one has been thrown out, but some have walked away based on conscience, feeling, as we often say, "better fed spiritually;" and second, there are indeed splinters in the American context more liberal than the Episcopal Church). One wonders if without Establishment these folks would have chosen to stay in. So, is the answer to my question that they remain together legally for reasons that don't affect their theologies of the episcopate?

Just a thought.

Tuesday, July 06, 2010

From Behind the Terminal....

Yes, I know I've been very quiet lately.  It's not that nothing relevant's been going on.  It is, rather, that I've been engaged in a couple of other projects that have focused away from the blog.

One of those has been preparation for peer review.  Peer review is required at intervals is required to maintain my Board Certification with the Association of Professional Chaplains (APC).  It's actually required every five years.  However, they only started this five years ago; so, I'm only coming to it now.  I'm in the last group to come to this who've been Certified for more than five years.

As an administrator, I appreciate the need for periodic review.  As a professional, this is part that effort to look at what I do and how I do it, and to consider what I might do better, what new I might take up, what old I might put down.  It's another application of the work of performance improvement that I've written on at length.

At the same time, I'll allow that I feel some ambivalence about evaluating myself.  If we really can't be objective about ourselves (and between phenomenology and quantum mechanics, I'm pretty clear we can't be objective about much of anything, much less ourselves), how can we evaluate ourselves in any way that's accurate?  Isn't it clearer to have others work from their own impressions, instead of reacting to mine?

On the other hand, if I don't do some reflection and share it, how can I ask for the help that I want, or at least think I need?  Much learning is based on the learner's contract, the learner's idea about what it's important to learn.  How can other help me, if I haven't at least suggested what help I need?

So, in the midst of this I'm working on writing about what I do.  My Best Beloved, God bless her, asked, "Why don't you just write, 'I've been doing this a lot longer than most of you, I do it a lot better than most of you, and so let's just celebrate how well I do."  Well, I've written in other circumstances that I have no humble opinions (and so, for example, won't write "IMHO" when responding to others' blogs); but that seems entirely too much.  Even if I did believe it, it wouldn't really invite much in the way of conversation.  And, I have enough self doubt to not be sure that I do better than others, even if I have been at it longer.

Part of the issue, too, is the difficulty in setting the limits of what a chaplain does.  Some of those limits are clear; so, for example, I'm not a nurse, and I don't mess with medication lines and pumps.  I'm not a therapist or clinical social worker, so I don't use the diagnosis of "depressed" in my charting, except to acknowledge that diagnosis has been made by another (whether reported in a professional note or by the patient).

On the other hand, I spend more of my time in therapeutic (active) listening than almost anyone around me, but I know I'm not the only one.  I am more focused on patients' spiritual needs than others around me, but I know I'm not the only one.  As I often say in orientation, I know I'm not the only one in my hospital who prays for patients, and occasionally not the only one who prays with patients.

Some years ago the APC sponsored a pilot study on the activities of chaplains serving as one-person departments.  Among the eleven chaplains who participated the breadth of activities was extensive.  One slide continues to play in my mind.  Chaplains were reporting on their work, and dividing up how much of their time was spent providing direct care from time spent in administrative and "indirect care" activities.  At one extreme was a chaplain who spent 90% in direct care and 10% in administrative and other activities.  At the other was a chaplain who spent 10% in direct care and 90% in other activities.  When all eleven were compared side by side in bar graphs, the line from one to the other was virtually straight.  There was even a person in the middle whose time was split 50/50!

So, as I seek to describe what I do, I'm wrestling with how to ask for comment on how I do my work, when it may be more toward one extreme or the other without being at all off the spectrum.  I do a lot - I think.  I don't think what I do is unusual, but I'm clear that it's different from many others.

Well, anyway, that's where the time and energy has been.  Perhaps once it's over I'll have a better understanding.  Probably once it's over I'll have more to say; but those are not necessarily the same.