BY: MALCOLM B. HERRING, MD, and JON D. RAHMAN, MD
Dr. Herring is a vascular surgeon based in Indianapolis; Dr. Rahman is system
vice president and chief medical officer, St. Vincent Health, Indianapolis.
Contemporary health care is a swirl of change. No one, however, has removed
the work of patient care. With so much to do, people naturally lose sight of
institutional mission and personal spirituality. When this happens in a health
care institution, it plays out in hundreds of ways. Patients experience hurried
and perfunctory care. Flashes of conflict surface at every level. People begin
to focus on their personal bottom lines. Is it possible to integrate hospitals,
mission, physicians, and spirituality? What is the present level of integration?
What is the status of each component?
Physicians are commonly the least integrated component in health care. They
are organized into practices and often aligned around a treatment specialty.
These practices have missions, too; they may not be stated, but they are rarely
designed to integrate with the hospital's mission. In fact, the hospital
often appears to physicians as their adversary. The hospital may, for example,
compete with the physician practice. Hospitals administer credentialing, peer
review, risk management, utilization review, and adjudication of access for
critical resources, all of which a physician may experience as interference.
The physician encounters hostility from outside the hospital, too. Medical malpractice,
continual reductions in reimbursement, deliberate delays in reimbursement, and
unreasonable patient demands — all these tend to set a general tone of embattlement.
The hospital's mission statement can be a sentence cobbled together by
a committee and relegated to a dusty shelf. It may be that its physicians have
never heard it or cannot remember it. It may be that the institution does not
really live by the mission statement and, instead, creates a sort of institutional
hypocrisy that destroys trust.
Spirituality is a concept that could have 30 definitions. For our purposes
here, we will define it as that which makes people uniquely human and gives
meaning and purpose to their lives. Often people hear the word "spirituality"
and think "religion." Such people generally fall into two categories.
They either reject religion or embrace it. If they reject it, they also reject
spirituality. If they embrace it, they carefully protect the tenets of their
own faith tradition, fearing that talk about spiritual development may be intended
to tempt them away from their faith tradition.
In this milieu, the integration of the mission into the hospital and personal
spirituality into the medical staff seems an improbable goal. Yet it is a goal
at St. Vincent Health, a network of health care organizations in central Indiana,
affiliated with Ascension Health, St. Louis. Mission integration is today a
priority throughout St. Vincent. However, in this article we will confine ourselves
to describing the work done with physicians at Seton Cove Spirituality Center,
which is on the St. Vincent Indianapolis campus.* The history of this work falls
into five phases. The first, which was a little nebulous, we call the phase
of the "hovering Spirit."
* For more on the Seton Cove Spirituality Center, see Rosemary
Hume, Sharon Richardt, and Beth Applegate, "Spirituality and Work," Health
Progress, May-June 2003, pp. 20-25.
Hovering Spirit: The Conceptualization Phase
In the beginning God created the heavens and the earth. Now the earth
was formless and empty, darkness was over the surface of the deep, and the
Spirit of God was hovering over the waters. And God said, 'Let there
be light,' and there was light.
— Genesis 1:1-3
The St. Vincent project to help physicians integrate spirituality into their
practices was initiated in 1997 by Sr. Sharon Richardt, DC, PhD, the facility's
vice president of mission services. Sr. Sharon began with an intense time of
supplication, asking God to send her helpers for this project. She asked Malcom
Herring, MD (one of this article's authors) to "champion" the
project. Dr. Herring had enjoyed a personal spiritual awakening a few months
before, an awakening that largely determined his attitude and sense of commitment
to the project.
The "hovering spirit" of creation was at work, but the project remained
ill-defined in the minds of the individuals involved. The project awaited God's
creative work at the individual level. In this ministry, maybe more than in
others, devotion to personal spiritual growth is critical. Personal prayer and
authentic dialogue with God characterized the launching of this project. Periods
of quiet, reflection, and retreat helped us to hear the "still small voice"
of God.
Whoever becomes involved in spiritual development must be open to the invitation
and direction of the Spirit of the Creator. Opening oneself involves at least
a daily trip into Scripture. It involves intimate participation in a community
of faith in which elements of encouragement and accountability prevail. It involves
worship within that community, genuine expressions of praise and awe of the
Creator, and participation in the sacraments. Joyful giving and volunteer service,
although they are sometimes not considered spiritual practices, also help open
us to the leading of the Spirit. Giving financially to the work of the Seton
Cove Spirituality Center increased the level of involvement and the quality
of the resources.
