Still Becoming an Episcopal Chaplain

 While I’ve been pretty slow in postíng in this strange and difficult year, I know some folks are still looking for my posts on becoming an Episcopal chaplain. With that in mind, our friends at the Episcopal Church Center want to be sure we have the best link to open the Application for Ecclesiastical Endorsement. The best current link is here. I’ve also shared this in Facebook and have updated the link at our website, Assembly of Episcopal Healthcare Chaplains.

And, if you have found your way here searching about becoming an Episcopal healthcare chaplain, those are also good resources. There is the AEHC Facebook page, and information on our website, including a flowchart about the process. You can contact me to ask for help, or contact AEHC from the web site, or find a connection on Facebook. We’re happy to provide information and support your process.

Striking a Balance

I was struck last week when I had these two articles on the Washington Post on the same day. The first, by physician James Hudson: “Our dangerous fear of pain”; and the second, by Amber Petrovish: “Some of us actually need painkillers. Can doctors ease up on us?”. As chaplain-types, we are, I think, aware (or we certainly should be) of the difficult balance. Our physician colleagues are caught between anxiety about over- or inappropriately prescribing and anxiety about leaving patients suffering. 

With that in mind, I would remind folks about General Convention resolution 2018-C037 “Call to Respond to Opioid Epidemic.”  The resolution explicitly speaks both to opioid addiction and to the need to adequately address real and chronic pain. It does spend more text on addressing addiction, but it is balanced in its intent.

It’s worth some time to read both opinion pieces, and then to review the Convention’s response. We need to be aware of the difficulty, and to be aware that the Church has spoken to it.

Ecclesiastical Endorsement in the Episcopal Church, 2019

As I have of late, this is also posted at Chaplair, the blog of the Assembly of Episcopal Healthcare Chaplains.

I’ve written before about ecclesiastical endorsement in the Episcopal Church. I have been through our process, and I have been watching the process now for going on 40 years. Over that time, some things have changed; and some things haven’t; and AEHC has been in the midst of it for almost all our 70 years.

In my last post I recalled how endorsement had gone from the individual bishop to AEHC, then the Office of the Bishop of Federal Chaplaincies. After that it went to the office of Mission. With that history in mind, let me clarify how the process works now. (And attached I have provided a flowchart.)

Once upon a time, it was individual bishops who endorsed for healthcare ministry. Now, it continues to be individual bishops who endorse for healthcare ministry. Yes, there is a process, but if an Episcopalian feels called specifically to healthcare ministry the first step is to be sure to have met with the bishop. This is true whether or not the prospective chaplain feels called to ordination or is pursuing certification. Healthcare chaplaincy is recognized as a specialized ministry and the Episcopal Church can endorse persons in any of the four orders for ministry. So, first be sure to connect to the bishop.

As referenced, for many of us the interest in ecclesiastical endorsement began in the pursuit of board certification. It is still required for the largest chaplain organizations (and I would encourage it for whether seeking certification or not). If you are pursuing certification, the next step is completing the form on line here. At this time this will be received by the Rev. Margaret Rose, Ecumenical and Interreligious Deputy to the Presiding Bishop, and our Endorsing Officer; and processed by Ann Hercules, Associate for Ministry Beyond the Episcopal Church. Note that the persons have changed at times, but the process has actually been stable for some time.

Note, too, when you look at the form, there is a requirement to affirm that you are up to date with the Church’s education on preventing and recognizing sexual abuse and ministry misconduct. This is normative for many ministries in the Episcopal Church, ordained and lay, paid and volunteer. Your diocesan office can help you get what you need.

Once the form is received, the Endorsing Office will reach out to the relevant bishop, asking if the bishop can endorse this applicant specifically for healthcare ministry (remember what I said to do first?). She or he will send the endorsement to the Office. Once received Margaret will send letters of endorsement to the endorsed chaplain and to the certifying body, with a copy to the bishop and a copy for the records.

Some have looked at the application and noted that it asks about certifying bodies. There has been concern that a person can only be endorsed if pursuing certification. Others have wondered whether chaplains not seeking certification are required to pursue endorsement. In fact, while many chaplaincy positions require certification, that’s not universal. However, I strongly believe every Episcopalian providing professional healthcare ministry should seek endorsement. For the reasons I have written before, I believe endorsement serves the Church, serves the chaplain, and serves the persons to whom the chaplain ministers. A person not seeking certification can be endorsed. Endorsement in that case, though, need not involve the form or the Endorsing Office. The chaplain can simply request and receive that directly from the bishop.

There is one further consideration. As noted the Episcopal Church will endorse persons in all four orders of ministry. However, if a lay person is endorsed, it is required that the endorsed chaplain arrange for a public service of commissioning. This both publically acknowledges the chaplain’s specialized ministry, and also the chaplain’s recognition of the authority of the Episcopal Church for that person’s ministry. Certifying bodies used to require this of all endorsed and certified lay chaplains. Because of the breadth of faith communities now involved in chaplaincy, the certifying bodies no longer require it. However, the Episcopal Church expects it, whether the endorsement is processed through the Endorsing Office or directly with the bishop.

