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BY: CARRIE STETZ
Ms. Stetz, a former editor of Health Progress, is a freelance writer.

Numerous polls and studies have documented the fact that most Americans believe that spirituality plays an important role in their health and quality of life. Spirituality is often used interchangeably with religion, although the terms are not synonymous. Whereas religion refers to a set doctrine of faith and guiding moral principles, spirituality can encompass many different concepts, including belief in a higher power that works in the universe, a sense of interconnectedness with all living things, or simply an awareness of the purpose and meaning of life. Although it shares many aspects with various forms of religion, spirituality can be nurtured outside religion; in fact, some agnostics and atheists may choose to describe themselves as "spiritual."

If the majority of patients seen in U.S. hospitals view prayer and spirituality as a component of healing and health, can physicians and other clinicians attend to this aspect of health care without understanding their own feelings on the subject? Mission — and through it, spirituality — purports to play a significant role in Catholic health care. But if the practitioners in a Catholic facility do not incorporate that aspect into the care they provide, what use does the facility's mission statement serve?

Spirituality at Avera Health
Avera Health, based in Sioux Falls, SD, is a regional health care system with four main facilities and more than 100 smaller locations in the upper Midwest. To Avera, spirituality is a vital part of healing. But incorporating spirituality in physicians' work there has been the result less of a specific, targeted effort than of infusing spirituality at every level of the system — and letting physicians explore the concept in their own ways.

Bob Voglewede, Avera's senior vice president of mission services, recalls that the current focus on spirituality began developing organically almost a decade ago. At that time, Michael McVay, MD, a physician at Yankton Medical Clinic, Yankton, SD, asked Voglewede about opportunities for physicians to approach the topic of spirituality. "I was doing something with managers around spirituality at Avera at that time, so I said I would be privileged to meet with him to discuss this further," recalled Voglewede. "What grew out of that initial conversation was an informal group of physicians that began meeting once a month to discuss issues relevant to spirituality. As word traveled, two other groups of physicians connected with Avera formed for the same purpose."

Now officially referred to as "physician spirituality/reflection groups," these three groups have been meeting monthly from September through May for the last six to eight years. Membership is informal and voluntary. Each group has both core members who have stayed through the years and others who attend when possible. As many as 14 of the latter may come to a given meeting.

The groups are based at McGreevy Clinic in Sioux Falls, SD;Brown Clinic in Watertown, SD; and Avera Sacred Heart Hospital in Yankton.Brown Clinic, although not an Avera facility, is an independent hospital with a strong relationship with Avera Health. The Avera Sacred Heart group has members from the Yankton Medical Clinic, as well as from the hospital, and is open to nurses and pastoral care chaplains.

Readings are an important part of the groups' agendas, and a wide variety of topics is open for discussion. "We don't want it to be just about religion," said Patricia Peters, MD, the facilitator of the McGreevy Clinic group. "We cover literature, history, politics, wars, the Holocaust, Gandhi — we are never at a loss for topics. As we discuss these things, we learn more about ourselves, which makes us better doctors and better human beings."

Clark Likness, MD, group facilitator for the Brown Clinic, agreed that discussion is at the heart of the groups' purpose. "We look at every side of the physician's perspective and practice; we look at how situations affect us, asking what we have learned from each other, such as how to approach anger, medical mistakes, and tough ethical issues."

Likness, a former Avera board member, explains how his participation in board meetings left an impression and influenced his decision to start a reflection group in Watertown. "Bob [Voglewede's] mission sessions at the start of every board meeting, which lasted 20 to 30 minutes, were very, very moving," Likness said. "They dealt with bioethics, care of the poor, and personal dilemmas; they always put us in the focus of what Avera Health should be doing in light of hospitality, compassion, and stewardship. He always focused on mission-driven values. Avera's continual focus is on who they are, what they're about, and why they do what they do."

Voglewede himself attributes the development and continued popularity of these groups to the physician leaders, whom he calls the "secret" to the success of the meetings. "I think it's because there isn't an opportunity to talk and share like this anywhere else. The physicians value the opportunity to share in a setting where no one is trying to impress anyone else."

Representative Councils
Another way that Avera has encouraged physician spirituality is by devoting time to it at every bimonthly meeting of its two Representative Councils, which are composed of one physician from every clinic affiliated with Avera McKennan Hospital, Sioux Falls. (The councils currently have 18 members from clinics in Sioux Falls and 15 members from small town rural clinics at some distance from Sioux Falls).