These recommendations may seem old hat to some people. To them, I suggest approaching
these practices in a new way, or perhaps seeking a wise spiritual director to
help them become revitalized. To others, the recommendations may seem unnecessary
steps to take before putting the spiritual development program components together.
If you are such a person, I encourage you to begin these preparations on faith
so that they will serve your program and not you alone. Some might imagine this
to be simply a preparatory exercise, but it is not. These recommendations are
the sustenance of the program. This ministry requires personal investment. You
can encourage spiritual growth only when allowing the Spirit to work through
you. The ill-defined period of the "hovering spirit" can be frustrating,
but the wise person will await the clear impetus of the Spirit before advancing
to the second phase.
Support among the Intercessors: The Healing Phase
Therefore confess your sins to each other and pray for each other so that
you may be healed. The prayer of a righteous man is powerful and effective.
— James 5:16
Dr. Sharon generously invested her wisdom, guidance, and time in Dr. Herring's
training and spiritual formation. In a 12-month-long program entitled "Mission
and Mentoring," Dr. Herring learned important information about the administrative
structure of St. Vincent Indianapolis and the heritage of the Daughters of Charity
of St. Vincent de Paul, the hospital's sponsor. During these months, he
made contacts with many other like-minded people at the hospital and received
their encouragement. The orientation he underwent included demonstrations of
the way the hospital's mission worked in many aspects of health care. Dr.
Herring also went on a spiritual retreat, during which he was encouraged to
foster the hospital's mission by working on a special project: integrating
institutional mission into the physician staff.
The first step of Dr. Herring's special project was to offer a spiritual
healing process for physicians. Bill Bazan, a consultant, had created a seven-hour
retreat based on a small-group discussion format. The retreat, called "Medicine
in Search of Meaning," helps physicians learn to use new skills to find
balance in their lives and to reveal meaning and purpose in their work.* Participants
identify factors that affect their estimation of personal value and make important
connections with fellow physicians through the sharing of common experiences
and concerns. The retreat helps physicians reintroduce spirit and joy to the
practice of medicine. Dr. Herring recruited nine physicians for the first retreat
and Bazan supplied the facilitators. Since then, 10 to 15 physicians have attended
such sessions, which are held once or twice each year for doctors from St. Vincent
Health.
* For more on "Medicine in Search of Meaning," see Bill J.
Bazan, Medicine in Search of Meaning: A Spiritual Journey for Physicians,
Caritas Publications, Mequon, WI, 1999.
A few months after the first retreat, Dr. Herring began a two-year period of
spiritual formation with Fr. Adrian Van Kaam and Susan Muto. Graduates of their
formation, called the Epiphany Certification Program, are awarded a certificate.*
Sr. Sharon made certification a condition for becoming a trainer at Seton Cove.
More to the point, the Epiphany Certification Program helped Dr. Herring clarify
his own spiritual awareness, develop a more comprehensive perspective on spirituality,
see further possibilities for integrating spirituality in the workplace, and
learn a new vocabulary for discussing spiritual issues among people from varied
faith traditions.
*For more on Fr. Van Kaam, Ms. Muto, and the Epiphany Certification
Program, see Hume, Richardt, and Applegate, "Spirituality and Work," p. 21.
In a superficial sense, training Dr. Herring was the prominent feature of this
phase in the development of the physician program. In fact, the essence of this
phase was intercessory prayer. Dr. Herring and Sr. Sharon and the mission services
team supported each other, the members of St. Vincent's medical staff,
and the physician-integration program with prayer. What resulted was healing
for the physicians, through the "Medicine in Search of Meaning" program,
and healing for Dr. Herring as well. The word "healing" has different
connotations; many people use it interchangeably with "cure." This
was healing for physicians in that it brought God closer to the center of a
collective spiritual formation. This was healing that brought many faith traditions
into the range of Seton Cove ministry and set the stage for the next phase.
Establishing Trust: The Phase of Faithfulness
Therefore, my dear brothers, stand firm. Let nothing move you. Always
give yourselves fully to the work of the Lord, because you know that your
labor in the Lord is not in vain.
