Engaging Patients in Spiritual Matters - or Don't Leave Your Faith Outside the Exam Room Door

Thank you for coming despite this freezing cold weather. I hope this evening "you and I may be mutually encouraged by each other’s faith." (Roman 1:12)

I saw a 75 year old gentleman yesterday for the first time. The reason stated on my schedule - "high BP/monitor meds". I had a clinical clerk with me. She did a fine job with taking a complex medical history - previously healthy until last June; then a heart attack followed by a triple vessel bypass surgery. Taking about a dozen different medications. Currently asymptomatic of cardiac related complications. BP measured 5 times with our BP-Tru machine 122/46 HR of 56 regular. When I went in to see him later, he revealed that he had low mood - feeling "apathetic" about life; lost interest in things that used to give him pleasure; no longer has an appetite; passive suicidal thoughts but stated he would never act on these because of his love for his family.

How do I engage this patient in spiritual matters?

Let me begin with a confession. After almost 30 years of clinical practice, not a single patient has come forth to tell me that he had become a Christian as a direct result of my sharing my faith with him. This seminar is not about sharing your faith with your patients, at least not in the traditional sense of evangelism, the use of tools like the Four Spiritual Laws etc. What I would like to share with you this evening is about living out your Christian faith as a physician or any health care provider. And by living out your faith you will first of all grow as a disciple of Jesus Christ. You will experience His transforming power even in the exam room. You will begin to stop doing things you know you ought not to do and instead you will be able to do more of the things you ought to do. And your patients will notice. There will naturally be conversation about the spiritual side of things. It doesn't really matter whether your patient is a Christian or not. You will bring help to him by providing a complete care package - help in the body, mind and the spirit. So, practically how do you do it?


Firstly, bring Christ into the exam room or operating theater. What I mean is before you enter the room, say a very short prayer: Jesus, please come in with me. Your prayer is immediately answered! For you know that He has promised never to leave you nor forsake you. His presence has always reminded me that I have been saved by grace:

"For it is by grace you have been saved, through faith—and this is not from yourselves, it is the gift of God— not by works, so that no one can boast." (Ephesian 2:8-9)

It is a tremendous comfort knowing that what would happen in the next 15-30 minutes in the exam room is the work of a loving and gracious God, who desires to have a relationship not only with me, but with the patient to whom I have the privilege to serve. I therefore leave my pride at the door and follow Jesus into the room. This simple act of asking Jesus to come and help has brought me tremendous comfort over the years. There is so much sweetness in my heart recalling those late night deliveries of babies, or right before seeing some very difficult patients, or having to break bad news to those with whom I have such deep relationships. So get into this habit. It only takes a second just before you knock on the door.


Secondly, I greet my patient with "How can I help you?", with a smile, like someone who has just been blessed with Jesus' company! In my heart I have been practicing the line "How can I serve you?". It is not fashionable to say it out loud. It just sounds weird! But once in a while I surprise a patient by saying it out loud. I remember this patient very clearly:

Miss C, a 35 year old single mom referred by "Health-Connect" - meaning she belonged to the group of high need patients with whom the province was trying to connect to a Family Health Team. Our FHT was obligated to take a few of these, quite reluctantly despite the financial incentive. Before I was able to say my greeting she pulled out a piece of paper with a long list of problems - and told me "I don't think you will like me". I looked at her in her eyes, and said to her (as sincerely as I could) "It is my privilege to serve you!" and she broke down and cried. Over the years, she had many challenges and at times I was not sure if anyone could help her but God's grace sustained me. She has become a famous patient in my practice to this day. My team members often asked me after a visit with her "How did it go?" I would say "I overwhelmed her with my love!" which usually brought out a round of laughter but deep in my heart I knew it was true. One day she came to see my resident and told him that she no longer needed the narcotic treatment because she was now managing her back pain with the help of prayers and support from church friends!" My resident, who was also a Christian, didn't know what to say. He went on to manage her diabetes. I later asked him what went through his mind. He told me that in his medical school training he had learned that spiritual thing was off limit. What would you do differently?

This patient, and all other patients, are all made in God's image.  They are all loved by God, who was willing to send His one and only Son to die on the cross for their sins. He also has a purpose for them. I would do well to remember this and tell all my patients that it is my privilege to serve them. For,

"Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me." (Matthews 25:40)


Thirdly, your patients are more interested in spiritual matters than you think. Do you agree?

Mrs X was told by the Oncologist that the latest test results showed that she had ovarian cancer. Mrs X, who has since passed away, was a devout Christian. She was disappointed that the doctor, who was also a Christian, did not even ask how her faith may play a role in facing such a difficult diagnosis and choice of treatment. Should we expect the oncologist to initiate the faith topic?

There are various studies that suggest that there is such thing as the "Spiritual Gap".

• 95% of Americans believed in God but ony 64% of physicians believed in God

• 77% of the patients surveyed believed physicians should consider their spiritual needs, but only 10-20% reported that their physicians discussed religion or spirituality with them

• 96% of physicians believed spiritual well-being is important in health but only 11% frequently inquired about spiritual issues

What is the evidence that spiritual well-being is important in health? Research shows that:

• spiritual belief is associated with positive effects in terms of reduced CHD, high BP, stroke, most cancers, and several health status indicators.