Now, once endorsed, do you ever need to do it again? Really, that depends. Are you in a certifying body that requires periodic peer review or a similar significant review of the ministry? For example, APC requires that every five years. The Endorsing Office would like you to renew your endorsement at that point, including the Church’s abuse prevention training. 

It would also be appropriate to renew endorsement if a job change takes you to a new diocese. You would in any case want to meet with the new bishop, and would likely need to meet the expectations of that diocese for abuse prevention training. It would be appropriate at that point to renew endorsement. The process would be the same: either to resubmit the application through the Endorsing Office or to work directly with the bishop.

So, that is the process. Again, check the flowchart below. I have tried in it to concisely describe the steps of the process. Margaret Rose has also reviewed it, and approved it. We hope, then, that this description and the attached flowchart make the endorsement process clear. And, always feel free to reach out to AEHC colleagues for help.

A Classic on Ecclesiastical Endorsement

As I prepare to write about the current process for ecclesiastical endorsement in the Episcopal Church, I thought I would reflect on the value of endorsement itself. That's all the more important because things have changed in professional chaplaincy in the last few years. As a place to start, I looked back at the article below. It was written by Rod Pierce and myself and published in Chaplair in November 1999. When I write about the process I'll make some additional comments about the current situation; but while I work on that, please enjoy this reflection from twenty years ago.

The Executive Council of the Episcopal Church Speaks to Vaccination

Most of the world may not have noticed, but the Executive Council of the Episcopal Church met last week. For those who don't know, the Executive Council is charged with carrying forward the decisions and programs of the General Convention between meetings every three years.

And even among those who are aware of the Executive Council, not all are aware that they also pass resolutions. Resolutions of General Convention are the highest-level statements of the positions and programs of the Episcopal Church. However, actions of Executive Council are also important. They address specific actions to carry out General Convention resolutions, and address issues that have come up since General Convention. If you're interested in a summary of all the actions of the most recent Executive Council, you can find them here. And if you're a real Episcopal geek, you can look for actions of Executive Council for the last 40 years or so in the Digital Archives of the Episcopal Church, here. (And thanks to the Episcopal Cafe, where these news stories have been shared.)

One resolve of Council had particular resonance for me, and I reproduce it in full:

Express grave concern and sorrow for the recent rise in easily preventable diseases due to anti-vaccination movements which have harmed thousands of children and adults; condemn the continued and intentional spreading of fraudulent research that suggested vaccines might cause harm; recognize no claim of theological or religious exemption from vaccination for our members and reiterates the spirit of General Convention policies that Episcopalians should seek the counsel of experienced medical professionals, scientific research and epidemiological evidence; call on the Office of Government Relations to advocate to the United States government for stronger vaccination mandates informed by epidemiological evidence and scientific research; urge all religious leaders to support evidence-based measures that ensure the strongest protections for our communities; ask congregations and dioceses to partner with medical professionals to counter false information, and to become educated about programs in their communities that can provide vaccinations and immunizations at reduced or no cost to those in need (MB011).

Some of my readers may know that one of my responsibilities in my last position (happily, one I could share with colleagues), was to review requests for exemption on religious grounds from mandatory flu vaccination. It was an interesting process, and perhaps I'll write more another time.

However, one matter I brought to that process was a request I'd received years earlier. I had a call from a priest, a rector in Virginia. She needed some help. She had a parishioner, a mother, who was terrified because of the misinformation, then already rampant, about vaccinations for children and autism. The parish priest wanted to ask the hospital chaplain whether I knew of any support for exemption in the Episcopal Church. I took some time to look into the Digital Archives myself (I am a geek), and found confirmation of what I already thought. General Convention had not spoken specifically about vaccines, but had a long history of supporting receiving modern medical care. Indeed, I suggested to the priest that, if anything, most would lean on that verse in Ecclesiasticus,"The Lord created medicines out of the earth, and the sensible will not despise them." (38:4) I suggested that the priest accompany the mother and children to the pediatrician to help the mother hear clearly what the doctor had to say, and to support her in her anxiety.

There are a few - a very few - religious traditions that reject vaccinations, even if they don't reject all health care. There are more folks who take a moral position (sometimes expressed in religious language, but often not; and in either case often poorly) against vaccinations as a violation of one's person. In those latter cases, it is always in individualistic choice, rejecting the concept of accepting a vaccine to love neighbor as self, by accepting vaccination to protect those who medically cannot. In taking this position, the Executive Council is certainly standing on sound science. What is more important, though, is that they are standing on sound faith: the expectation that Episcopalians can accept vaccination, not only to protect themselves, but also to protect their neighbors.

Distributing the Costs of Care, Part 3: It’s Already All of Us

So, I’ve asserted (and I hope folks have agreed) that a thing costs what it costs, whether a strawberry or a medical procedure. I’ve also discussed that what makes those things seem affordable to us (at least, to the extent we do find them affordable; but we’ll come back to that) is that costs aren’t really just costs to us: the costs are distributed across a lot of people in the network of the economy. The clear conclusion (and hardly a new one) is that we’re all in this together.