—1 Corinthians 15:58
People with no experience of the Seton Cove Spirituality Center may resist
learning about it. Breaking through that resistance involves understanding the
resistance. Fear is probably at the heart of this resistance. The physician
who has never experienced Seton Cove may be unfamiliar with the culture found
in spirituality centers. Such a doctor may imagine that he or she will be embarrassed
by having to answer questions he or she does not understand. Previous experiences
with a particular faith tradition may have fostered negative expectations. The
physician may fear that moral lapses will be targeted. He or she may fear that
acquaintances will ridicule involvement in spiritual activities. The physician
may fear that, because Seton Cove's sponsorship iý Roman Catholic,
he or she will be proselytized to become Roman Catholic. Many fear that, if
they became participants, they might be required to reveal deeply personal information.
Some imagine the programs at Seton Cove to be watered-down religion or "new
age" spirituality. Some believe spirituality is fluff and therefore inconsequential.
What steps can we take to persuade physicians to try one of our programs? What
steps can we take to establish their trust?
Step One: Establishing Creativity One of Ascension Health's core
values is "creativity." Creativity is the first step on the way to
trust. The programs at Seton Cove seek to create an atmosphere of anticipation.
The titles of program topics are designed to communicate the content and to
raise curiosity; they are not designed to be "cute." Physicians will
be looking for topics that they can use in their own lives. For most, their
work is their life. These titles must therefore promise them something they
can use in their work.
Step Two: Achieving Applicability Individual programs cannot simply
promise to be useful; they must deliver. To do that, they must have high applicability.
Achieving applicability requires the mission services team to identify the perceived
needs of physicians on the hospital's staff. Doing this is the work of
everyone on the team. Each team member can help by listening to physicians in
meetings, lounges, and the lunch room. They can use surveys and talk to people
who interact with physicians every day. Seton Cove's director, Beth Applegate,
RN, MSN, invested many hours in one-on-one interviews with physicians, covering
key spiritual questions.
Applicability also requires detailed research uncovering the materials needed
to meet perceived needs. Spirituality is common to all human beings. Therefore,
much of the material that is used for other staff at Seton Cove will apply to
physicians as well. Even so, doctors generally view their needs, training, and
life experience as unique, and consequently are more disposed to register for
programs that are "for physicians."
Step Three: Achieving Excellence This is a key step because it actually
builds trust among participating physicians. This trust comes slowly and only
after a tremendous investment of time and effort. Nevertheless, each excellent
program turns out 10 to 15 physicians who are likely to register for later programs
and two or three who will actually talk to others about their experience. One
can ill afford a poor quality program during start-up.
Whether excellence is achieved hinges on how well we, first, evaluate needs
and, second, address those needs with the content of the program. Addressing
the needs is as much a team effort as identifying them. Although Dr. Herring
has taken the lead on program development, key mission services team members
need to critique the content. A frank exchange of information is mandatory at
this point. The traditional attitude of "physician-in-charge" must
be set aside for this step to succeed.
Excellence grows through constant program evaluation and revision. Participants
are encouraged to give "brutally honest" evaluations of each program.
Their comments, which are written, can be anonymous. Because of constant improvement,
most programs are in their third or fourth edition. Some of the comments illuminate
how physicians use these programs. One said that he appreciated "understanding
the stresses of other groups of doctors." Another enjoyed the "time
spent thinking!" One first-time participaýt remarked on the program's
novelty: "Introductory course — all new, interesting, helpful."
Another was helped by the program to realize anew the implications of being
a physician: "I need to continue to realize that I am a leader, like it
or not, in several roles. I need to further develop skills. This is a very organized
way of helping me understand leading a group."
Unlike program excellence, excellence in spiritual growth cannot be measured.
But there are some helpful indicators. We can observe physicians developing
stronger and healthier relationships, even during the course of a program. Behaviors
change in the hospital, and physicians refer their colleagues to the Seton Cove
programs. Some broader measures of effectiveness are patient and physician satisfaction
surveys that include specific questions about how we address spiritual and emotional
issues. Of these two, physician surveys prove more sensitive than patient surveys,
which tend to be influenced by health care experiences that have nothing to
do with the behavior or spiritual maturity of physicians.
