Julia Baggish 0:09
Hi, I’m Julia bagish, and this is the voices in bioethics Podcast. Today we welcome psychiatrist and bioethicist Robert Klitzman to the podcast his newest book, Doctor, Will You Pray For Me, examines the spiritual and religious lives of patients and explores the role of chaplains in the field of medicine and healthcare. Thank you for joining us today, Dr Klitzman, and welcome to the podcast.
Robert Klitzman 0:30
Thank you delighted to be here.
Julia Baggish 0:32
Likewise, just to kick things off, what inspired you to write, Doctor, Will You Pray For Me?
Robert Klitzman 0:39
So several things led me to write it. Unfortunately, on 911 my sister died at the World Trade Center. She worked there for Cantor Fitzgerald and one of the top floors, and at 830 in the morning, she called her best friend, and then no one has ever heard from her since then. And it was a very traumatic time for my family and for me and for all of us in New York and throughout the country, throughout the world, but I found myself wondering, Why me? Why did this happen to our family, not to many others, and my family and I took care of reporting her as a missing person. With the FBI I had to go down to FBI offices and report as a missing person, and we were hoping somehow that she would turn up in the first few days, and we had no body, so we wondered, should we have a memorial service? Should we just assume she’s dead, even though there’s no body? So it was a very difficult time, and I took care of all the things that we needed to do. Eventually, we emptied her apartment and sold her apartment, got rid of her belongings, very traumatic. And then after all that, my body just gave out, and for two weeks, I just felt comfortable laying in bed. Didn’t want to watch TV or read, and I thought I had the flu. And people said, No, these are symptoms of grief. And I said, No, no, I have the flu because it might hurt for my body to move. And invariably, they were right. And I was surprised that I, as a psychiatrist, did not realize that these were, in fact, symptoms of grief. In other words, just a bodily feeling of I just hurt to move it. I only felt comfortable in the nice, cool sheets in my bed. And it got me to think how much we don’t know as doctors, about what the experience of patients is or are. And we see what we think about patients, but don’t really know what it’s like. And in psychiatry, often we look down a little bit at patients who somaticize. A lot of primary care doctors say that half of the patients they see have mental health problems. Really, they complain about, you know, their back hurts, or their body hurts, or they have pain here or pain there, and there’s no real explanation, and we think that they’re somaticizing, and yet, I realize that’s we know that depression and other symptoms and mental health states involve chemicals in the brain and the body, and it’s a natural part of that experience. So based on that, I got interested in, and I should say, I went to, I’m Jewish, I went to my synagogue, went to a Buddhist service. We walked around and rang bells, and none of it really got me over it, so to speak, or was a huge help. And then one day, I was just sitting in Central Park watching the grass blow and the trees move in the wind. And I thought, well, you know, nature goes on, and that was very reassuring to me. So I became interested in how other doctors deal with medical problems they face when they become patients themselves. And so I ended up getting funding from the NIH and doing a study and writing a book called When Doctors Become Patients. So I interviewed 75 doctors who became patients and asked them, you know, how is it different for you being a physician now, having been a patient as opposed to being a physician before, you were a patient with a serious illness? And they, many of them, said versions of the following. They said, Well, you know, patients used to say to me, Doc, would you pray for me and I’d go, yeah, yeah, whatever. I’d poo, poo it. And then I became a patient with a serious illness, and didn’t know if I would leave the hospital alive, and I suddenly realized how important these spiritual issues are, and existential issues and religious issues, doctors told me, and so I kept that in my mind as interesting. And then I had funding and to interview people about experiences with genetic illness, genetic variants that cause disease. And I interviewed people who had Huntington’s Disease, which is caused by a dominant mutation or set of repeats in the genome, and they would say things to me like, well, I know I have Huntington’s because I have the gene, but why did God give me the gene and not my sister? Or why did God give the mutation to my sister, but not to me. So again, these issues of people looking for larger understanding of their illness struck me. I then did a study of assisted reproductive technologies and wrote a book called Designing Babies: How Technology is Changing Ways We Create Children. And again, people would say to me things like, Well, my sister says to me, I’m having trouble having a child, and my sister says, Well, I guess God didn’t mean for you to have a child. Or they’d say to me, Well, I wonder maybe, did God not mean for me to have a child? And I thought, why are people bringing God into this? So I realized how important religious, spiritual and existential issues are to many people, and how they kind. Come up when people were dealing with illness and disease, and so I was interested in this space, and I was surprised that there were a lot of questions about how this plays out for people today, particularly, and part of that is because we live at a time of great political polarization, and a lot of that is involved with religious polarization. So the largest group on the right consist of evangelical Christians, but the number of people who are religious overall is decreasing. The number of people who are Christian is decreasing in the past few decades by a third. The number of people who say that they are nothing in particular or spiritual but not religious is going way up. So I wondered, What is this like for patients and their families, when they face end of life issues, when they face serious illness, et cetera. So I got interested in I ended up realizing that chaplains are the people who really deal with these issues. And so I realized it would be important to understand how chaplains deal with these challenges when they come up. What do they do? What challenge do they face in doing it? And I realized there hadn’t been such a study of chaplains, and so I decided to do it.