David Flicek, vice president of clinic operations at Avera McKennan, sets aside the first 30 minutes of each of these groups' meetings for a structured discussion of mission-oriented topics, such as religious diversity or case studies concerning care of the poor. Facilitation rotates from physician to physician with each meeting, which is begun with a reflection or prayer.

"Some of these physicians are from isolated rural sites, up to 175 miles away," said Flicek. "These discussions give them a sense of unity,that they are not the only ones dealing with specific issues. It helps them know they are connected to the mission and to the organization through each other." New members to the council tend to be quiet and assess the situation before participating. "All physicians are invited to share their experiences,"said Flicek. "And once they realize it's a safe environment, just about everyone begins to share their opinions."

After hearing more than seven years of physician feedback, Flicek knows that council members are happy that a meeting's first focus is on mission. "The doctors really appreciate the fact that we discuss spirituality, not just the bottom line. The day-to-day life of the physician may feel like all paperwork, all business, and worry about the bills being paid. Taking time to reflect on why they are physicians makes them feel good."

The expectation of Representative Council meetings is that participating physicians will take what they have experienced back to their own clinics. "When they go back to their day-to-day grind, how can they incorporate what they have experienced here with their partners?" said Flicek. "The councils have started talking about how to move these conversations into the local clinics. We are trying to get that dialogue going. We want to foster physician-to-physician discussion to get the mission deeper within the medical staff."

Cultivating an atmosphere that encourages spirituality has reaped benefits for the system as well as the physicians. "I think it builds a certain loyalty to Avera, a certain appreciation of Avera for supporting this opportunity for reflection," Voglewede said. "It nourishes people, and they appreciate that.

"People tell us that we are different from our competitors," he continued. "Everyone at Avera has a sense of what that means; it's spiritual, it's interpersonal, it's the way we treat one another. If we're going to continue that tradition, we have to spend time thinking and talking about how we do it. For that we need physician leaders — physicians who get it, appreciate it, and will speak up for it. Physicians need to think about spirituality and be conscious of and nurture this kind of culture."

Suggested Readings for Physicians

Eck, Diana L., A New Religious America: How a "Christian Country" Has Become the World's Most Religiously Diverse Nation, Harper,San Francisco, 2002.

Frank, Arthur W., At the Will of the Body: Reflections on Illness, Houghton Mifflin, Boston, 1991.

Gawande, Atul, A Surgeon's Notes on an Imperfect Science, Metropolitan Books/Henry Holt, New York City, 2002.

Hilfiker, David, Healing the Wounds: A Physician Looks at His Work, Pantheon Books, New York City, 1985.

Hill, Brennan R., Eight Spiritual Heroes: Their Search for God, St. Anthony Messenger Press, Cincinnati, 2002.

Kidder, Tracy, Mountains beyond Mountains: The Quest of Dr. Paul Farmer, the Man Who Would Cure the World, Random House, New York City, 2004.

Olsen, Arthur, et al., eds., The Call to Care: Dimensions, Dilemmas, and Directions of Caring, Ex Machina Publishing for the Center for Ethics and Caring at Sioux Valley Hospital, Sioux Falls, SD, 2003.

Ralph, Margaret Nutting, "And God Said What?" An Introduction to Biblical Literacy Forms, rev. ed., Paulist Press, Mahwah, NJ, 2003.

Remen, Rachel Naomi, Kitchen Table Wisdom: Stories that Heal, Riverhead Books, New York City, 1997.

Shipler, David K., The Working Poor: Invisible in America, Knopf, New York City, 2004.

Sulmasy, Daniel P., The Healer's Calling: Spirituality for Physicians and Other Health Care Professionals, Paulist Press, Mahwah, NJ, 1997.

Wicks, Robert J., Living a Gentle, Passionate Life, Paulist Press, Mahwah, NJ, 2000.

Wicks, Robert J., Riding the Dragon: 10 Lessons for Inner Strength in Challenging Times, Sorin Books, Notre Dame, IN, 2003.

Young, Roxanne, ed., A Piece of My Mind: A Collection of Essays from JAMA, American Medical Association, 2000.