Step Four: Maintaining Integrity The fourth step on the way to trust
is maintaining integrity. Physicians can spot a phony. Maintaining integrity
is especially vital for the physician champion, Dr. Herring. Paying attention
to personal spiritual practices is vital to the maintenance of integrity. Integrity
is also imperative for others on the mission team. Having integrity means living
a life that seeks to honor the Spirit of Christ. It also means living a life
that is consistent with the hospital's mission, vision, and values. Hospital
employees everywhere tend to be watchful for failures of integrity in their
facility's operations; at St. Vincent, because of its strong emphasis on
spirituality, private-practice physicians put the hospital administration and
Seton Cove under heightened scrutiny.
Authenticity, a component of integrity, is emphasized at Seton Cove because
it is especially important. Any physician champion who hopes to be a model of
perfection will be frustrated and tempted to try to cover up personal flaws
and drift into a judgmental attitude. This ministry's power depends on
the ability of the physician champion to be open about personal weaknesses and
flaws, when appropriate. It is not a ministry of "airing dirty linen."
Rather, it calls for developing humility. It does not call the champion to debase
him- or herself, but to discern the personal value that God assigns.
During this phase, we began to develop our own physician programs, rather than
continuing with the "Medicine in Search of Meaning" program. Our first,
a program for physician leaders, was called "Leading the Mission."
It is based on the teachings of Christ and the models of "servant leadership"
described by Robert Greenleaf. "Leading the Mission" taps deeply into
our institutional roots here at St. Vincent, emphasizing our mission, vision,
and values. Drawing on the wisdom of leading business people in our community,
it explores some of the basic skills possessed by a "servant leader."
Listening, communication, describing a vision of the future, conceptualization,
and leadership-style analysis are among the several skills taught in the program.
From it, physicians also acquire a framework for personal growth.
Later, we developed other programs that amplify various components of "Leading
the Mission." The first such program, "Leading through Conflict,"
teaches basic conflict management, develops the spiritual underpinning for effective
conflict resolution, identifies the participant's dominant conflict style,
teaches style identification and strategic style selection, and outlines ways
to deal with a disruptive physician.
The second amplified program, "Beyond Teams," helps physician leaders
create caring communities within their working teams. Featuring a diagnostic
algorithm for common group problems, "Beyond Teams" teaches meeting
management, consensus development, creative diversity, phases of group development,
and how to care for the group.
Each of these programs offers continuing medical education credits. (Some of
them also offer a meal.) Trust builds as Seton Cove faculty members articulate
spirituality without proselytizing, pray for the participants, and widen their
contacts. The number of alumni grew each year since 1997 (see Table); as of
2003, the total was more than 344. (Some physicians participated more than once.)
Spirituality Infused at Bedside: The Implementation Phase
As he went along, he saw a man blind from birth. His disciples asked him,
'Rabbi, who sinned, this man or his parents, that he was born blind?'
'Neither this man nor his parents sinned,' said Jesus, 'but this
happened so that the work of God might be displayed in his life.'
— John 9:1-3
Nowhere in Scripture is the reason for Christ's healing more sharply etched
than this passage. At Ascension Health, our mission is "rooted in the loving
ministry of Jesus as healer." As our institutions emulate the loving ministry
of Jesus as healer, it is critical for individuals associated with institutions
to focus their efforts on Jesus' goal, "that the work of God might
be displayed" in patient's lives. Physicians have a powerful role
to play in raising the awareness of God's work in patient care, although
relatively few choose to take the role.
"Spirituality and Disease Management" is an unusual program, designed
to foster this role. It provides tools, and emphasizes the nuts and bolts of
bedside ministry. This ministry is intended to benefit not just patients but
staff as well. For example, the program creates an environment that helps participants
feel safe enough to have meaningful dialogue between nurses and physicians.
One nurse commented that although she had long resented one of the physician
participants, she came to see him in a different light during this program.
Now, she said, she views him with tremendous respect. Events of this kind prepare
the way to a most special phase of integration.
Community: The Phase of the Future
I pray also for those who will believe in me through their message, that
all of them may be one, Father, just as you are in me and I am in you. May
they also be in us so that the world may believe that you have sent me.
— John 17: 20-21
Our vision for the future is that physicians, staff, and patients will experience
spiritual healing. We foresee a future in which they enter into a community
of the Spirit during each health care encounter. We see a future in which our
physicians and associates seek to display God's grace in patients'
lives and an attitude of great mutual respect and deference prevails. We see
this as a loving community of health care, where physicians, associates, and
patients "become one" and are invited into the community of the Holy
Trinity.