Julia Baggish 6:03
Thank you for sharing that. And I think you touch on how really your health and one’s health and their identity is so intertwined with their health. And so I think it’s important that we look at the holistic health of the patient when we talk about how we experience illness and disease overall, dovetailing off of the kind of personal experience that you shared with losing your sister 911 and then also, I know in your book, I think in the first chapter, you touch on a young woman who’s a cancer patient, how do you think that hospitals and healthcare providers can address this gap between spiritual health and physical health.
Robert Klitzman 6:40
So I think it could be addressed much better than it is. And thank you for framing it in terms of Holistic Health, which I think is really important and central to this. I think one issue is that providers, doctors, nurses and others, need to be aware that patients are wrestling not just with the medical facts of a condition, but with the larger mental and spiritual for lack of better term and existential aspects of that. And some is moral distress. Some is just often being alone, being afraid. And these feelings may not rise the level of a diagnosable major depression that you want to treat or need to treat with antidepressants, but they are part of what patients are experiencing, and physicians in particular, need to be aware of this and be open to patients mentioning it. So for instance, there are many conversations that happen in which a doctor says, How you doing to a patient? The patient will say, Well, I just hope God is ready for me when I’m gonna get there. And the doctor will say, Well, have you taken your medicine this week? You know, have you made the appointment with the PT or the cardiologist, as opposed to saying, Well, tell me about that. What are you thinking about that, you know? Or Doctor, how you say, how you doing? Patient says, Well, you know, just getting ready for heaven or something like that. So I think being aware of that and open to that is very important. I think also in medical education, physicians should be aware, even if just through a few minutes in a lecture, of what are the kinds of issues that people of different faiths may face and how to respond. And of course, to be clear, physicians don’t need to get involved in long conversations with this if they don’t want. They could just say, you know, by the way, we have chaplains, we have spiritual care specialists who are happy to talk with you about this. But I think rather than just ignore it, that to realize that these issues are there, or to even perhaps say, you know, lots of patients when they’re struggling with a serious illness, some patients ask a lot of questions about why me, some people don’t what’s that like for you, etc. So I think those are entrees into this. So I think being aware of these issues, not just skipping over them or missing them, particularly when patients raise them, is important. I mentioned a story that’s in the book of when I was a trainee as an intern, I remember having a young woman who had metastatic cancer, and she was Catholic, and I sensed that that was very important to her. She had a picture of Jesus at the foot of her bed, and she wore a cross. Her mother wore a cross. And I could see she was despairing, and she was near the end of her life. And I said to my attending my supervisor, I said, Well, you know, should we call a priest? And he looked at me as if, I said, Should we call the Voodoo doctor? He thought this was like, What do you care like? Who cares like? You know, we’re focused on how much chemotherapy to give her. You know, what her you know, blood cell counts, or as a result, what do you care about? You know, calling a priest or not? And then little while later, I saw that a priest visit her, and her mood seemed to pick up when I saw her. At first, she was full of life, and after a few weeks, she would just stare at the wall all day, curled in a fetal position. And after the chaplain came, she would sit up and she would eat again, and she was a little more engaged, and unfortunately, she died a few weeks later. But I thought that whatever the priest said to her was very helpful, and that rather than just ignore it, as my supervisor was saying, we could have addressed it in some way better, or let her know. It just so happened that a priest happened to come but the many hospitals have no chaplain. Chaplains don’t see all patients, so I think being able to know that that’s a resource for patients could be very helpful.
