Rose Shandrow and Dr. Rachel Naomi Remen Discuss How Their Experiences Have Shaped the Way They Regard the Spirit's Place in Health Care
Editor's note: At this year's Catholic Health Assembly in San Diego, two highly regarded professionals who are deeply committed to fostering holistic approaches to health and health care are scheduled to take the stage. Rose Shandrow, system director of Spiritual Care Services at Franciscan Health System in Tacoma, Wash., is being honored by CHA this year with a mid-career award for outstanding leadership in pastoral and spiritual care. And Rachel Naomi Remen, MD, co-founder and medical director of the Commonweal Cancer Help Program and author of Kitchen Table Wisdom: Stories That Heal, a book that looks at medicine as a spiritual path, is one of the keynote speakers.
Because both of these women share a common passion, we thought it would be interesting to forgo the usual interview format here and allow Ms. Shandrow and Dr. Remen to engage in a conversation from which the rest of us can learn and draw inspiration. The following discussion took place May 6.
Shandrow: "Spirituality" and "spiritual care" are such intangible terms. Their definitions can vary depending on who you talk to. How do you define spirituality and spiritual care? How do you differentiate these terms in your profession?
Remen: Well, I don't really differentiate spiritual reality from reality. There is no relationship that doesn't have a spiritual dimension. There's no choice that is not a spiritual choice. Certainly in the setting of illness, there is a tendency for this dimension of every human being to awaken. Illness moves us closer to the soul. We become much more aware of the sacred nature of reality. So we do not need to introduce the spiritual into our health care relationships, we simply need to recognize that it's already there and create opportunities for it to show itself. For example, in dealing with people with cancer, all you may need to do is ask a question, something like, 'Since you were diagnosed with cancer, has anything happened that is unusual that makes you wonder about the nature of life?' And people will often tell you things. They will share dreams. They may tell you about the deep joy of simply having a cup of tea or feeling blessed by being able to breathe in and out. Inviting people to share their experience enables these experiences to become more conscious and deeper for them and for you, too. What has your experience been?
Shandrow: In pastoral care, whenever we encounter an individual, we seek to establish a rapport, a sense of trust. This can be done by actively listening to the person. By doing so, we can understand the other person's concern at a deeper level. We can pick up phrases that will break the conversation open even more until we eventually touch upon the heart of their issues. I often use swimming as a metaphor for this process. Encountering a person for the first time is like dog paddling. And as you get to know someone better, you are snorkeling into their issue. Then, when you really establish good rapport and trust, you enable them to do deep-sea diving into their own soul. In reading your book, I have appreciated your use of metaphors. It has been very enlightening.
Remen: What a beautiful image that is. It seems to me that often metaphor is the only way that we can communicate spiritual experience. The words just fail us, don't they?
Shandrow: They do.
Remen: What you said about listening is so central to this work. Sixteen years ago, I developed a course at the University of California at San Francisco School of Medicine for first-year medical students called The Healer's Art, which is now taught in 59 other medical schools across the country and around the world. The course encourages discussion of dimensions of medicine we rarely talk about openly; of mystery, awe, calling, commitment and covenant. And it all starts with an explanation of generous listening. When most people listen to others they are usually very busy thinking: Do I like this person? Do I agree with what this person saying? Is this other person better educated or smarter than I am? And, of course, we are all trained to evaluate and analyze what's broken in the person who is speaking and to arrive at the best way of fixing the problem. So we become really busy, so busy that we are often not hearing others at all.
In The Healer's Art course, we silence all of this by encouraging the medical students to listen generously to each other. We suggest that students listen simply to know what is true for the person speaking to them at this moment in his or her life; just to receive whatever the other person saying, their truth. When you listen in this open way, other people may be able to hear their personal truth for the first time. To remember who they are and what matters. And frequently this turns out to be something transcendent or universal; something of a spiritual nature. It may be something about love or generosity or any of the universals of spirit that come through us all, or about the mystery itself.
Shandrow: What insights would you share with colleagues who have a more "Western view" of medicine? Typically, delving into spirituality comes out of an "Eastern view." In other words, what insights would you share with those colleagues who still haven't embraced the holistic view of medicine?