This always gives me pause when leaders in government and business talk about reducing healthcare costs. If I pay attention, it becomes clear that they’re not talking about reducing what a thing costs. They’re talking about reducing what it costs  in one category or another. And, they’re not always talking about the same category. When the political leader speaks about reducing costs, sometimes he or she talks about reducing what I as an individual pay out of pocket; or sometimes about what I pay in premiums; or sometimes about what I pay (and, sometimes, what we all pay) in taxes. And, sometimes when I listen the leader is talking about what a business pays in the process of being accountable (that’s what regulations do, after all); or what the total is paid through taxes, as opposed to how that affects my pocket.

But, note that, as the current system is running (employer based insurance for most, Government-based insurance for the elder and the poorer), those changes are mutually exclusive. To reduce what I pay out of pocket, I end up paying more in premiums; or, conceivably, I could end up paying more in taxes. A thing costs what it costs, and the difference is in how those costs are distributed.

Also concerning to me are those polítical leaders (and, I will say I don’t hear this from healthcare providers or from supply industries) who seem to want to reduce how much I pay for the benefit of someone else (and, really, usually someone elder or poorer or both). Now, as an Episcopal priest I will assert that such an argument is immoral - broadly un-Biblical, and definitely un-Christlike. However, I also want to look back at our discussion so far and suggest that it’s simply unworkable.

A thing costs what it costs. If costs are redistributed, they appear to change, but that’s deceptive. They will still come back to me, but in a different form - and sometimes one that is destructive.

For example, there are ongoing efforts to reduce Government expenditures for Medicaid, both federal and state. The visible consequence as of those are pretty hard. Look at the number of rural and regional hospitals that have closed over the past few years. People lose care. Communities lose jobs. But also, people end up getting care that costs more, traveling farther, needing more intense and expensive care, and dying. Since hospitals cannot by law refuse emergency care (and that is the law), they make up elsewhere what they lose on those patients. Their basic costs structures go up; their negotiations with insurers go up; and my bills go up. The analogy of squeezing the balloon is apt: it may appear to reduce my taxes, and look good for the political leader, but it will still hit me somewhere else.

What can most effectively reduce my personal expenses? To most widely distribute the costs across the most people. Which leads us to Medicare for All.

It wouldn’t surprise anyone who knows me that I think we would all benefit most from a system offering universal access and requiring universal participation. That is, everyone can get care, because this most widely distributes the amortization of costs of equipment and paying for professionals. And, everyone pays something, in some way that is progressive related to economic capacity (considering both income and wealth), because this most widely distributes, and most justly distributes, financial resources in the system.

Now, at this point no one knows what a Medicare for All plan would do, except perhaps these two points; mostly because there is more than one plan proposed under that heading, and they don’t all agree. However, I do want to note that in some ways we already have something for all in Medicare.  

We normally just think of the insurance for folks over 65 and folks with significant disabilities paid for by Medicare. However, that also means Medicare is perhaps the biggest insurer, and so has a great deal of influence in how widely costs are distributed. I’m not on Medicare, but my insurer knows what Medicare is willing to pay, and wants to negotiate my rates accordingly.

Another aspect in which Medicare serves all is that most if not all medical education is paid for in full by Medicare. This certainly applies to the vast majority of medical residency positions. For most medical residents, hospitals are reimbursed in full for the cost of salaries and perhaps for benefits. In addition, Medicare pays in part for many other kinds of clinical education. This includes nurses, therapists of various kinds, and even chaplains. If you get care from a physician who is in or has completed a residency, your physician was provided to you in part by Medicare. For teaching hospitals, this means that a good deal of the budget that allows them to take care of the poor and allows them to keep their equipment current is relieved by Medicare.

Finally, we can’t undervalue how Medicare has kept many, many seniors out of poverty. Some of us may remember commercials on television before Medicare was in acted, identifying the elderly in urban settings as particularly and acutely poor. Now that I am retired and up on the Plateau, I see that level of financial concern in the rural poor almost every day. Medicare by itself has raised many folks out of poverty and bankruptcy for the two generations we’ve had it.

These are ways in which Medicare currently serves all of us. These are also examples of the value of seeing our healthcare as a social good, and not just as an individual good.

A thing costs what it costs, whether a strawberry or a medical procedure. We are concerned about paying for the healthcare of others, but in fact we are already doing that. We can decide whether that continues to be something that happens outside our view, or if we want to be deliberate and public and all involved in those decisions. To do that, we need to distribute those funds and those costs as widely as possible; and in these United States as widely as possible means all citizens and all residents.

The thing costs what it costs, and we are all always  already sharing those costs, whether we are aware of it or not. Maybe it’s time to recognize that social connection and to see healthcare as a social good, and not just a retail product.

Distributing the Costs of Care, Part Two: More Than Just Me

A thing costs what it costs. That’s as true for a medical procedure as it is for a strawberry.

I started with a new primary care provider recently. That start involved meeting with a new professional provider, and a set of lab studies and tests - nothing exciting, but part of the process.