Julia Baggish 10:00
Absolutely, and you mentioned the dismissal of certain providers, or maybe dismissal that there’s an importance to spiritual health, or that there’s a place for it within their practice. How do you think providers can be respectful of patients’ wishes while still being respectful of their own value set, particularly if they don’t find themselves to be religious, and how can they navigate care of the patient when these two value sets are not in agreeance?
Robert Klitzman 10:26
So physicians don’t need to be religious or spiritual, et cetera, but they need to be aware that for some patients, these are important issues, just like not every patient has a cardiac problem or kidney problem, they may have a mental health problem or a neurologic problem or a bone problem. But you want to be aware that for some patients, these are issues. For some patients less so. So I think physicians should be open to that. They could just say, you know, we have chaplains, we have spiritual care specialists who could talk with you if you’d like. And I think those are the bottom lines. Now, certainly there are times, though, when a patient may want an abortion, for instance, and a physician may be anti abortion, not want to provide an abortion, and that is that physicians right, but the physician has a responsibility to offer a this is where abortion is legal, and states where it’s legal, to offer the name of a provider who will provide an abortion. So if a physician feels that in his or her religious views, a certain procedure is not appropriate, or the physician doesn’t feel comfortable offering it all else being equal to, you know, help the patient find some other physician who can provide it is important that being said, I think there’s a lot of misunderstanding about this, and a lot involves communication. So one Muslim physician who I interviewed, and I should say, there’s a lot of Islamophobia. Unfortunately in our society, a lot of Muslim patients are afraid to write down when they enter a hospital on admission forms that they’re Muslim. They’re afraid they’ll be discriminated against. For instance, then there’s a lot of misunderstanding, I think, about Islam. So a lot of us as physicians know very little about Islam. I think that’s a chan and being able to treat Muslim patients, and in many urban areas, are quite a few Muslim patients who need our help. But one Muslim physician I interviewed said, No, I don’t know what to do. He said, when patients ask me how they’ll do I’ll say, well, it’s all in the hands of God. It’s all the will of Allah, because that’s true to my beliefs. But patients get very frustrated and angry with that, and angry with that, and I don’t understand why, and I don’t understand what to do or say. And I said, Well, I think they may be hearing you say that it’s all in the hands of God, and there’s nothing I can do about it. So I think what you can say is, instead, gee, we’re going to do everything we can to help you, but in the end, some say it’s all in the hands of God or something like that. So in other words, you could be true to your beliefs, but realize how that may be heard by the patient. In fact, someone else I spoke to recently said that when she was in the hospital with cancer a number of years ago, two nurses said, Well, we’re going to pray for you. When she got there and she thought, I don’t want your prayers. I want to get better-
Julia Baggish 12:55
Right.
Robert Klitzman 12:56
She misheard that a nurse saying we’re going to pray for you, meant, well, we’re not also going to help you. So I think it’s important to realize that there’s a lot of misunderstandings about this space, about spiritual existential issues. There’s a lot of room for misunderstanding, and so you can be true to your faith, but just realize how that may be seen by the patient in a way that is not the message you intend to give.
Julia Baggish 13:19
Absolutely! And what do you think contributes to this desire to separate medicine from spirituality or religion, and why the kind of taboo around having chaplains or spiritual leaders in the hospital?