• spiritual belief is associated with reduced all-cause morbidity and mortality.

• this association is found no matter how religion was defined or measured (i.e., as beliefs, experiences, behavior, or attitudes).

• this findings have been generally positive across all cultures

• spiritual belief is associated with higher rates of overall well being and life satisfaction

• lower rates of depressive symptoms and suicide

• lower rates of divorce and higher rates of marital satisfaction

• and lower rates of alcohol abuse and other drug abuse, including cigarette smoking and recreational drug use

Don't you think it's time to take spiritual matters seriously?


Fourthly so how do you start? How about learning to take a spiritual history? Usually patients come with lots of problems and the last thing you remember to do is to take a spiritual history! By spiritual history I don't mean asking what they put down as their religion or whether they go to church - although that may be better than nothing. We often know about their smoking and alcohol status or any drug allergies but often forget that they are all spiritual beings. If you believe that your patients' spiritual history matters, what questions do you ask? Let me just say that whatever you do it must be well integrated in your usual clinical inquiries. And it really helps if you see your patients over many visits (as in family practice). And your questions should be appropriate to the problems at hand and should increase with ease as you build a robust doctor-patient relationship. Sometimes it just happens, especially among Christian patients.

I have known Mrs Y over the years. She has a lovely family who are all my patients. I don't remember exactly how we have become familiar with each others faith. So I asked her. She would have wanted to come to share this with you personally but her husband is quite ill at the moment. This is what she tells me via email:

How did you come to know that Dr. Chan is a Christian and that you feel confident to share with him your faith journey and how it has an impact on your illness and your husband's illness?

We have had the opportunity to experience the care of some tremendous health professionals over the years. We have been fortunate to always be serviced by individuals with professional demeanor and sound knowledge and expertise in their field. There are, however non-quantifiable traits that emerge in a client, patient interaction that tell you there is something different at work.

We don’t recall Dr. Chan overtly mentioning that he was a Christian, but we do recall him affirming us when we told him of the support we were receiving from our faith community after my mother passed away and I was seeing him for sleep disturbances and associated physical ailments. We sensed he gave an endorsement for including our faith community as part of our healing and recovery along with his prescriptions for my physical symptoms. Without specifically saying so, it was as if he knew what I was already thinking in that I did not want to abandon my spiritual resolves while seeking help from him, which was greatly appreciated.

Confirmation that I was in the care of a physician who had great respect for divine providence and protection came when faced with the debilitating and heartbreaking news that my husband was suffering from a degenerative disease. Dr. Chan prayed with us in his office and took the time to talk with us about managing symptoms and coping with changes to my husband’s condition.  Knowing our physician is guided by faith helps me to feel as though he can be more of a human vehicle to be used by God to work a miracle in stemming the digression of my husband’s illness at best, or at the very least, reassuring us that God has not left us during this dark period of time.

Now if you are really stuck, I have a tool which I have never used but do believe that it will help you when you are totally stuck, like the FIFE (Feelings, Ideas, Functioning, Expectations) which you have learned in your communication skills training. It's called the HOPE Assessment. I have the reference for it if you want.

The HOPE Assessment (Handout)
H: Sources of Hope, meaning, comfort, strength, peace, love and connection
O: Organized religion
P: Personal spirituality and Practices
E: Effects on medical care and end-of-life issues

H Questions:
We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support?
What do you hold on to during difficult times?
What sustains you and keeps you going?
For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs; is this true for you?

O Questions:
Do you consider yourself part of an organized religion? How important is this to you?
What aspects of your religions are helpful and not so helpful to you?
Are you part of a religious or spiritual community? Does it help you? How?

P Questions:
Do you have personal spiritual beliefs that are independent of organized religion? What are they?
Do you believe in God? What kind of relationship do you have with God?
What aspects of your spirituality or spiritual practices do you find most helpful to you personally? (e.g., prayer, meditation, reading scripture, attending religious services, listening to music, hiking, communing with nature)

E Questions:
Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually? (Or affected your relationship with God?)
Are you worried about any conflicts between your beliefs and your medical situation/care/decisions?
Are there any specific practices or restrictions I should know about in providing your medical care? (e.g., dietary restrictions, use of blood products)


Finally, what about prescribing spiritual therapy or treatment. The first and most important treatment is YOU. Yes you are the biggest pill according to Dr. Michael Balint. You are most certainly contributing to what is known as the Placebo effect in the scientific sense. Your living faith will encourage patients to trust the greater healer Jesus Christ who is ever so pleased to help in the most amazing way, always even better than what we ask. You must be receptive to the stage your patient is in - do not preach. Let the spirit guide you.