Now, I will have certain expenses out of pocket for that, but how those charges are determined is, again, a reflection of a slew of costs. There is the cost of the professional’s time; and, trust me: these days any health care business has some idea what to charge by the hour, even if that’s not how the charge is reported on the bill. And then, going into that cost is the cost of educating that professional, which may or may not include education loan debt. There is the cost of the computer system used to keep the records, the software it runs on, and the hardware that holds it. There’s the cost of the malpractice insurance that any professional will have; for after all, a suit can be filed before anybody actually determines whether the facts support it. And of course there are the costs of the facility - rent, utilities, insurance. There are also costs of getting paid: paying someone to issue the bills, to report to the insurance company, to know relevant law and regulation. And, there are the costs of not getting paid. Medical debt has been an important cause of bankruptcy for individuals, even if that’s been reduced under the Affordable Care Act. Sometimes people can’t, or won’t pay.

And that’s a simple new patient visit. Had I needed a procedure, then there would have been more costs: the required equipment, and amortization of that; the costs of nurses and other technicians, including their professional education and expenses; and, again, losses to charity care or refusal to pay. That’s kind of like the dropped box of strawberries: costs are raised and/or shifted to that the institution can cover here what is lost there. The big difference in healthcare of course, is that it’s not a $4.00 box of strawberries, but a $50,000 hospital stay.

All of this affects, but isn’t shown in the bill I will receive. What the bill will show, though, is something about the ways that my out of pocket costs are reduced by the distribution of charges. There are, of course, all the other patients in my new professional’s practice. More important, though, is insurance. Insurance, really, is the ultimate distribution of charges. I’m one of a large group that pays into the insurance company, and so far I’ve hardly ever had to use as much in one year as I paid - or, since so far my insurance is been provided by employer, as much as was paid in on my behalf. The insurance company distributes the costs of any current claim across the premiums paid by all the covered members. Then, again, my employer distributes the costs. The employer negotiates with the insurance company based on a pool of covered employees, figuring that the expenses for any individual employee will be lower. (I’ve written before that the currency of that negotiation is not dollars but “covered lives” - you and me and our family members.)

A medical procedure costs what it costs. For good and ill, though, I won’t see that cost. What I will see is what I pay out of pocket, and also what the insurance company paid on my behalf. Oh, and I may also see the results of the negotiation between hospital and insurance company as a discount or reduction. Of course, that’s what I see. Another patient with another insurer or another employer (or a person not having either) will see different numbers. That’s because there’s a different negotiation with each different company. Oh, and because for any given procedure with any given patient the insurer may renegotiate and pay less - which almost inevitably ends up with you or me paying more out of pocket.

We hear about that a lot now in efforts for “price transparency” for medical procedures. Everybody agrees it would be a nice idea. However, it’s hard in practice. There are differences in negotiations between each institution and each insurer. There are differences in negotiations between each medical practice (and most medical practices are still small businesses). Newer equipment costs more, and takes more procedures to amortize out that older. And, of course, large research and educational health care centers in urban settings take both higher risk patients, who need more resources; and more patients who can’t pay. A procedure costs what it costs; but the various inputs into those costs can vary a lot from setting to setting, as can the various ways to distribute costs as widely as possible. A procedure costs what it costs; and it may well cost more in one place than another.

Of course, we may also be willing to pay those costs. If I need a procedure, I may be willing to pay more for the professionals and the institution that have more experience - literally, that have offered that procedure more times to more patients. Professionals and institutions with more experience get better results. Or, I may be high risk myself for one reason or another. So, I may well be willing to pay for an institution with more resources. I don’t know I’ll need them; but if I do need them I don’t want to have to go somewhere else.

Then, of course, there is emergency care. If it’s really an emergency, I’m not about to start haggling over prices. I want to be where the right people and the right equipment are available for a good outcome, not a lower bill. And, I want those resources available 24 hours a day, whether I’m using them right now or not. “Just in time” may work well enough in having the right parts at the car plant for assembly, but I don’t want to trust “just in time” staffing for my emergency room. “Just in time” staffing may not be just in time to save me.

But, still, the biggest issue with price transparency, and one of the biggest things shaping what I pay out of pocket, is the sheer number of different insurance companies negotiating with the number of different health systems and institutions, and professional practices; and that includes the two biggest insurers, Medicare and Medicaid.

Once again, that sheer number is also part of the distribution of costs. My out of pocket expense feels small because the insurer distributes all my expenses across the premiums of all of us who are members; and because my providers, professional and institution alike, distribute my expenses across all the patients cared for using that expertise and equipment. A thing costs what it costs, whether a strawberry or a medical procedure. It can just feel less expensive to me because of how a lot of other people participate in paying those actual costs; and that will be the starting place for part Three.

Distributing the Costs of Care, Part One

Can we begin with a simple premise, that a thing costs what it costs?

I know that sounds trivially true, but in fact most of the time, most of us don’t think that way. That is, we note what we pay out of pocket for an item, but don’t think about all the costs that went into what we pay.

I bought some strawberries yesterday morning. What that box of strawberries costs is the result of a whole slew of expenses. What did the farmer pay for the land, and what is the measurable (if tiny) incremental cost of one strawberry in light of those and other costs of production - water, fertilizer, labor, etc? What is the cost of processing and shipping that strawberry; of warehousing it for the wholesaler; of having it in my local market? Just because we don’t think about that strawberry’s contribution to paying the electric bill of the grocery story doesn’t mean that it isn’t there and fixed. When we remember that a thing costs what it costs, we can look beyond just what we pay out of pocket.

