Saturday, December 29, 2012

Chaplains in the News on the Left Coast

Perhaps it was because it was the Feast of Stephen: check out this article at SFGate, the on line presence of the San Francisco Chronicle. It shares with the public a story of those who are "going out," not only on the 26th, but day by day (and, yes, one of them is an Episcopal priest). It's a good piece, highlighting the work that chaplains do for all patients, and how important that work is to those served. So, head over and take a look. (Hat tip to Episcopal Cafe, who saw it first.)

Monday, December 17, 2012

Standards of Practice for Chaplains: Standard 1, Part B

I left off my last reflection on Standard 1 of the Standards of Practice for Acute Care with this paragraph:

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.
So, how shall we evaluate the data as relevant and/or pertinent (in this case, that may be a distinction without a difference)? Well, we do have some help in clarifying that. In fact the Committee that drafted the Standards of Practice went farther, and did offer some further reflection. (Again, you can link to the Standards from this page, and then scroll down to the more detailed reflections.) The interpretation of the Standard includes,


A chaplaincy assessment in health care settings involves relevant biomedical, psycho-social, and spiritual/religious factors, including the needs, hopes, and resources of the individual patient and/or family.

A comprehensive chaplaincy assessment process includes:

  • Gathering and evaluating information about the spiritual/religious, emotional and social needs, hopes, and resources of the patient or the situation
  • Prioritizing care for those whose needs appear to outweigh their resources


.
My first reaction is that the first sentence doesn’t help us a lot. “Relevant biomedical, psycho-social, and spiritual/religious factors” would, in a hospital, seem to cover just about all the information gathered. However, I think the further categories are helpful. “[T]he spiritual/religious, emotional and social needs, hopes, and resources” do give us something to work with. Note, too, that both the persons (“the individual patient and/or family”) and circumstances (“of the patient or the situation”) are important.

So, if we return to the language of the Standard itself, “relevant” and “pertinent” are related to the needs, hopes, resources, and capacities (whether needs outweigh hopes and resources) of particular persons in specific situations. This, then, gives us categories that allow us to structure our assessments and organize our responses. It also allows us to set some boundaries and make appropriate referrals. For example, while the patient’s biomedical needs might well outweigh resources (after all, how else would someone end up in our institution?), our response is going to be limited primarily to advocacy. We can let the nurse know when the patient reports pain, but we won’t be providing medication ourselves. The same applies to psycho-social needs. Depending on how professionals relate in a specific institution, the chaplain can advocate about social needs, and may have some resources to bring to bear. On the other hand, except in particular circumstances, a chaplain will not be providing psychotherapy for a patient. (Let me say explicitly that I do think we all share in the same first intervention: therapeutic listening. And while therapeutic listening is therapeutic, it only extends into therapy per se if we’re trained for it.) And in most of our institutions even social needs will be referred. While we may have some resources, most chaplains depend heavily on the social workers, case managers, and discharge planners they work with to meet social and/or financial needs.

Which leads us to focus especially on “spiritual/religious factors,” which will certainly include “the needs, hopes, and resources” available. The fact is that this is something of a soapbox of mine. Institutions have or make available professionals trained in psychology and social work. Most of them are quite conscious that they aren’t trained to address spiritual/religious needs. We are. The reasons institutions have us is to address those spiritual/religious needs. So, while we want to be alert to the impact that biomedical and psycho-social needs have on spiritual/religious needs, it is the latter that are our domain and should be our focus.

So, what is relevant and pertinent is data that assesses spiritual/religious needs, hopes, and resources of this person (which may not be expressed in religious language at all), as these are expressed in this situation and affected by biomedical and psycho-social factors. We would hope that, as we would refer appropriate when biomedical and psycho-social needs are affecting the spiritual/religious needs, our colleagues in other professions would refer when spiritual/religious needs seem to be affecting biomedical and/or psycho-social needs. (Well, one can hope….)

Let me make one further reflection on the further explication of the Standard from the Committee. The examples they offer of how one might demonstrate compliance with the Standard is focused not on the data but on qualifications of the tools. Specifically, the Examples refer to “an accepted model” or to “published models for spiritual/religious assessment.” The problem is that these are really more aspirational than real. There are certainly published models for spiritual/religious assessment. However, none of them has been “accepted” across the profession. Each has its strengths. The good folks at Healthcare Chaplaincy Inc. have compiled a list of articles and book chapters that highlight a number of them. But, beyond publication per se none of them has been accepted broadly, or in any official sense.

Moreover, most of them were developed prior to the development of electronic documentation. While one would expect that the categories of any model could be adapted to an electronic platform, each platform has its own limitations – How many fields for data? How many characters per field? As we merge those two tools, we then have to make our own interpretive decisions. What is amenable to a list of bullets or boxes to check? What requires narrative? Knowledge of a variety of models is interesting, but we can only apply one or two in shaping our documentation – and that will inherently shape our assessment. (Remember the proverb that begins, “If your only tool is a hammer,….”)

So, it seems to me that the specifics of the tool – Which model? Which platform? How configured – are secondary to the intent. The measure has to be whether the assessment tool gathers information about spiritual/religious needs, hopes, and resources, with room to note how biomedical and psycho-social needs have impact on them. If the tool does that, it would seem adequate and appropriate to the task. If the tool does that, and the chaplain uses the tool faithfully, I think the chaplain would be meeting the Standard.

Wednesday, December 12, 2012

What Was the Cause of the Stomach Upset?


Last week my Best Beloved pointed me to this article in the New York Times on line. The topic is a new research study that takes a close look at one of the most common medicine regimens in use: taking low dose aspirin to prevent clots that might lead to heart attack or stroke.