Robert Klitzman 13:34
That’s a great question. So a number of years ago, I was in Greece, and I went to Epidaurus, which is a site of the largest intact theater from the ancient world. And famously, if you drop a pin on the stage, all 10,000 people could hear it perfectly, this perfect acoustics, and it’s a UNESCO World Heritage Site, and it’s very famous. But what I didn’t realize is that it was in the center of a hospital that in ancient Greece, this was a center of Hippocrates, of Asclepius, who was the god of healing, and there was a theater, but there was also a hospital and a temple. And I thought, what a wonderful notion that you have with a hospital, you also have a temple and a theater. And I think that through the 19th century, certainly through the first half of the 19th century, medicine was more closely tied with religion and spirituality. There were even in New York City and in other cities, there is Methodist Hospital, Presbyterian Hospital, there are Jewish hospitals or Baptist hospitals. And then at the end of the 19th century, when medicine became more scientific, when we discovered the germ theory of disease, that diseases are, in fact, caused by bacteria and viruses, which we can often identify and treat, Medicine said, Well, we’re scientific, and all this other stuff is quackery. And so medicine had to become more and more scientific and distance itself from, quote, non scientific approaches or practices. And I think, though, that that, as I found when I interviewed doctors who became patients, that’s not how patients experience their illness. So the woman, for instance, with cancer, who I mentioned, whom the Priest visited, she didn’t think, well, here is my blood cell counts and my chemotherapy on the one hand, and over there, somewhere else are my concerns about what’s going to happen to me when I die, or am I dying, or what with the value of my life, or what’s the purpose of my life or my value, or how can I have hope at this point in my life? For patients, this is all part of the same experience. It’s one experience, and these affect each other. So I think that we need to recognize that and understand and value what chaplains do. And part of this ends up being important from policy perspective, because chaplains are not directly reimbursed outside of the VA system. They’re reimbursed in the Veterans Administration System, VA hospitals, but outside of that, there’s no direct reimbursement, and so they tend to be underfunded, undervalued. About a quarter of hospitals have no chaplains. Many hospitals have volunteer chaplains, who are just local clergy who may only know about their particular faith. They may be whatever it is, you know, Catholic, Protestant, Jewish, and they’re not comfortable necessarily, with talking to patients of other faiths, they may also not be comfortable or know much about medical situations. So if someone says, I have a you know, a stage two versus a stage four cancer, you know, someone who understands what that means medically will be able to respond differently. Those have different meanings in terms of how what the prognosis is and what the concerns of the patient may be. So chaplains, who are trained have a better sense of how to talk to patients who are dealing with complex medical situations, and board certified chaplains today are well trained to be multi faith, to be non denominational, actually, and to be able to sort of deal with patients and help patients find meaning and hope and purpose and connection, regardless of their beliefs or their lack of beliefs. One chaplain I interviewed, for instance, said that he recently knocked on a patient’s door and said, I’m from the chaplaincy. And the patient put up her hands in a cross and said, You are anathema to me. Get out. My God is CNN. I believe in politics and the facts. And he was taken aback and left kind of shaking. The next day, he went back. I said, let me try again. And he knocked on the door and said, Remember me? And she went, Yeah. He said, Well, I know your goddess as CNN and facts and politics, but what do you think of what’s going on politically these days? And so they sat and had a conversation. And it turned out this was a woman who was basically dying. Was very lonely. No one came and visited her. She was a non believer, but she very much valued having this relationship, being able to talk about what was meaningful to her. And so I think it’s an example of how chaplaincy plays a role, even if not fully religious, in patients lives and in medicine, and how we connect this. And also, I think in our fragmented hospital systems today, often the only person doing any kind of psychotherapy in a hospital are chaplains. So the only person, if you’re diagnosed with terminal cancer to say, well, how you doing? What’s it like for you, is the chaplain. There are psychiatrists sometimes, but they’re focused more on giving medications for people who are seriously depressed or psychotic. There are social workers, but they often end up having to spend time with discharge planning, arranging for a bed in a nursing home, or arranging for home health aide when the person gets out, or trying to get insurance for the hospital coverage. So chaplains play very important roles. I think we need to take more appreciation of.
Julia Baggish 18:15
Absolutely and a few moments ago, we were discussing a patient that the two nurses said they would pray for it seems like there’s quite a thin line to walk with mentioning religion or spirituality and ensuring that the patient understands that you’re still there to help in a medical sense as well. How do you think that religion helps patients grapple with scenarios in which they feel like they have no control over their outcome?