And, of course, we can remember that those costs are shared with others. If my box of strawberries were priced so that my purchase would sustain the market, I wouldn’t be able to afford them. If I alone were paying the fuel charges of the trucker and the labor charges of the wholesaler, that box of strawberries would be far out of reach. I can only afford those strawberries because a whole host of folks participate in distributing the costs of those expenses. That’s the difference between the economy of a large society and -  well, really, any society. Once upon a time, perhaps, there was an individual working an individual plot of land and providing only for himself, and so paying personally all the costs of having a strawberry; but once folks started living in communities and sharing resources and exchanging (even in barter), costs started getting distributed.

That’s particularly true when we find a “bargain.” If I find my box of strawberries on sale, it might be that the farmer somehow produced for less, or that diesel was temporarily down. Or, it might be that these strawberries are getting close to the end of their shelf life, and the store loses less by selling them at a reduced price than by letting them get old and not selling them at all. And, after all, the store can take that decision, not out of the goodness of anyone’s heart, but because the store can adjust prices somewhere else, and so better distribute those costs. Someone else paying a dime more for apples allows me to pay a dime less for strawberries. It costs less out of my pocket, but it didn’t cost less in the real costs of production. J, at each stage of production, one of the costs that gets distributed is losses. If one field fails, that’s going to raise the price (not the cost) of the strawberries from fields that succeed. If someone drops a box in the store and all those berries are ruined, you can be sure that the store has some calculation of how that loss can be made up elsewhere. In a market economy, those losses get covered, or the person at that level can no longer produce or provide.

A thing costs what it costs, with all those costs of production figured in, and with all those distributions of costs worked out. What it costs out of pocket is a combination of all those costs, and how all those costs are distributed.  It’s true of a strawberry; and it’s true of a medical procedure. And that’s a thought that I will explore in Part Two.

On the Principle of Double Effect Writ Large

A news item caught my attention in the last few days. (From NPR. If I say "I heard on the news," there's a very good chance that's where I heard it.) The story was Veterans Claiming Illness From Burn Pits Lose Court Fight. The gist of the story is that veterans of Iraq and Afghanistan have reported significant health problems that they attribute to trash burned close enough to barracks that troops experienced long term exposure breathing toxic chemicals in the smoke. They have sued the contractor who did the burning, and the federal courts have said they can't sue because the contractor was only following orders. Parallels to the Agent Orange fight of Viet Nam veterans have been noted.

And then in the story there was this comment: "That fight shifts to Congress, which is where burn pit veterans will have to turn next, now that they've lost in court." But, Congress has already made some changes that may well affect this case.

Congress has acted and the President Trump has ordered that veterans have more access to non-Veterans Affairs health care. That could, I think, be a significant difference between this case and Agent Orange. That could mean comment from a lot of physicians that the VA doesn't supervise, and whose comments the VA can't restrict. That could mean more research and more information on what these vets are actually experiencing, and what the likely exposures are. Ultimately, that could mean more information that an administration can't restrict, and that officials can't avoid.

I'm not a veteran of armed service, and I have great respect for those who are. More particularly, some veterans, and specifically Viet Nam veterans have been important people for me. I've also been in health care for 40 years or so. On both counts I've noted the Agent Orange issues over the years. There is too much history of an issue affecting veterans that officials wanted to avoid. By making it easier for veterans to seek care outside the VA system, they may well have made avoidance harder.

What I Did on my Summer Vaca.... General Convention: Responding to the Opioid Crisis 2

I wanted to give an update on my earlier post from before General Convention. Specifically, I wanted to update readers on C037 Responding to the Opioid Crisis.

As most of my readers know, each resolution addressed at General Convention requires public testimony to the designated legislative committee. As I noted in my earlier post, I was on Legislative Committee 8 Social Justice and United States Policy, and it was our committee that addressed resolution C037.

In the testimony we heard moving testimony about the impact of the opioid crisis on individuals and families, and about how the Church might be engaged. We also heard another issue addressed. We heard about the problems of patients with chronic conditions and especially chronic pain whose access to appropriate medications was being affected by legislative and regulatory responses to the opioid crisis. In fact, this is an issue I'm also aware of. The Center for Practical Bioethics, one of our great resources in Kansas City, has had among its programs the PAINS Project. (That project has recently transferred to the Academy of Integrative Pain Management [AIPM].)

It is important to realize both concerns are accurate. There is a crisis in the United States, and especially in more economically distressed populations, in addiction to opioid drugs; and while that has turned in the last year or two from abuse primarily of prescription drugs to problems with heroin and imported synthetic fentanyl, control and proper use of the prescription drugs is important. There is also a crisis of poorly managed chronic pain, and patients who need the prescription drugs, and sometimes in unusual dosages, not only to just manage from day to day but to continue to function, to work, to participate in life.

So, when you look at the link above to the finalized language of C037, you'll see we addressed both. We retained concern about the opioid crisis, and continued the request for a task force in the Church to address it. We also acknowledged the proper uses for those drugs and called on the Church to understand and to advocate for those who appropriately need them. Really, I think we did a pretty good job of recognizing both problems, and in speaking to the Episcopal Church about the two needs.