The article highlights several questions about aspirin therapy that have come up over the years. There’s general agreement that a lot of folks benefit from taking low dose aspirin. On the other hand, aspirin, even at low doses, has some risk of irritating the stomach lining and causing some bleeding. So, does an enteric coating – a coating that delays the digestion and absorption of the aspirin – spare the stomach and prevent the bleeding? On the other hand, does it interfere with absorption so that the benefit isn’t as great? There has been a theory, too, that some people don’t benefit at all from the aspirin because of “aspirin resistance.” So, is that a real problem? Or does perhaps the enteric coating prevent the absorption, creating the symptoms of “aspirin resistance?”

This is a news article. While it provides a good general description of the clinical questions, it doesn’t go into detail. I’m sure that articles written for more clinical audiences will address the scientific questions in more detail.

However, what I really do like about this article is how well it highlights the various conflicting interests. Read it at all carefully, and you’ll see the questions the reporter raises about the relationships between research funding and research results. There are legitimate questions, really. I believe that the researchers want to benefit patients. I believe they look at their research results and interpretations, and are honest. At the same time, it’s also clear that there are commercial supporters for each position, prepared to fund further research that will help seem to argue for their products. And while correlation is not causation, those connections between research funding and research results are as worthy of study as the medications themselves.

So take a few minutes with this article. It’s hardly definitive. There will need to be more research to justify any of these clinical positions. But it shines a light on the interconnections between research, researchers, and funders – connections that are arguably troubling.

Wednesday, November 28, 2012

Standards of Practice for Chaplain: Standard 1, Part A


I know it’s been a while. Bear with me.

Many of the professions involved in health care have long had Standards of Practice. For example, you can learn about nursing standards here; or about social workers here.

In 2009 a group  with representatives from the Association of Professional Chaplains (APC) and the National Association of Catholic Chaplains (NACC) produced a set of Standards of Practice for Chaplains in Acute Care (which is to say, in hospital settings). You can learn more about that process and access the Standards here.  The Standards may have several benefits for us in the profession.

Having Standards of Practice will now help chaplains communicate with others about chaplaincy and assist chaplains in discussions with other chaplains. Ultimately, the goal is to ensure a consistently high clinical practice for our profession.

With these goals in mind, my department is embracing these Standards of Practice. Over time they should become the framework for our work, and the way that we “tell our story” to other chaplains and to administrators.

That means I need to be thinking through these Standards myself. I need to be able to speak to them if I’m going to help others embrace them; and one of my most effective ways to think is to think out loud here.

The Standards are divided into three sections. Section 1 is Chaplaincy Care with Patients and Families. The sections begin with “Standard 1, Assessment: The chaplain gathers and evaluates relevant data pertinent to the patient’s situation and/or bio-psycho-social-spiritual/religious health.”

As I look at the Standard, the first issue has to be definition of terms. For me, the hardest isn’t really the strangest. “Bio-psycho-social-spiritual/religious health” is simply – no, let’s just say really – a jargonistic way to speak to the health of the whole person, incorporating an expectation that a person who is holistically healthy is spiritually healthy.

No, I’m much more concerned first about “relevant data pertinent to the patient’s situation….” What are we considering data?

One of the older documentation frameworks, used in many cases in Social Work and also sometimes by chaplains, is the classic SOAP note: Subjective, Objective, Assessment, Plan. The categories that are about data are Subjective and Objective: what are the statements the person can make based on perception (Subjective – like “Patient appears anxious”); and what are the statements that others would also see as facts (Objective – like “Patient is holding a rosary”). Both the subjective and objective statements are data; and by identifying some as “subjective” and some as “objective” there is some acknowledgement of differences of authority.

So, for chaplains, what might we consider data? What we perceive, certainly; and what is reported. For example, both what we have in the present moment can inform us, and also what stories we hear from patients and family members. A patient’s statement about church membership is data, and so is the patient’s story about a childhood experience in Sunday School.

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.

Wednesday, November 14, 2012

New Resources for Episcopal Wonks

I have referred a number of times to great stuff one can find on line through the Digital Archives of the Episcopal Church. It's where I've found past Resolutions of General Convention and Actions of the Executive Council. Well, now there's a whole new resource there: the Reports to General Convention (better known as the Blue Book) for Conventions dating back to 1976.

What can you find there? Between Conventions there are a variety of groups who meet to carry forward the priorities set by each Convention. They are the Commissions, Committees, Agencies, and Boards (CCAB's) of the Church - some under the jurisdiction of General Convention itself, some of the Executive Council, and some of one or both of the Houses of Deputies and of Bishops (often referred to as the "Interim Bodies"). Each Interim Body reports to the next General Convention on its work. Part of those reports may be specific resolutions to General Convention (the "A" resolutions). However, each report also gives discussion, reflection, and rationale for the work and priorities of the Church. So, each report gives a window into the thinking within the Church on a given issue. To make matters easier, the good archivists separated out each report. So, you don't have to open up a 400+ page Blue Book. You can link to a specific report.

Now, sometimes you'll have to dig a little to see which body had responsibility for a particular topic. Some bodies have changed their names over time, and some have been added. However, each document is searchable. 

So, if you want to know what has been said to the General Convention on a topic, often by some of the best minds in the Episcopal Church, this is the place to look. It offers a depth and perspective on many issues that you won't get just looking at a resolution. And since these reports are received by General Convention, they will show for each Convention the best work for the time, if not necessarily the official statements (which resolutions would), often by some of our best minds.

So, go dive in. You'll be amazed (and perhaps sometimes appalled) by what you find.

Thursday, November 08, 2012

Reflection for the Day 11-8-2012

A woman stopped me in a parking lot this morning. She wanted money for gas. I gave her some. She wanted a little more "for milk for the children." I gave her a little more.