Remen: In my experience, very few people are really that compartmentalized. I have taught continuing medical education programs to physicians for many years, and in an average year, I may have the opportunity to address up to 20,000 physicians in various presentations and talks. I would say that most people in medicine have a secret life, a set of experiences that they do not often share with others, even other doctors. We have deeply moving realizations and transcendent experiences. It's just that we don't talk to each other about it a whole lot. And so by talking to people openly about such things, I give them permission to share these experiences with me. I encourage physicians to bring their hearts to their work.
I believe that the heart is an organ of perception, a way of seeing, and when you see your work not only through the intellect but also through the heart, you can recognize meaning in the most routine of medical tasks. I often talk to doctors about the power of meaning to transform the experience of work and deepen our satisfaction and fulfillment in it. When you see through the heart and not just the intellect you can remember why it is you came into this work and be strengthened in committing to it despite the difficulties of practicing medicine in today's environment. When I invite doctors to share what this work means to them, I often ask if there is a symbol that captures the meaning of their work for them. Many of these symbols embody spirit.
Shandrow: Back to our metaphors.
Remen: Yes, back to this wonderful language of multi-level communication.
Shandrow: Dr. Remen, you have provided deep and meaningful insights for others through your books and presentations. What are your sources of inspiration? Who or what has moved you from a clinical point of view to this holistic outlook on healing?
Remen: I was really moved to a larger view of medicine, and the possibilities of service within medicine, by my own physical illness. I have had Crohn's disease for 55 years now, a very significant disease of the intestine and the joints. I have had eight surgeries and even had a near-death experience. I live within significant limitations, and this has changed my ideas about the task of medicine, the dignity of suffering and the hidden strengths that are possible in all human beings. It has also taught me about the importance of the sort of companionship beyond cure that reflects back to people the meaning in their suffering. So I would say that the thing that changed me was being a 15-year-old girl and being told that I would be dead by the time I was 40. That was for me a powerful transformational event. And then I began discovering how to go forward one step at a time. Even at a time of great weakness and pain, all you need to do is take one more step. Anyone who takes that step with you is a healer.
Shandrow: It sounds like you had many companions with you in this journey.
Remen: I have been cared for by many doctors and nurses who were unafraid to open their hearts to me and accompany me even though they did not know how to cure me; people who were not afraid of the unknown. Over 55 years, hundreds of professionals have shared with me their expertise, their love, their kindness, their beliefs. There's a saying that it takes a village to raise a child. Well, it takes a village to heal someone, too.
Shandrow: From your experience, how do you see health care unfolding into the future?
Remen: Many of the challenges facing doctors today have a strictly economic basis. Most doctors in this country are no longer in private practice. They don't set their own values and standards because they work for organizations that are economically driven; whose goals are profit rather than service. An average physician may be required to see 30 to 40 patients in a day. Doctors spend a high percentage of time doing paperwork rather than medicine, or persuading someone with minimal medical training, hired by an insurance company, why a more expensive drug will be far more effective for a patient's problem than the one covered by the company. Physicians are commonly asked to work and live below their level of personal excellence. They are being asked to betray some of the deep values which they have held since childhood, their intention to respond with their best to the needs of other people in times of trouble, of taking time to listen to what matters to a patient and offering human support as well as health care. Doctors are being asked to betray these values on a regular basis in order to continue to provide for their own families. I think the soul of medicine is under siege right now in ways that have never happened before in the history of medicine. External economic pressure has created a major spiritual crisis in medicine today. The system is very broken and eventually will fail. I do not think we will have this system 10 years from now because it cannot continue on like this.
Shandrow: Looking into our future in light of where we are today, is there any particular insight that you would like to offer to the future leaders of health care?
Remen: Medicine is a very old lineage of values, perspectives and beliefs that are handed down from student to teacher, and have enabled medicine to embody its integrity for generations. Medicine is not a job; it's a spiritual path that has been characterized for thousands of years by compassion, service, harmlessness, reverence for life, and most fundamentally by love. Holding to this lineage, attempting to live by it daily, is how we can keep this ancient and noble professional alive. Lineage has become a very important issue for physicians in today's world. It reminds us of who we are and what medicine is. As pressures from the outside intensify, people find themselves looking more deeply within and questioning, 'Why am I here in this work?' Often they discover a doctor's soul in themselves.