In addition, the groups have been reading articles from Health Progress and other publications. They also discussed the Avera Health publication Caring Voices, a collection of 15 essays by people who have been involved in various ways with dying and death. A limited number of copies are available. Avera has produced an 18-minute video detailing how mission and spirituality are expressed in the system.

For more information, contact Bob Voglewede at Avera Health (605-322-4708).

Physician Roundtable

The leaders of the physician reflection groups that grew from Avera's nurturing of a culture of spirituality agreed to speak with Health Progress about their experiences and insights into sharing and discussing personal opinions with peers in an open, informal environment. Patricia Peters, MD, is a physician with McGreevy Clinic in Sioux Falls; Clark Likness, MD, is a physician with Brown Clinic in Watertown; and Michael McVay, MD, is a physician with Yankton Medical Clinic.

Health Progress: How have you benefited from participating in these reflection groups?

Likness:
I'm a better person — at times more empathetic, more caring. I know myself and my own barriers and limitations better. I've learned I don't have to know everything. Part of being a better physician is knowing your limitations. I'm a small part of God's work — it helps me move forward from patient to patient and avoid burnout.

McVay:
I have found deeper meaning for myself. Before, I was trying to look at how to connect to patients on certain core faith beliefs. But I found that when a patient is suffering from an illness, the way to approach it is to find out what gives meaning to the patient. This experience has given me the framework to ask the right questions.

Peters:
I find it personally and professionally rewarding, not just in the doctor/patient relationship, but in the human/human relationship. It spills over into other aspects of life as well; we talk about so many topics that involve the greater world, which is important because not everyone is just like us.

Likness:
Renewal is a huge part of this — supporting each other by discussing cases of sudden death and dying, for example. Sometimes you do everything you can but get a bad outcome. Those really hurt, and you wonder if there was more you could have done. This program helps me to not get angry or frustrated, to recognize that God is with us every day.

Health Progress:
Do you think a better appreciation of spirituality is important to physicians?

McVay:
Physicians are the hardest group to crack; some are too busy, some feel threatened by the topic of spirituality. But for the most part, that's because of the culture of medicine.

Peters:
Sometimes our experience and treatment in medical school and residency affects how we view medicine today — especially women, who may have had a rough go. In this group there are times we can visit that topic.

McVay:
Competition intensifies with residency. Young doctors become more closed, and it's harder to hold on to ideals that brought them into medicine in the first place. You become known for productivity and how good you are with a procedure, for example. But you lose touch with the meaning. And what gives deep meaning to life is the spiritual.

I equate spirituality with meaning in life rather than a set of core beliefs of a certain faith system. I was struggling to find meaning in my medical practice — I wanted to go deeper than ECGs and echocardiograms. This group allows me to redirect my mind from what kind of test I'm administering — it opens me and allows me to be more present with a patient.

Health Progress:
How are these sessions valuable to physicians? To Avera? To patients?

Likness:
Studying Muslim, Christian, and Jewish diversity has been very important to us in a rural community. It helps us be more diverse in our understanding of the populations we are attending to. We have a large Native American population, a growing Hispanic population, and refugees from Southeast Asia and Eastern Europe.

McVay:
Any system that gives support to spiritual exploration and dialogue is going to be a better system. It increases care and compassion. In some systems that is entirely lacking, and everything is process driven. You can provide good patient care and have good numbers, but if you don't have a compassionate base it's going to be pretty dry.

Peters:
Other systems, especially at the administrative level, seem more concerned about the financial bottom line and push, push, push for that. Avera Health's mission is rooted in the Gospel; most of the employees at Avera work as if they're on a mission with the Gospel and treat people with loving care.

Likness:
I hope it has improved patient care — but how do you measure that? If we can enhance the compassion, make ourselves better listeners able to hear and better comprehend what our patients and family members are saying, that's better care. Does it translate to every patient encounter? No. But over the long haul, it is a process that truly lends itself to our being more open, more supportive, and more forgiving of patients who blow off everything you say to them. We are all human and we make choices, good and not so good, and we keep trying.

Peters:
It's important because this is one way that doctors from my group can sit together — even only once a month — and talk about something else besides the science of medicine, like the psyche of the patient. Many times topics help us with that aspect of medical care, which makes us better doctors and helps us in relationships with nurses, receptionists, and colleagues. We think more about how we treat other people because of our work with these readings.

McVay:
Trying to discuss questions about suffering and illness that come up in our readings helps us try to help our patients find meaning in it — and that improves patient care.