I had two concerns that were both in my mind. One was whether I'd actually done her good. I couldn't know whether she would use the money well or poorly. I might be sustaining a vicious habit, ultimately harming her. Sometimes, we're told, better to say no and press the person to seek help from an agency that can provide access to more resources. So, one thought was to wonder whether I was helping or harming her.

The second thought was whether in the process I'd been cheerful enough.

Sunday, October 14, 2012

More Data for More Reflection on Health Care and the Market

In my last post, I asked this question: "If [employer-provided] health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs?" Well, I think we have an answer, and it isn't a happy one. 

Take a look at this article from Associated Press, picked by the Huffington Post: "Darden Restaurants Tests Hiring Of More Part-Time Employees To Avoid Obamacare Costs." Darden Restaurants, Inc., best known as owners of Olive Garden and Red Lobster, is making a deliberate choice to reduce its costs for employer-provided health care by reducing the number of employees who work enough hours to qualify. The authors of the article also note that other restaurant chains are making the same decision.

Now, there's nothing illegal about this. I think it's immoral, but in one sense that's neither here nor there (and, in the classic trilogy, I would worry about "fattening," but that's for another time). I simply hold this up as the other side of depending on the market and competition to provide access to health care. If we believe that universal access to health care is a good thing, and should be seen as a civil right, we simply can't depend on the market and competition to bring it about.


Thursday, October 11, 2012

More Reflection on Health Care and the Market

While I'm not watching the Vice Presidential Debate....

There are two things that bother me when anyone speaks optimistically about how a market approach and competition will solve problems of access to health care (whether in response to the Affordable Care Act, or as a means for changing Medicare). One is that those persons either don't know how the market for health care actually works, or they hope that we don't know.

The second is that we have seen how the market and competition will (or won't) work in providing access to health care. We have a long tradition of treating access to health care (not to say health itself) as a retail commodity. In private practice, each physician practice is a small business. It stands or falls on whether it makes enough revenue to pay the physician and all the physician's employees and all the business' expenses. That is, the physician practice needs to make a profit. 

The same is true of institutions. Oh, there are not-for-profit institutions; but they still have to keep ahead of the cost of living. Call it "margin" instead of "profit;" but the institution has to accomplish it. As the not-for-profit folks remind themselves, "no margin, no mission." For-profit institutions, like any other for-profit businesses, are accountable to their owners and investors to be profitable.

The same is true of insurance companies. Certainly, there are several important government insurance programs - Medicare, Medicaid, and TriCare - but the vast majority of insurers are for-profit corporations. The negotiations that happen, whether between individual and agent or between corporate  benefits departments and brokers, involve striking a balance between service and price. It's really not that different, really, from leasing a car.

Now, those negotiations rarely happen at "point of sale." That's because we do participate in groups to purchase access to health care. So, others do the negotiating on our behalf. So, maybe it's not retail. If not, though, it's wholesale, just as GM and Ford negotiate with their parts suppliers, and the person who purchases the car doesn't get to negotiate for one starter motor over another. Nobody questions that the wholesale process is a market process with a lot of competition involved.

Now, some might say that the government insurance programs have totally changed the market. I would suggest that they haven't for two reasons. The first is that most of us get our insurance, our access to health care, through an employer, whether our own or a family member's; and most of us don't work for government (including all the various governmental levels and bodies). The second is that the not-for-profit players haven't affected the ability of the for-profit players to make a profit. Sure, there are some insurers who don't have members because those members are covered by government; but all those government insurers are still doing business with physicians, institutions, pharmaceutical companies, etc, that are not government institutions, and most are making a reasonable and healthy profit.

There was, however, a time when we did have an entirely market orientation to health care. It lasted until the establishment of Medicare in 1967. Last weekend I spoke to nurses who graduated from nursing school well before that date. I was young then, but I still remember the public service announcements focusing on how many of our elderly were impoverished. One of the consequences of that poverty was that many couldn't afford health care. In recent years we've been concerned about seniors being faced with a choice between food and medicine. In those days it was also an issue - there just weren't as many medications available. Medicare wasn't created on a whim. It was created because this was a real problem, and people were suffering and dying for lack of care. The same is true of Medicaid. Medicare and Medicaid were developed because in a market approach to health care, competition wasn't working. If competition were going to work now, why wasn't it working then?

Now, some might ask about employer-based health care. Actually, employer-based health care was a result of competition in the market. In World War II there was a shortage of labor - more jobs than employees, what with so many in the military, and the demand so great for war materiel. However, wages were frozen, in an effort to control costs. So, employers had to find a new way to compete for employees. They started offering new benefits, including health insurance that the employer helped provide. So, employer-based health insurance did come as a result of a market.

But, that was a different market indeed. We're nowhere near the demand for labor that we knew in the War Years, or even in the Post-war Years. If health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs? See, that's the other problem with trusting competition to solve the issue. That works in the individual's favor when the market is up and tight, but the market isn't always up and tight. Indeed, it's not realistic to imagine that it will always be up and tight, or even much more than half the time. But, as we will remember if we remember what it was like before Medicare for seniors, or before the expansion that came with the Second World War, there were an awful lot of folks who couldn't afford health care. A market approach and competition just weren't getting the job done.

So, no, I'm not prepared to leave it to the market, or to trust competition to address the problem. It didn't it before. Indeed, it isn't doing it now, even with government programs to cover an awful lot of the most vulnerable, the least insurable. Based on history, on our national experience, I have no hope that it will work in the future.

Saturday, October 06, 2012

Appreciating Nurses


An address delivered to the 2012 Homecoming of the Saint Luke's College of Health Sciences.The luncheon was hosted by the class of 1962.