Robert Klitzman 18:40
Yeah, it’s a great question. So I think that chaplains can help patients in coming to a sense of meaning and purpose, hope, connection, etc. So for instance, one chaplain I interviewed said that he was visiting a patient. The patient said, you know, I’ve kind of been a mean son of a bitch, and, you know, I’m still alive here. What’s the point in my life? Like, you know, why am I even still alive? Like, you know, this is ridiculous, you know. And you know, What has my life meant in the end? And the chaplain picked up a piece of bread that was on the patient’s tray and say, let’s talk about bread for a minute. You know, bread is kind of amazing. It grows from the earth. It’s a natural thing. Wheat is it tastes good. It helps us. You know, Jesus apparently said, you know, I am the bread of life. And you know, maybe the point of life is not to have accomplished great things, but just appreciate the moment, appreciate the food we’re given in front of us that we’re about to eat, that we’re eating this day. What gives us nutrition? Maybe just the point of life, just to appreciate the small things of life. And that really moved the patient who then felt much better, really sort of readjusted his attitude. So I think that there are things that chaplains can do. And again, some of it may not be religion with a capital R, but just encouraging us to reach out, to figure out what’s important to us. Another chaplain I described in the book told me the story about a young man who was brain dead. He had wanted to donate his organs. And that was the plan. And the surgeon said, Okay, we’re going to roll your son to the operating room. And he was kept alive at that point on machines, on lung and heart machines, and we’ll unplug him there. He’ll die in the or and then we’ll harvest his organs. And the family kind of got upset and said, well, we want to be there when he dies. And the surgeon said, Absolutely not. It’s in the operating room. It has to be sterile. You’ll delay things. We can’t lose time, because the organs, if we wait too long, won’t be as viable for the person who’ll be getting them. So the family said, Well, maybe we don’t want to donate the organs. So there was a lot of tension, and the chaplain said, Well, let me talk to everyone. So the chaplain arranged for the family to gown up sterilely And to just go to the room the operating for two minutes, and they promise I’ll be there for two minutes, and then they’ll leave. So everyone was agreeing, and that’s what happened. They rolled the child in when they were there, the chaplain said to the Mother, did your son have a favorite song? And the mother said he did amazing grace. So they all sang Amazing Grace. The family sang, and then the doctors sang, the nurses sang. Everyone sang Amazing Grace. Started to cry, and then they unplug the son, and they left the room as planned. And as they left, the mother said to the chaplain, thank you so much. We got to sing my son into heaven. So I think that’s a great example of how these are little things, or may seem little, but can have great meaning to patients, to families, and are things that chaplains can do, even if, quote, the patient’s dying.
Julia Baggish 21:22
Absolutely, and have profound impact for the families that are left behind absolutely. In what ways do you think chaplains and medical providers can learn from each other in patient care and well being, that was a great example that you just gave.