Shandrow: One of the rewarding experiences of working in pastoral care is knowing the importance of keeping the spiritual dimension of "who we are" alive. There really is a need for collaboration between chaplains and physicians.
Remen: We usually teach The Healer's Art course to first-year medical students when they have been in school for four months. The course enables them to examine some of the basic issues of medicine: the experience of loss and what heals loss, the importance of presence, the experience of mystery and awe and calling and dedication. This year, for the first time, we had four of the hospital chaplaincy fellows join us, and they formed a small study group within the course in the same way that the medical students do. These chaplains took the course as if they were medical students.
The interchange between these two kinds of students enriched everyone. The chaplains were able to articulate and share what the medical students often feel about sacred experience, and it gave them permission and language to talk about it. In the end, we could not differentiate between the chaplains and the medical students. All of these young people are called into this work as they have been called into this work for thousands of years. In the case of the medical students, they may not recognize that their experience of choosing their work is shaped by calling. Given the time and opportunity to reflect, they often discover that this is indeed true for them.
Shandrow: Right. It's been our experience that after having that kind of rich dialogue, we all can sense that our ordinary work really is an extraordinary ministry.
Remen: Yes, the consecration of the ordinary. What the students discover for themselves is that the essential nature of this work is service; service to people in their wholeness, to their souls, their minds, their hearts, their bodies. They discover that this requires that they, too, bring their wholeness to this work. At the close of the course we enable each student to write a Hippocratic Oath, a personal mission statement to share with their peers. Some years ago, a young man wrote this:
May you find in me the mother of the world.
May my hands be a mother's hands.
My heart be a mother's heart.
May my response to your suffering be a mother's response to your suffering.
May I sit with you in the dark as a mother sits in the dark.
May you know through our relationship that there is something in this world that can be trusted.
The ways in which we create a difference in the lives of others are very powerful and very old and have not changed over generations. The meaning of this work is not science; the meaning of this work is service, and service is a special kind of love.
Rose Shandrow Rose Shandrow is the system director, Department of Spiritual Care Services, at Franciscan Health System in Tacoma, Wash. She provides leadership for integrating spiritual care across a complex regional system that includes four acute care hospitals, a hospice house and 35 medical clinics. She worked with her team of experts in developing a comprehensive and systematic process for assessing, documenting and addressing spiritual care needs of patient, family and staff. Along with her colleagues, she provided workshops on the spiritual assessment framework and evaluation methodology for the 2007 Catholic Health Initiatives Live Meeting presentations, the 2007 Catholic Health Assembly and the 2008 National Association of Catholic Chaplains meeting. She works collaboratively with her vice president of mission to provide leadership for mission effectiveness, ethics and congregational health ministries.
Shandrow serves on many boards and is currently president of the Advisory Council of the Catholic Community Services, Tacoma Chapter. Prior to joining Franciscan Health System, she worked at Seattle University's School of Theology and Ministry, where she received her master's of divinity degree.
Rachel Naomi Remen, MD
Rachel Naomi Remen, MD, is one of the earliest pioneers in the mind/body holistic health movement and is among the first to recognize the role of the spirit in health and the recovery from illness. She is co-founder and medical director of the Commonweal Cancer Help Program featured in the Bill Moyers PBS series, Healing and the Mind, and has cared for people with cancer and their families for almost 30 years. She is also a nationally recognized medical reformer and educator who sees the practice of medicine as a spiritual path.
Dr. Remen is author of The New York Times bestseller Kitchen Table Wisdom: Stories That Heal and My Grandfather's Blessings: Stories of Strength, Refuge and Belonging. She has spoken to thousands of people throughout the country, reminding them of the power of their humanity and the ability to use their lives to make a difference. With a 48-year personal history of Crohn's disease, her work is a unique blend of the viewpoint of physician and patient.