First, let me thank the Alumni of Saint Luke’s College, along with the Faculty and Administration of the College, for the opportunity to be with you today. I’m pleased and honored.

The story is told that in the world as it was before the turn of the Twentieth Century two men met in a train compartment. One was a businessman of some success, an important man and a Christian. The other was an older man, a Jew wearing clothes worn with age and dusty with long travel. The world being as it was back then, the Christian merchant behaved toward the elderly Jew badly. He was rude and even obnoxious. Fortunately, the encounter was blessedly short. The businessman stayed just long enough to make clear his bigotry, and then huffed off to find another compartment.

When he reached his the city that was his destination, he happened to remark at the station about how annoyed he had been to encounter the elderly Jew on the train. The person listening, however, had a different reaction. “The man you met,” he said, “is the Chief Rabbi of this town. He is a scholar recognized even by our Christian clergy, and the most important leader of his people here. He is a man of great influence throughout the city.”

This caused the businessman no end of concern. The last thing he had wanted to do was to offend someone with that kind of influence. He decided that he had to apologize, and as soon as possible. He sought and was granted a meeting.

This time the rabbi received him in his own home. It was comfortably and elegantly appointed. Fine carpets were on the floors. Lamps made the room bright. This time the rabbi was dressed, not in his traveling clothes, but in the finest black wool. It was altogether a different appearance. The businessman apologized humbly, making clear that he would not have been so rude had he know whom he addressed.

“Ah,” said the rabbi. “I appreciate your wish to apologize. Unfortunately, I can’t accept your apology. You see, when you were so rude, you were rude to someone you thought a poor and ordinary Jew. Therefore, you must find a poor and ordinary Jew and apologize to him.”

When I was invited to speak to you, it was suggested that I speak to you to thank you for your dedication to nursing and to healing, and to appreciate your caring spirits. I found myself thinking that these would be fine things to do. On the other hand, I had to stop and think about how best to do that, and about what perspectives I might want to bring to the process.

For example, sort of like the businessman in the story, I found myself stopping to think about just whom I should thank. Should I thank the mature and experienced nurses whose lives and careers were shaped so long ago by their three years learning nursing at Saint Luke’s Hospital? Certainly, there is a lot to express gratitude for in years of service to patients and their families, working with so many professional colleagues. I think, too, that there’s a lot to be thankful for in how the perspective of nursing shaped their lives out of the hospital. All the nurses I know – and I’ve lived with one myself for almost twenty-five years now – brought to all of their lives the balance of compassion and organization, of gentle hands and rigorous minds, that they brought to their careers at the bedside. Yes, there much to thank them for.

On the other hand, shouldn’t I also thank those young women, however many years ago, who finished three strenuous years and walked, wide-eyed and scared and excited into new careers as nurses?  There is much to appreciate about the hope and energy and commitment that they brought to work that was so important and that they were only beginning to understand. They entered into a field of nursing and a context of health care that was changing even as they were learning it. The graduates of 1962 hadn’t heard yet of Medicare, because it didn’t exist. The Bird Ventilator was just replacing the Iron Lung. The multidisciplinary intensive care unit was still a new concept. How could they have imagined all the changes they would experience in their careers? Certainly, we need to be grateful for their enthusiasm and their courage in those first days after their graduation.

Or, is there some point in between? Nurses at any point in their varied careers continue to encounter patients and families and colleagues who need all the care and compassion and wisdom that they have to offer. They show again and again the courage and patience, the flexibility and resilience, the knowledge they have and the commitment to gain more, that is all part of a career in nursing. At any point in a nurse’s career we can find many things to appreciate.

I had to think, too, about what perspective I might bring to offering gratitude. Who am I to thank you and to offer appreciation, not only on my own behalf but for Saint Luke’s Hospital?

Should I express my gratitude as a patient? Certainly, I’ve been a patient. I’ve had a number of surgeries and procedures at Saint Luke’s Hospital and in the Saint Luke’s Health System. That’s in no small part because I trusted the nurses and other colleagues with whom I have worked. Now, like others in health care I can be – well, let’s say I can be a bit idiosyncratic as a patient. I was in recovery after knee surgery, and just becoming aware. I knew the voice of my nurse when she said, “Marshall, are you awake?” I must have said something like “Yes,” because she said, “We just want to see if your brain is working.”

I said, “The square of the hypotenuse of a right triangle is equal to the sums of the squares of the other sides.”

The nurse said, “What?”

I said, “Four score and seven years ago our forefathers brought forth upon this continent a new nation.”

She said, “What are you doing?”

I said, “I’m seeing if my brain works.” Then I don’t remember anything for a while.

Well, we know that those of us who work in health care can be odd, not to say difficult patients. In spite of that – or perhaps more because of that – I am grateful for the nurses who have taken care of me. Now, I’ll admit that as a child I wasn’t as immediately grateful for the nurse’s care as I became. However, from the nurse who fought my childhood fever with an ice bath to the nurse who just this week gave me an absolutely painless flu shot, nurses have taken care of my health and met my needs, and I appreciate that.

Or, should I express my appreciation as a colleague? Ministers, and especially chaplains, sometimes get called “doctors of the soul.” However, I have long contended that we have more in common with nurses than with doctors. In general, we don’t diagnose; we assess. We aren’t looking as much for pathology as for holistic function. We are concerned with the whole person, and not specialized for isolated systems. No, clergy are much more nurses of the soul than physicians.