Take a look at the final resolution. Consider how both problems are appearing in your own community, even in your own congregation. Recognize as well that sometimes that's how resolutions get "perfected:" testimony changes how your Deputies and Bishops understand an issue, and how we see God's call to the Church. 

General Convention: Responding to the Opioid Crisis

I’m getting close to General Convention, and there are a couple more resolutions that relate to health and healthcare. One is C037 Call to Respond to Opioid Epidemic. The text is below:

Resolved, the House of _______ concurring, That the 79th General Convention call all dioceses and parishes in The Episcopal Church to respond to the opioid epidemic with training, pastoral care, advocacy, and liturgy; and be it further

Resolved, That dioceses and parishes be encouraged to: partner with First Responders and others in the medical community to host trainings on how to administer Narcan in the event of an overdose; partner with other faith communities and recovery programs in their local contexts to offer pastoral care to those affected by this epidemic; partner with other faith leaders to advocate with local and state government regarding policies and laws to promote healing and wholeness for those affected by this epidemic; and to lift up the needs of those affected by the epidemic in the Prayers of the People; and be it further

Resolved, That the 79th General Convention direct the Office of Government Relations of The Episcopal Church to advocate for the federal government of the United States to address this as public health crisis, affirming that opioid addiction is a disease, which needs adequate resources for treatment options; and be it further

Resolved, That the 79th General Convention direct the Standing Commission on Liturgy and Music to develop additional liturgical resources to address the needs and concerns of those whose lives have been profoundly affected by this epidemic.

THis is certainly not the first resolution relating to addition, including to opioids. At the same time, it is certainly timely. In addition, the call to the Standing Commission for Liturgy and Music suggests responses that are within our tradition of addressing important needs with both social and liturgical responses.

The call to make Narcan more widely available could save lives. In the hands of more professionals, and especially of those who are in the field, could be helpful indeed.  Whether that can extend beyond professionals could be debated.

However, this is a worthwhile effort. I do expect it will pass, if perhaps adapted. 

General Convention: Disaster Resilience

I've continued to look at resolutions to General Convention that have some relation to healthcare topics. One recently added that I want to hold up is D007: Disaster Resilience Policy. As the text is somewhat lengthy, I won't copy in the whole thing, but I do encourage you to read it.

The larger points of the policy are to commend Episcopal Relief and Development in their past work of disaster relief, and to encourage dioceses and congregations, working with ERD, to develop not only short term but also longer term resources and plans to respond to disaster. That longer term response is the point of "resilience:" that to rebuild and restore after a disaster takes a long time, and a longer commitment of resources and effort.

I was, though, struck by one further sentence: "That the General Convention urge the U.S. federal government to fund and support not only immediate, but also long-term community and economic recovery from human-caused and natural disasters in the 50 States and U.S. Territories in equal treatment,...." [emphasis mine] That seems particularly apt, especially in light of the recently reported Harvard study estimating that in Puerto Rico Hurricane Maria resulted in thousands more deaths than have been reported by official agencies. The study uses the criteria of the Centers for Disease Control and Prevention (the justly-famous CDC), and reflects both those who died directly (flying debris, floods, etc.) and those who died because the healthcare and social systems around them were destroyed and not quickly rebuilt.

While there can be arguments whether responses of governments at all levels have been adequate in our recent disasters, including Maria (in 2017 territories and states of the United States were also struck by Hurricanes Harvey and Irma), there's a strong case to be made that federal resources to the states affected were significantly and proportionally greater than those provided to Puerto Rico. I can't speak to whether the response to the U.S. Virgin Islands was more similar to the states or to Puerto Rico; but the differences between that territory and the states has been widely reported and evaluated. In that light the call for equal treatment for territories as for states seems especially poignant.

By the way, please remember that the Resolutions in the Virtual Binder for General Convention are available to anyone. Link to the Virtual Binder, or link through from the General Convention web site, and you can see what's proposed. Remember that what's proposed may not be what's actually debated and voted on; but's it's where we'll start. So, take some time to look and see what might interest you.

General Convention 2018: Environmental Racism

So, it is another General Convention year. We'll be meeting again (yeah, I'm in it one more time) in Austin, Texas, July 4 through 13 - and some of us will arrive earlier or stay later. As I say every three years, "General Convention is coming. Pray hard!"

So far, only one resolution has been entered in the topic of Health. That is resolution A011,  "Oppose Environmental Racism."

Resolved, the House of _______ concurring, That the 79th General Convention affirm that fossil fuel-based power plants are the single largest source of carbon dioxide pollution in the United States and major contributors to climate change; these emissions not only threaten the environmental stability of our planet, but also the health of young children and their families, disproportionately affecting the poorest among us; and be it further

Resolved, That the Church recommit to and direct the Office of Government Relations and the Episcopal Public Policy Network to oppose Environmental Racism expressed in such ways as the locating of extraction, production, and disposal industries where they disproportionately harm neighborhoods inhabited by people of color and low income communities. And to oppose coal, gas, oil, and uranium extraction and its subsequent transportation which threaten the health and sanctity of communities and the livelihood of future generations; especially as such industries are located disproportionately nearby low income communities and neighborhoods inhabited by people of color.

