God at the Bedside
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We agree with Dr. Groopman (March 18 issue)1 that religious faith may be an essential part of coping with illness and death for many patients and doctors, affecting the quality of life if not medical outcomes. Although many patients raise religious questions with their doctors,2 doctors can no more be spiritual care experts than they can be experts in all medical specialties.
We, a physician and a chaplain, believe the answer to these dilemmas lies in a partnership between the physician and the professional chaplain. Board-certified chaplains have graduate-level theological and clinical training that enables them to assess a patient's faith system and religious practice and help the patient use that faith in coping with illness.3 Like medical specialists, chaplains can consult with physicians, who can then deal directly with patients' spiritual concerns.
In examining the roles of the physician and the chaplain in spiritual care, it may be most helpful to use the model of general practitioners and specialists. The physician, as a general practitioner, performs spiritual assessments according to one of several models4 and sometimes provides basic spiritual care learned through consultations with the chaplain. The chaplain is the specialist, consulting with the doctor and counseling patients who are referred with important spiritual concerns. The chaplain may also provide spiritual care to health care professionals whose faith is challenged by the tragedies they face.
Had Dr. Groopman consulted a professional chaplain, he would have had the opportunity to learn basic spiritual assessment and discuss the role it played in his practice as well as its intersection with his personal faith. Then he would have been prepared to respond to Anna's request for prayer and might have appreciated the difference between a request to pray "for" her and one to pray "with" her. He would have recognized that the Orthodox Jewish patient could have benefited from a referral to a spiritual specialist who might have helped her to find other ways to deal with her guilt. And he would have had someone to consult about his own theological concerns while working in pediatric oncology.
Rev. George Handzo, M.Div., M.A.
HealthCare Chaplaincy
New York, NY 10022
Harold G. Koenig, M.D.
Duke University Medical School
Durham, NC 27710
References
Groopman J. God at the bedside. N Engl J Med 2004;350:1176-1178.
Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803-1806.
VandeCreek L, Burton L. Professional chaplaincy: its role and importance in healthcare. Schaumburg, Ill.: Association of Professional Chaplains, 2001.
Koenig HG. Spirituality in patient care. Radnor, Templeton Foundation Press, 2002.
Dr. Groopman replies: A partnership between physicians and clergy is a time-honored approach to patient care. Classically, the physician focused on urgent clinical needs, whereas the chaplain addressed spiritual issues. Handzo and Koenig propose a new model of the doctor as a spiritual general practitioner who handles routine care of the soul and refers selected patients to the clergyperson as the spiritual specialist. This model is worthy of examination but may break down in certain cases because of a key limitation in the analogy. A general practitioner and a medical specialist are both doctors who read from the same clinical canon of modern science, whereas a physician and a hospital chaplain may subscribe to very different dogmas. They may see the world differently with respect to the interpretation of human suffering and the effects of theology on health and disease. Aligning the views of the patient, physician, and clergyperson may be difficult, if not impossible.
What happens when the chaplain's and the patient's beliefs are at odds with the doctor's? Will a deeply religious patient feel alienated from her physician if he is an atheist who expresses discomfort when a chaplain asks him to participate in any form of prayer, "for" or "with" the patient? The Orthodox Jewish woman with breast cancer, whom I describe in detail elsewhere,1 forcefully asserted that she did not want any contact with a hospital chaplain; once I as a medical student opened the door by taking a "spiritual history," I was seen as the primary arbiter. Some doctors may not want even to open that door if it means they will be placed in such a position. And although a member of the clergy may offer a distraught doctor explanations of why his young patients suffer and die, responses to the vexing question of theodicy vary widely among faiths. Some in my tradition find it unanswerable.
We are at a cultural and historical juncture where different models of clinical and spiritual care are being tested. I suspect none will prove perfect. But then, medicine is an imperfect science, and religion is not a science but a path toward a lessening of our imperfections.
Jerome Groopman, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
References
Groopman J. The anatomy of hope: how people prevail in the face of illness. New York: Random House, 2004.
We, a physician and a chaplain, believe the answer to these dilemmas lies in a partnership between the physician and the professional chaplain. Board-certified chaplains have graduate-level theological and clinical training that enables them to assess a patient's faith system and religious practice and help the patient use that faith in coping with illness.3 Like medical specialists, chaplains can consult with physicians, who can then deal directly with patients' spiritual concerns.
In examining the roles of the physician and the chaplain in spiritual care, it may be most helpful to use the model of general practitioners and specialists. The physician, as a general practitioner, performs spiritual assessments according to one of several models4 and sometimes provides basic spiritual care learned through consultations with the chaplain. The chaplain is the specialist, consulting with the doctor and counseling patients who are referred with important spiritual concerns. The chaplain may also provide spiritual care to health care professionals whose faith is challenged by the tragedies they face.
Had Dr. Groopman consulted a professional chaplain, he would have had the opportunity to learn basic spiritual assessment and discuss the role it played in his practice as well as its intersection with his personal faith. Then he would have been prepared to respond to Anna's request for prayer and might have appreciated the difference between a request to pray "for" her and one to pray "with" her. He would have recognized that the Orthodox Jewish patient could have benefited from a referral to a spiritual specialist who might have helped her to find other ways to deal with her guilt. And he would have had someone to consult about his own theological concerns while working in pediatric oncology.
Rev. George Handzo, M.Div., M.A.
HealthCare Chaplaincy
New York, NY 10022
Harold G. Koenig, M.D.
Duke University Medical School
Durham, NC 27710
References
Groopman J. God at the bedside. N Engl J Med 2004;350:1176-1178.
Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803-1806.
VandeCreek L, Burton L. Professional chaplaincy: its role and importance in healthcare. Schaumburg, Ill.: Association of Professional Chaplains, 2001.
Koenig HG. Spirituality in patient care. Radnor, Templeton Foundation Press, 2002.
Dr. Groopman replies: A partnership between physicians and clergy is a time-honored approach to patient care. Classically, the physician focused on urgent clinical needs, whereas the chaplain addressed spiritual issues. Handzo and Koenig propose a new model of the doctor as a spiritual general practitioner who handles routine care of the soul and refers selected patients to the clergyperson as the spiritual specialist. This model is worthy of examination but may break down in certain cases because of a key limitation in the analogy. A general practitioner and a medical specialist are both doctors who read from the same clinical canon of modern science, whereas a physician and a hospital chaplain may subscribe to very different dogmas. They may see the world differently with respect to the interpretation of human suffering and the effects of theology on health and disease. Aligning the views of the patient, physician, and clergyperson may be difficult, if not impossible.
What happens when the chaplain's and the patient's beliefs are at odds with the doctor's? Will a deeply religious patient feel alienated from her physician if he is an atheist who expresses discomfort when a chaplain asks him to participate in any form of prayer, "for" or "with" the patient? The Orthodox Jewish woman with breast cancer, whom I describe in detail elsewhere,1 forcefully asserted that she did not want any contact with a hospital chaplain; once I as a medical student opened the door by taking a "spiritual history," I was seen as the primary arbiter. Some doctors may not want even to open that door if it means they will be placed in such a position. And although a member of the clergy may offer a distraught doctor explanations of why his young patients suffer and die, responses to the vexing question of theodicy vary widely among faiths. Some in my tradition find it unanswerable.
We are at a cultural and historical juncture where different models of clinical and spiritual care are being tested. I suspect none will prove perfect. But then, medicine is an imperfect science, and religion is not a science but a path toward a lessening of our imperfections.
Jerome Groopman, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
References
Groopman J. The anatomy of hope: how people prevail in the face of illness. New York: Random House, 2004.