I’m especially conscious of that as a chaplain. Chaplains work more closely with nurses than with any other professionals in health care. The biggest reason for that is that the nurse is truly the care coordinator. In a sense doctors direct care, determining goals of treatment and writing appropriate orders. It’s still the nurse who coordinates care, both in the direct care she or he provides and in how she or he guides and coordinates the care of others, including chaplains. And there is another reason. Uniquely among our colleagues in health care, it is nurses who share our concern about a patient’s spiritual needs. As a chaplain I can’t be everywhere at once. God can, but I can’t. I depend on the wisdom and the holistic perspective of the nurses I work with to help me be with the patients and families, and the staff, who most need my care. I can hardly tell you how grateful I am for that.

Or, perhaps I should express my gratitude as an Episcopal priest and as Director of Spiritual Care in an Episcopal hospital. You know, when you came as students you were not most of you part of the Episcopal tradition, but you were soon aware it was an Episcopal hospital. I’m sure many of you remember chapel attendance with Chaplain Beachy. Nor perhaps are you members of the Episcopal tradition now. However, you share with the Episcopal tradition a commitment to health and wholeness, and to respecting the dignity of every human being.

You quickly became aware that you shared in that with the Episcopal Church as you trained in an institution started and led by Episcopalians. However, you probably weren’t aware of many ways in which the Episcopal Church shared with you that commitment to ministries of healing. We have long had, for example, a Standing Commission for Health for the Episcopal Church. I have the honor of serving on it.

More important, at least for an Episcopalian, it shapes our worship. Like some other churches, the Episcopal Church remembers in worship those who have been heroes and heroines of the faith. You know, I’m sure, that we remember Saint Luke. Indeed, Saint Luke’s Day and Saint Luke’s Week are just around the corner, when the hospital and the health system celebrate the ministries of chaplains. But, perhaps you didn’t know that Florence Nightingale is also in the Episcopal Calendar. Vincent De Paul is in the Episcopal Calendar. So are the Mayo and the Menninger families. And there are those known less well. There are the Martyrs of Memphis, who died providing care at the bedsides of yellow fever victims in Memphis, Tennessee. There are Damian and Marianne of Molokai, who served to the end patients suffering with leprosy. There is Innocent of Alaska, an Orthodox bishop who served among the Aleut and saved many lives when he convinced them to accept smallpox vaccination. They were not all Episcopal either, but they all shared, and shared with us, a commitment to the health and wholeness of those they served. So, perhaps as a chaplain and Episcopal priest, and as the Director of Spiritual Wellness at Saint Luke’s Hospital I can offer you thanks.

Really, all these perspectives are important. We can express appreciation for the nurses you were as new grads and for the nurses you became in your careers. We can be grateful as patients you served and as colleagues you served with. We can offer our thanks as individuals, and as members with you of that community across years of history and lines of tradition that is committed to service and health and wholeness. The fact is that you are deserving of our thanks and of our appreciation; and I am honored with this opportunity in some small way to express our gratitude. So, for all you have offered and all you have been as nurses, and for the many ways that you have cared for us and honored the hospital and the school where you began: thank you. Thank you very much. the 2012 Homecoming of the Saint Luke's College of Allied Health

First, let me thank the Alumni of Saint Luke’s College, along with the Faculty and Administration of the College, for the opportunity to be with you today. I’m pleased and honored.

The story is told that in the world as it was before the turn of the Twentieth Century two men met in a train compartment. One was a businessman of some success, an important man and a Christian. The other was an older man, a Jew wearing clothes worn with age and dusty with long travel. The world being as it was back then, the Christian merchant behaved toward the elderly Jew badly. He was rude and even obnoxious. Fortunately, the encounter was blessedly short. The businessman stayed just long enough to make clear his bigotry, and then huffed off to find another compartment.

When he reached his the city that was his destination, he happened to remark at the station about how annoyed he had been to encounter the elderly Jew on the train. The person listening, however, had a different reaction. “The man you met,” he said, “is the Chief Rabbi of this town. He is a scholar recognized even by our Christian clergy, and the most important leader of his people here. He is a man of great influence throughout the city.”

This caused the businessman no end of concern. The last thing he had wanted to do was to offend someone with that kind of influence. He decided that he had to apologize, and as soon as possible. He sought and was granted a meeting.

This time the rabbi received him in his own home. It was comfortably and elegantly appointed. Fine carpets were on the floors. Lamps made the room bright. This time the rabbi was dressed, not in his traveling clothes, but in the finest black wool. It was altogether a different appearance. The businessman apologized humbly, making clear that he would not have been so rude had he know whom he addressed.

“Ah,” said the rabbi. “I appreciate your wish to apologize. Unfortunately, I can’t accept your apology. You see, when you were so rude, you were rude to someone you thought a poor and ordinary Jew. Therefore, you must find a poor and ordinary Jew and apologize to him.”

When I was invited to speak to you, it was suggested that I speak to you to thank you for your dedication to nursing and to healing, and to appreciate your caring spirits. I found myself thinking that these would be fine things to do. On the other hand, I had to stop and think about how best to do that, and about what perspectives I might want to bring to the process.

For example, sort of like the businessman in the story, I found myself stopping to think about just whom I should thank. Should I thank the mature and experienced nurses whose lives and careers were shaped so long ago by their three years learning nursing at Saint Luke’s Hospital? Certainly, there is a lot to express gratitude for in years of service to patients and their families, working with so many professional colleagues. I think, too, that there’s a lot to be thankful for in how the perspective of nursing shaped their lives out of the hospital. All the nurses I know – and I’ve lived with one myself for almost twenty-five years now – brought to all of their lives the balance of compassion and organization, of gentle hands and rigorous minds, that they brought to their careers at the bedside. Yes, there much to thank them for.