The resolution has been put forth by the Advisory Council on the Stewardship of Creation. They have described the concern about Environmental Racism in the body of there solution. While their report does not go into further detail, it does highlight three Eco-justice sites, all of which would seem to qualify.

I would expect to see other resolutions that would speak to health. In the meantime, we can consider how addressing Environmental Racism could serve the health needs of our neighbors.

On the Tradition of Healthcare: Happy Holiday

Invocation for the Saint Luke's Health System Leadership Meeting, 11/30/2017. Our System is faith-based, rooted in the Episcopal Church. In radical hospitality, we are explicitly supportive of the traditions of all our patients, families, and staff.

 

Welcome to the Holiday Season! But, what is a holiday?

Our word "holiday" comes from older versions of English that spoke of "holy days." Not that the idea is particularly English: here are those days in any spiritual tradition that stand out, and that call for different behavior. Work stops. Sometimes even war stops. Families gather, communities gather, and do something different for the day. It may be to feast, or it may be to fast. It may call for quiet and private reflection, or it may call for public celebration and public service. It is a day that stands out, when believers stand out, from other days.

Welcome to the Holiday Season. Looking at November, December, and into January, and looking just at on line resources, there are special observations in ten different faith traditions, and several civic observations as well – and that’s without counting separately the distinctive practices within broader traditions. Some commemorate births. Some remember special revelations. Some are as much about cultural heritage as about religion per se, although those observing would not likely make that distinction. Certainly, this period is a season of holidays – of holy days – for many different communities.

 

There are those holy days that we might identify in this tradition of health care. There are those "first times." I remember the first patient seen in the Emergency Room at Saint Luke’s South, not long after midnight when we first lit the sign. We remember the first heart transplant, both that initial surgery half a world away, and the first one done at Saint Luke’s. We remember new resources and facilities, from the first hospital established 130 years ago to the completion of the new Anderson County Hospital. We remember special honors – state Quality awards, or the Baldrige: days of honor and prestige.

 

And then there are those more personal days. Every surgery is a holy day, a special day of observation for patient and family. Every discharge is a holy day, whether it is a day of feasting or fasting. Every birth is holy day, as is every death. It is our vocation, and also our privilege to participate in these holy days, directly or indirectly, and to work to make them days of honor and celebration; to make them memorable for hope and grace and compassion and mercy.

 

Welcome to the Holiday Season. May each of us in our own communities celebrate, knowing that our colleagues support us in celebration. And, may each of us in our health system celebrate those other "holy days," in support of those we serve, and those we serve with. Amen.

On the Tradition of Healthcare 6.29.2017

Invocation for the Saint Luke's Health System Leadership Meeting, 6/29/2017. Our System is faith-based, rooted in the Episcopal Church. In radical hospitality, we are explicitly supportive of the traditions of all our patients, families, and staff.

We as a group come from a number of different traditions. But, some of you have heard me suggest that there is a tradition we share, one that is a tradition of healthcare; and a recognition that healthcare in all its variations is holy work.

That tradition is old, older than we know. The Code of Hammurabi sets compensations and punishments for doctors and surgeons. Hippocrates learned his profession from his father and grandfather. Shimon ben Sirach was quoting his father when he wrote, 

Honor physicians for their services, for the Lord created them; for their gift of healing comes from the Most High, and they are rewarded by the king.

There is a tradition that is healthcare, healthcare as holy work, and we are all participating in it.

We, though, are not simply participating. We are leading. On the back of each badge in the room is our commitment to “the spiritual health of the communities we serve.” For us the communities we serve first, I think, are those we serve with. They are the physicians, yes; and also the nurses, therapists, technicians, engineers, housekeepers, volunteers - all those who share with us in creating and sustaining institutions of curing and healing, of caring and compassion and hope.

As we lead, there are various ways we might support the spiritual health of those we serve with; but I am sure this will be among them. We must reflect to them how each person contributes to the health and safety of every patient; and how each role expresses our commitments to service and compassion. We must recognize in them, and let them recognize in us, that we all participate in the tradition that is healthcare, and the knowledge that any service of healthcare - every service of healthcare - is holy work. Amen.

Insight into Supporting Those Who Have Served in, and All Too Close To, Combat

I am just young enough that I did not have to worry about being drafted in the Viet Nam era. This not to say that I did not worry: I had already thought through how I might try to have some choice in my service if I was drafted (I had rejected the thought of somehow not serving). I registered as I was supposed to, but it didn't turn out to be an issue. As many will remember, in those waning days of Viet Nam the draft was determined by lottery; and just before my 18th birthday the lottery was suspended. That was not a call I received.

That was not to say, however, that I wasn't touched. I have older cousins, most of them women; and among their husbands were several who served. One of them was a career officer, who had more than one combat deployment. In our family that was appreciated and welcomed, if not always understood; but I was also aware of just how hostile the world outside the family could be for those returning veterans.