Robert Klitzman 21:37
Yes, right. So I think, and as I’ve as we’ve mentioned, as we’ve been discussing, I think providers can learn that these are important issues for patients. A lot of doctors hear religion, they think, Oh, my God, this is, you know, whatever their vision of religion is. It’s sitting in long services that they don’t like, or get boring, or it’s all about, you know. And there, I should say, there have been, there are a lot of people are atheists. There are books called The God Delusion and etc, etc. And there are other books with names like, you know, Proof of Heaven and Heaven is for Real, that stories of people go die, and they meet someone go to heaven, and they meet a guy with in a white robe with a white beard. So there’s varying, varying views of all this, shall I say. But I think to realize that some of this is just finding meaning and hope and connection with people, the person with bread, for instance, that I described, just coming to appreciate the moment, people ask, Why me? People say, you know, did I do something wrong? Why did God let me down again? These are issues, as I thought, you know, when my sister died and wondered, why me? And why did our family get affected by this? By 911 no one else I knew had someone who died. Of course, there is no answer. Why me? I mean, you know, but I found myself that was sort of an innate feeling that sort of rose up in my mind, even though, you know, there’s no answer for that. I mean, she happened to be working there. And there’s, there’s a lot of things we don’t understand. There’s a lot of chaos, a lot of randomness in the universe. It’s hard for our brains that evolved during the Stone Age and before that to sort of make sense of so I think that physicians can learn that these are important issues to patients, realize that they could listen for them and respond, even if very briefly, if need be. I think that chaplains do a lot of good. I think a lot of chaplains feel very much dismissed and marginalized. And I think that chaplains have a lot to offer. I think that often they are taught and trained to be humble, and they don’t stand up for themselves and what they have to offer as much as they can. Some chaplains have told me, for instance, that they have found very important medical information. One chaplain told me a story, for instance, that man came in with stomach pain and got a million dollar workup, and they found nothing, and he came back a few months later and had a stomach pain. Got a million dollar workup. They found nothing. And several months later, he came back again, and the chaplain said, Well, let me talk to him. And the chaplain said, Well, when did the pain start? And he said, Oh, January 18, 2018 what happened then? Well, my wife died, and no one had talked to him about why then, for instance, and there are many, many other examples in the book where chaplains end up finding out key information that is very helpful, but I think chaplains can benefit from being a little more systematic and learning more medical terms so that they can speak more of the doctor’s language so they don’t feel outside the medical system so much or excluded. I think there’s two different vocabularies at work here, and I think the more each side can learn a little bit of the other side’s vocabulary, the better off they’ll be. A lot of chaplains know very little medicine, if anything. So to them, what a stage two versus a stage four cancer is they’re not sure about. So I also think chaplains do a lot of mediation, but don’t really have formal training in mediation. I think they can learn to do that better. It’s a few examples in the book. Well, the case I mentioned about the wheeling the child who was going to donate organs, right, where the chaplain actually, in fact, mediated between the patient’s family and the doctors. Otherwise there’d be no go between. Well, there were one could just do that naturally or sort of intuitively. But there are also skills in mediation that one can learn and practice and improve on and bioethics mediation is a very important set of skills of being a neutral party and listening to both parties and etc. I think that these gaining respect. I think these are skills that chaplains have, but may not explicitly teach them to other chaplins as part of the training, etc. So I think that they can each come closer together and learn from each other, part in language and approaches, et cetera, and what they do.
Julia Baggish 25:25
Absolutely. Just to wrap things up and to bring this back to your kind of personal point of view, framing things as a psychiatrist and bioethicist, how have your own experiences with religion and faith influenced the ways in which you approach care?
Robert Klitzman 25:39
Well, I think partly as a teacher, partly as an educator, and both educating students in our masters of bioethics program, but I also speak to medical students as part of their training in various ways, various institutions. And I also engage in public education, educating the broader public about various issues that are important. So I think emphasizing how important these issues are to patients, how patients and families should not feel alone in having these questions and thoughts and facing these issues. They should know that chaplains are there and can help them, that there are spiritual specialists who, regardless of one’s own faith, are there and can help them. They may want to ask to see a chaplain. Not many do, but that’s how many patients and families do. But to know that is a resource there that can be very helpful for them as they’re going through difficult times, and to realize that these questions of a lot of people don’t want to mention to their doctor, gee, I’m wondering about what’s going to happen to me after I die, what’s going to happen to my family? I feel hopeless. I feel, I mean, able to get by in the day, and I’m able to sort of eat and do the things I need to do, but I’m feeling kind of like, what’s the point in my life? And I think that to help train providers and others that these are thoughts that many people have, we need to be more aware of them and aware of them in our family members who may be ill, and ourselves, friends, patients, etc. So I think most it’s increasing awareness, and the more we are all aware of these issues, the better off we’ll all be.
Julia Baggish 27:02
Thank you for bringing this incredibly important work of the chaplains to light and to writing this book. It was, it was a wonderful book. I’m grateful to have read it, and very grateful to have had you on the podcast today. Really enjoyed hearing your insights. And thank you everybody for listening and have a wonderful day.
Robert Klitzman 27:21
Thank you!