On the other hand, shouldn’t I also thank those young women, however many years ago, who finished three strenuous years and walked, wide-eyed and scared and excited into new careers as nurses?  There is much to appreciate about the hope and energy and commitment that they brought to work that was so important and that they were only beginning to understand. They entered into a field of nursing and a context of health care that was changing even as they were learning it. The graduates of 1962 hadn’t heard yet of Medicare, because it didn’t exist. The Bird Ventilator was just replacing the Iron Lung. The multidisciplinary intensive care unit was still a new concept. How could they have imagined all the changes they would experience in their careers? Certainly, we need to be grateful for their enthusiasm and their courage in those first days after their graduation.

Or, is there some point in between? Nurses at any point in their varied careers continue to encounter patients and families and colleagues who need all the care and compassion and wisdom that they have to offer. They show again and again the courage and patience, the flexibility and resilience, the knowledge they have and the commitment to gain more, that is all part of a career in nursing. At any point in a nurse’s career we can find many things to appreciate.

I had to think, too, about what perspective I might bring to offering gratitude. Who am I to thank you and to offer appreciation, not only on my own behalf but for Saint Luke’s Hospital?

Should I express my gratitude as a patient? Certainly, I’ve been a patient. I’ve had a number of surgeries and procedures at Saint Luke’s Hospital and in the Saint Luke’s Health System. That’s in no small part because I trusted the nurses and other colleagues with whom I have worked. Now, like others in health care I can be – well, let’s say I can be a bit idiosyncratic as a patient. I was in recovery after knee surgery, and just becoming aware. I knew the voice of my nurse when she said, “Marshall, are you awake?” I must have said something like “Yes,” because she said, “We just want to see if your brain is working.”

I said, “The square of the hypotenuse of a right triangle is equal to the sums of the squares of the other sides.”

The nurse said, “What?”

I said, “Four score and seven years ago our forefathers brought forth upon this continent a new nation.”

She said, “What are you doing?”

I said, “I’m seeing if my brain works.” Then I don’t remember anything for a while.

Well, we know that those of us who work in health care can be odd, not to say difficult patients. In spite of that – or perhaps more because of that – I am grateful for the nurses who have taken care of me. Now, I’ll admit that as a child I wasn’t as immediately grateful for the nurse’s care as I became. However, from the nurse who fought my childhood fever with an ice bath to the nurse who just this week gave me an absolutely painless flu shot, nurses have taken care of my health and met my needs, and I appreciate that.

Or, should I express my appreciation as a colleague? Ministers, and especially chaplains, sometimes get called “doctors of the soul.” However, I have long contended that we have more in common with nurses than with doctors. In general, we don’t diagnose; we assess. We aren’t looking as much for pathology as for holistic function. We are concerned with the whole person, and not specialized for isolated systems. No, clergy are much more nurses of the soul than physicians.

I’m especially conscious of that as a chaplain. Chaplains work more closely with nurses than with any other professionals in health care. The biggest reason for that is that the nurse is truly the care coordinator. In a sense doctors direct care, determining goals of treatment and writing appropriate orders. It’s still the nurse who coordinates care, both in the direct care she or he provides and in how she or he guides and coordinates the care of others, including chaplains. And there is another reason. Uniquely among our colleagues in health care, it is nurses who share our concern about a patient’s spiritual needs. As a chaplain I can’t be everywhere at once. God can, but I can’t. I depend on the wisdom and the holistic perspective of the nurses I work with to help me be with the patients and families, and the staff, who most need my care. I can hardly tell you how grateful I am for that.

Or, perhaps I should express my gratitude as an Episcopal priest and as Director of Spiritual Care in an Episcopal hospital. You know, when you came as students you were not most of you part of the Episcopal tradition, but you were soon aware it was an Episcopal hospital. I’m sure many of you remember chapel attendance with Chaplain Beachy. Nor perhaps are you members of the Episcopal tradition now. However, you share with the Episcopal tradition a commitment to health and wholeness, and to respecting the dignity of every human being.

You quickly became aware that you shared in that with the Episcopal Church as you trained in an institution started and led by Episcopalians. However, you probably weren’t aware of many ways in which the Episcopal Church shared with you that commitment to ministries of healing. We have long had, for example, a Standing Commission for Health for the Episcopal Church. I have the honor of serving on it.

More important, at least for an Episcopalian, it shapes our worship. Like some other churches, the Episcopal Church remembers in worship those who have been heroes and heroines of the faith. You know, I’m sure, that we remember Saint Luke. Indeed, Saint Luke’s Day and Saint Luke’s Week are just around the corner, when the hospital and the health system celebrate the ministries of chaplains. But, perhaps you didn’t know that Florence Nightingale is also in the Episcopal Calendar. Vincent De Paul is in the Episcopal Calendar. So are the Mayo and the Menninger families. And there are those known less well. There are the Martyrs of Memphis, who died providing care at the bedsides of yellow fever victims in Memphis, Tennessee. There are Damian and Marianne of Molokai, who served to the end patients suffering with leprosy. There is Innocent of Alaska, an Orthodox bishop who served among the Aleut and saved many lives when he convinced them to accept smallpox vaccination. They were not all Episcopal either, but they all shared, and shared with us, a commitment to the health and wholeness of those they served. So, perhaps as a chaplain and Episcopal priest, and as the Director of Spiritual Wellness at Saint Luke’s Hospital I can offer you thanks.

Really, all these perspectives are important. We can express appreciation for the nurses you were as new grads and for the nurses you became in your careers. We can be grateful as patients you served and as colleagues you served with. We can offer our thanks as individuals, and as members with you of that community across years of history and lines of tradition that is committed to service and health and wholeness. The fact is that you are deserving of our thanks and of our appreciation; and I am honored with this opportunity in some small way to express our gratitude. So, for all you have offered and all you have been as nurses, and for the many ways that you have cared for us and honored the hospital and the school where you began: thank you. Thank you very much.