This comes to mind today as I have been reading the article "Only God Can Judge Me": Faith, Trauma, and Combat. The author is Nathan Solomon, a U. S. Navy Chaplain. I recommend it highly.

Central to Solomon's thesis are the categories of the Sent, the Senders, and the Liminal Ones. It should register immediately that the Sent are the service members who experience combat, whether directly or in support services. The Senders are, really, all of us: the nation, the society whose goals the service members seek to serve. The Liminal Ones are the chaplains who support the Sent. They are themselves Sent, and at the same time they bring something of the rest of us, the Senders, as well. 

For each of these groups, Solomon examines the experience in three categories: "What It Means," "What It Costs," and "Living With It." The explorations are honest, and through the paper the differences among the experiences of Sent, Senders, and Liminal Ones are well laid out. There is particular attention to how the churches (sic), both denominations and congregations, might want to examine ministries. 

While the article is written primarily for congregational clergy, I think there is value here for healthcare chaplains as well. Around us are those who have experienced combat trauma, among our patients and their families, and among our professional colleagues. While few of us could claim the same experiences, we do have some experience of serving with violent trauma, and that might make us - and call us to be - better listeners, better pastors, for those around us. 

On Keeping Healthcare Stable

Some of you may wonder why I haven't said too much about the threats to adequate healthcare for all Americans. Some of you may wonder why I have said "keep healthcare stable," instead of just defending the Affordable Care Act. I have done that because I actually work in healthcare, and want to be clear, including by when and where I'm logged in, that these are my opinions and not a reflection of or a reflection on my employer.

That said (and I can't imagine anyone will be surprised), I do have opinions. First and foremost, I think we have sold the Act incorrectly. The name of the act that is labeled Obamacare is "The Patient Protection and Affordable Care Act." We've spent so much time letting folks complain about what "affordable" might mean, and for whom, that we are now at risk for letting the "protection" get washed away. Pay close attention: it is the protections that are truly popular - no exclusions for pre-existing conditions; equity on preventive care for both men and women; equity for mental health with physical health; subsidies to allow the most vulnerable to afford insurance; insurability for folks whose employment and lack of income had left them out; coverage for children on a parent's policy until age 26; a set of minimum standards for what a policy should provide. It is also the protections that make this less "affordable;" and so it is the protections that are at risk. So, not just "Defend the ACA;" "Defend the Patient Protection Act."

So, I speak about "keep healthcare stable" because I can imagine improvements to the Patient Protection and Affordable Care Act; and even a replacement that might be better. At that point, I heard Paul Simon singing about "the myth of fingerprints:" I don't care much whose name is on the bill as long as the bill does the right things. Call it Romneycare instead. Call it the German Model, because this is basically how the Germans meet everyone's needs. Call it Trumpcare or Ryancare - I don't care, as long as it's a real replacement - you know, one that does at least what the old one did (EVERYTHING the old one did), and perhaps more, and perhaps more economically. One of our major auto insurance companies has this ad out, with a focus on their full replacement policy. The hook, proclaimed by the actor complaining about another company is, "Do they expect you to drive 3/4 of a car?" So, I am interested in stability more than the myth of fingerprints. I don't care whose name is one it; but 3/4 of a replacement for the Patient Protection and Affordable Care Act is not a true replacement.

I am also concerned about stability because healthcare is one of the largest employers, as a sector of the economy. These are good jobs, professional jobs, that can't be outsourced overseas. In my years in the business one of its hallmarks has been the many people who have started at the bottom and used employer-supported resources to have better jobs and better pay. One of the patient protections at risk if things aren't stable is an adequate workforce to care for them. Note that at this point I'm not talking about chaplains. We are so small a part of the industry already that we can't sway much. I'm talking about nurses, therapists, lab scientists, and pharmacists. To have them when we need them means we need to keep healthcare stable.

So, there I am: I'm willing to hear that there's a better way; but those who claim that need to actually offer something better. They need to offer it clearly, and they need to offer it before dismantling what is in place. For patient protection, affordability, and a stable economy - things that have actually been helped by the Patient Protection and Affordable Care Act - we need to keep healthcare stable.

Opportunity for Fun for Wonks and Geeks Like Me

This morning I received a link to a page that ought to be exciting - if you think knowing about published research is exciting. Take a look at the Top 100 Articles of 2016 as compiled by Altmetric. Altmetric is new to me, too. They say of themselves, "Altmetric is a Digital Science company based in London, UK. Our mission is to track and analyse the online activity around scholarly research outputs."

At any rate, their list of the most reviewed articles is interesting. They include at least one unexpected author. And, at least some of the articles are available for anyone to read (and, yes, for some you'll need to get the journal in which it was published).

So, take a quick look to see at least which was number 1. Take a quick scan, and you'll discover a number that are not only of broad interest, but also accessible to a broad audience. (And thanks to Becker's Hospital Review for the link.)
 

Up at the Cafe: On Healthcare for All

I have a new piece up at Episcopal Cafe - my first in quite a while. The topic is to continue commenting on where the Episcopal Church is on health care. Specifically, General Convention has repeatedly called us to work for universal access to affordable, quality healthcare. (I've written about that before, including here and here.) 

Go over, take a look, and let me know what you think, whether there or here.