Sunday, September 30, 2012

A Survey of Sorts

For the years I have had this blog, I have used a service to tell me how many folks visited the site, what question or search string brought them, where they were viewing from, and what post was of particular interest. Sometimes I see patterns, and I wonder how they came to be.

So, let me ask about one. Each year at about this time, my post "A (Poor) Moral Argument About Universal Health Coverage" begins to get a series of views. They all, or almost all, come from Cape Town in South Africa. In fact, all, or almost all, come from the system of the University of Cape Town. The consistency over the five years since I put up the post has fascinated me. So, I'm curious. Is there a course for which the post is suggested as a source? If so, I'd love to know what it is. I'm flattered, of course; but mostly I'm just curious. Someone want to share about the interest each year in this post? Leave a comment and let me know.

Tuesday, September 25, 2012

A Familiar Problem

Over at the Episcopal Cafe yesterday, there was this interesting post,Happy Monday morning. Let's discuss the problem of evil. I thought that was an interesting title - just the sort of thing that happens at my house. (No, really, it does! That's a tribute in many ways to My Best Beloved; but that's a story for another time.)

That post was stimulated by The Problem of Evil by Sr. Bernadette Reis, fsp. I can commend both her article and the responses at the Cafe. It is, after all, a subject that will never go out of style.

At the Cafe article, one of the respondents wrote of finding an understanding of the problem of evil that was "satisfying." My own response to that was, "I don't think anyone can or should find an understanding of the problem of evil that is "satisfying." I have the one that I can live with, but I take no pleasure in it, nor am I "satisfied" by it. It's simply the one that allows me to stand with integrity and still believe what I do believe about God.

I do get the question often. As a chaplain it's part of my stock in trade. As I said, I have the answer I can live with; and while I first want the patient to come to an answer the patient can live with, if asked I will share it. I preface it, though, admitting that it doesn't "satisfy" me. It's just what I can live with."

I do mean what I wrote about "what I can live with." I have an understanding that is as much about preserving my understanding of who God is, as it is about logically making sense of why bad things happen to good people - or at all. My response is a conscious compromise. It is, in the classic definition of theology, "faith seeking understanding," and not considering logical constructs hoping to find God.

Another respondent asked about whether the term "evil" applied to the lion hunting the zebra. I'm not sure it does; but I'm sure the related concern about "pain" does apply, and so I had to find an understanding that at least took that seriously. I don't want to anthropomorphize, but I do want to take seriously that other creatures are sensate, if not sentient.

And so I came to the conclusion that God withholds God's self and cries a lot. That is, God loves and wants us to love. However, to love - to really love - requires free will. However, that's not enough. I'm not sure what I want to say about the free will of a middle sized fish to eat a smaller fish. Rather, it's about the context that allows for free will - about what we see as "fallenness." We can imagine a creation within which "there is no pain or grief but life eternal;" but within that creation, is there really freedom to love - which is to say, freedom not to love? We would say that in perfection God is compelling, in the sense of being so wonderfully loving and attractive who could resist? However, if God is compelling in the other sense - or even in that sense - is the love real?

So, God has to leave room within creation for things not to be perfect - as animals after the Flood became carnivores, and we became omnivores (whether you take the Flood literally or metaphorically). God does indeed allow randomness and failure and pain, because without that latitude there is no real capacity for love. We can't love God and we can't love one another if there's no room to fail.

This is why I'm not "satisfied" with my understanding. I don't like the idea of God withholding God's self, especially when I continue to believe in what God can do even when it's not what God does do. On the other hand, I can believe in not giving children everything they want or preserving them from all pain. I've made that decision in my own life. So, I can imagine God making that decision in a context of love.

Now, there is some accountability, at least for us. Jesus said of the man born blind, "It's not about who sinned. It's about our opportunity to do good." I don't know about fish or zebras or lions, but I do believe we are accountable for the pain we cause or relieve, for the evil we do. I hope God is accountable, to God's self if not to us; and I believe that God suggested that by choosing to be one of us and accept just those limitations we have and those pains that we have. Indeed, if God truly loves us, God is in some sense accountable to us. I just don't quite know how I'm qualified to hold God accountable.

So, God has a creation within which stuff can happen. God doesn't enjoy it - indeed, God feels pain in it. God stands back to give room for us to love and to fail, and to show love for others. And God cries a lot.

As I said, I don't find that "satisfying." It's just what I can live with.

Monday, September 03, 2012

Recovering From a Dry Throat....

I know it's been a dry summer - both in the weather and the garden, and in my voice here. Here's hoping that the fall will offer more opportunity for me to think out loud,

And with that in mind: I preached again at St. Mary Magdalene Episcopal Church. You can listen to the sermon by linking here. It's about a plot - well, really, about a couple of plots. I'll be honored of you take the time to listen.

Tuesday, July 24, 2012

A Voice Close to Home

Periodically I'll find an article by or about someone in healthcare ministry and recommend it as "a voice of a chaplain." I've found another, and this one in my own back yard. The Rev. Jeremiah Spencer has spent years now in hospital chaplaincy, and I've had the honor to know him personally. He served both a major hospital and a parish; and there were times when I saw him more often in my hospital visiting parishioners than at gatherings of chaplains.

Jerry was profiled this past Sunday in the Kansas City Star. I commend the interview for your reading.

Monday, July 23, 2012

One Last Point - Or Is It Two?

My last reflection on General Convention (well, at least the last one I'd planned) has gone up today at the Episcopal Cafe. It addresses the question sung so many years ago by Firesign Theater: "How can you be in two places at once, when you're not anywhere at all?" I'm a good bit more hopeful about the General Convention being "in two places at once." So, go take a look. I hope you find it interesting.

Thursday, July 12, 2012

Those With Ears to Hear

I've posted another reflection from the floor of the House of Deputies. I found myself considering our struggles to hear one another. I hope you find it interesting.

Wednesday, July 11, 2012

Comment for the Feast of St. Benedict

On this Feast of St. Benedict, I wonder if we can't offer this translation of conversatio mori into contemporary terms: conversatio mori is a (life-)long-term plan of ongoing performance improvement in our efforts to live our Christian faith.

Tuesday, July 10, 2012

From the Midst of the House: Thoughts from the General Convention

If you've wondered where I've been, let me answer that I've been sending my work on General Convention to the Episcopal Cafe. So, if you'd like to see my most recent thoughts, check here and here. If you're already following things at Episcopal Cafe, you may have seen my comments and impressions from the Floor. If you're not, certainly look at my thoughts; and also look at the many other comments noted there. General Convention is a busy and complicated experience, and the more voices you hear, the better sense of it you'll have.

Sunday, July 01, 2012

General Convention and GMO's


I’ve had less to say to this point about General Convention (at least here at the Bedside). That’s because this year I have more responsibilities. I’m not sorry, but it has made a difference.

That doesn’t mean that I haven’t been paying attention to health-related issues coming up. One of those is the issue of genetically-modified organism (GMO) foods. There is a resolution this year on the topic:

Resolution A013 Study Genetically Modified Food Crops
 Resolved, the House of _______ concurring, That the 77th General Convention seek to inform the Church of the issues surrounding the development of genetically engineered crop plants and the patenting of genetically modified organisms (GMOs); by charging the Standing Commission on Anglican and International Peace with Justice Concerns, the Standing Commission on Health, the Executive Council Committee on Science, Technology and Faith, the Standing Commission on Social Justice and Public Policy, and other CCABs deemed relevant, to jointly study those issues and report to the 78th General Convention; and be it further 
Resolved, That in commissioning such study, the 77th General Convention intend to empower the 78th General Convention to take action toward developing policy that will allow the Office of Government Relations to address these issues as they relate to Congressional farm bills and other federal policy or legislation; and be it further 
Resolved, That the 77th General Convention seek to empower with information those organizations of The Episcopal Church that strive to address equity and social justice in matters such as global economic development, the environment, sustainable agriculture, health, and nutrition; and be it further 
Resolved, That the 77th General Convention encourage individual Episcopalians seek to undertake study about GMOs and reflection upon the theology and stewardship of creation; to learn about the influence both domestic and globally of GMOs upon agriculture, economic development, the environment, alleviation of hunger, and biodiversity.

The resolution has been offered by the Standing Commission on Anglican and International Peace with Justice Concerns, and so it’s no surprise that the focus of the rationale is the effect of GMO foods on small farmers at home and abroad.

With the development of strains of genetically modified foods crops and their dissemination worldwide, concerns are being raised about the impact of genetically modified organisms (GMOs) on ecological sustainability and global economic justice.
 The issue of patenting geneplasm and other life forms raises both general and contextually specific ethical questions. When the question arises about patenting crop seeds, the particular considerations have much to do with economic justice for small-scale farmers. This applies to family farmers and sustainable farming in the United States, and especially to small-scale and subsistence farmers in the developing world.
 The Executive Council commissioned a report on these issues in 2011 and has sought counsel from experts in the field. Given that these are complex issues, pertinent to both domestic and international policy, The Episcopal Church would do well to follow the example of the Lutheran Church of America and other denominations in seeking to identify the moral, ethical and theological principles involved.

While the Standing Commission on Anglican and International Peace with Justice Concerns offered the resolution and rationale, there is virtually nothing on the topic in their report in the Blue Book (pp. 95-107). On the other hand, the Standing Commission on Health, which is called on in the resolution to study the issue, is ahead of the game. In their report, the do in fact comment on GMO foods (Blue Book pp. 144-150). That being the case, it is also not surprising that the focus is on the techniques of biogenetics and the health issues when we eat them.

Both the concerns about GMO’s and agriculture (and especially the control of staple crops by agribusiness corporations), and issues of GMO’s in the food chain deserve study. There are other concerns that might have received more focus, and other actions that might have been suggested (especially labeling of foods with GMO’s in the ingredients). However, this is at least a beginning.  

Saturday, June 30, 2012

What I Get Excited About

I know I've been quiet lately. I've posted little here, although I've been commenting occasionally here and there. Fact is, I've been getting ready for the General Convention. It starts in days, and I'll be part of it.


Which led to my newest post at the Episcopal Cafe. It has my thoughts about what makes General Convention fun and exciting (and, no, it isn't all the A resolutions). So, go take a look to see what keeps me going.


And check in daily at the Cafe. There will be ongoing news and comments from the Convention frequently, and good stuff from my valued colleagues. If you want to know what's really going on, don't depend on the mainstream media (or their media competitors who pretend they're not "mainstream"). Go to the Cafe.


If you're going to Convention, perhaps I'll see you there. And if you're not, keep up in prayer.

Thursday, June 07, 2012

Blogging the CPE Experience 2012


Every summer I look around for students in CPE programs who are blogging about their experience. This year I’ve found an interesting collection of writers. I was pleased this year to find some Episcopalians writing about their experience. Take a look at these students and authors.








These are all students in CPE for the Summer. But in addition, I found a blog from a CPE Supervisory Candidate. That means that she’s experience in clinical pastoral education, and is now training to be a clinical pastoral educator. Take a look at


As always, I encourage folks to read and comment at these blogs, and especially to offer support. The best of CPE experiences is challenging, and the students will appreciate knowing that others are supportive and encouraging.