The second most important treatment is prayer. You and your patient together plead for God to help. I often pray with my patients. In all my years when I asked my patient whether I could pray the answer has always been yes. I often tell my patients I have been praying for them and sometimes it can lead to deeper conversation:

Mrs A had terminal adrenal cancer and I was doing my palliative care visits to her home. I told her I had been praying for her and asked her what I might ask God on her behalf. She, a devout Catholic, asked me to pray that she may be accepted by God when she meets Him. I was able to explain the truth from scripture how it was her faith and not her work that she would be accepted. For.

"God demonstrates his own love for us in this: While we were still sinners, Christ died for us." (Romans 5:8)

Prayer brings benefits to both you and your patients.

"Let us then approach God’s throne of grace with confidence, so that we may receive mercy and find grace to help us in our time of need." (Hebrews 4:16)

I know some of my patients pray for me!  

Mr. & Mrs B moved from Kingston to retire here in Hamilton. Through CMDS directory their original family doctor in Kingston recommended them to see me. I was honored to accept them into my practice. They both had serious health issues. From time to time I asked them "How am I doing?". I was delighted to hear (with a great big grin on their face), "We have been praying for you!". 

Yes I am truly blessed that some of my Christian patients are praying for me, to do God's work faithfully.

Lastly, this is one reason I think memorizing scripture really helps. When I sense that an encouragement from scripture is warranted there is always something I can say, better than my own words, that will help my patient. Sometimes, I am even surprised by my patients response! 

Mrs Z is a deacon in her church. After a lengthy visit managing her uncontrolled diabetes and hypertension, just on our way to the door, I said to her "May I leave you with a blessing, "I lift up my eyes to the mountains— where does my help come from?"...
And she finished the rest of these great verses from Psalm 121,
"   My help comes from the Lord,
    the Maker of heaven and earth." (Psalm 121:1-2)

She left with both of us knowing that we are good in God's mighty hands!

Let me encourage you with this scripture I learned just this past weekend:
"Each of you should use whatever gift you have received to serve others, as faithful stewards of God’s grace in its various forms." (1 Peter 4:10)

Did Moses write the first five books of scripture? God's Future Plan

I was reading Leviticus 14 this morning. Like the several chapters before this, it gave instructions to the levitical priests (descendants of Levi, but really began with Aaron, Moses' older brother) on the sacrificial and dietary laws, as well as management of skin diseases and household molds. These were written in amazing details (in fact chapters 13 and 14 contained some of the most number of verses in a single chapter!). Now I had been taught that Moses wrote these first five books of the Old Testament (often called the Pentateuch) and I had held these books as authoritative and inerrant etc. There had been many times when I puzzled over the lengthy details of what appeared to be irrelevant and at times absurd rituals. Now I know even Jesus and the apostles had quoted from these writings. What should my attitude be when I spend time reading this, as in letting God speak to me through His Word?

I found this book "Who Wrote the Bible?" by Washington Gladden quite helpful. In chapter II "What did Moses Write?" he helped me put a proper perspective on reading the "Torah" (as the Pentateuch is also called). Basically his conclusions were:
1. The Pentateuch could never have been written by any one man, inspired or otherwise.
2. It is a composite work, in which many hands have been engaged. The production of it extends over many centuries.
3. It contains writings which are as old as the time of Moses, and some that are much older. It is impossible to tell how much of it came from the hand of Moses, but there are considerable portions of it which, although they may have been somewhat modified by later editors, are substantially as he left them.
 
In terms of answering the question whether Jesus and the apostles also held the same view, he said:
"It is upon this that the advocates of the traditional view of the Old Testament wholly rely. "Christ was authority," they say; "the New Testament writers were inspired; you all admit this; now Christ and the New Testament writers constantly quote the Scriptures of the Old Testament as inspired and as authoritative. Therefore they must be the infallible word of God." To this it is sufficient to reply, Christ and the apostles do quote the Old Testament Scriptures; they find a great treasure of inspired and inspiring truth in them, and so can we; they recognize the fact that they are organically related to that kingdom which Christ came to found, and that they record the earlier stages of that great course of revelation which culminates in Christ; but they nowhere pronounce any of these writings free from error; there is not a hint or suggestion anywhere in the New Testament that any of the writings of the Old Testament are infallible; and Christ himself, as we have seen, clearly warns his disciples that they do not even furnish a safe rule of moral conduct. After this, the attempt to prove the inerrancy of the Old Testament by summoning as witnesses the writers of the New Testament may as well be abandoned."

In my other reading this week, I have been working through slowly these two books:
(1) "Surprised by Hope - Rethinking Heaven, the Resurrection, and the Mission of the Church" by NT Wright, and
(2) "Triple Jeopardy for the West - Aggressive Secularism, Radical Islamism, and Multiculturalism" by Michael Nazir-Ali

Let me quote just one thing I learned from NT Wright and leave my comments on Nazir-Ali's book to next week:

On God's Future Plan (Part II of Surprised by Hope"), Wright wrote that the two options of the world view - Evolutionary Optimism and Souls in Transit were both not based on scripture. He then argued from scripture that our hope lies on our understanding of the "new creation" - not only a reality for Christ's followers ("Therefore, if anyone is in Christ, the new creation has come: The old has gone, the new is here!" 2 Corinthians 5:17) but also a promise of "new heavens and a new earth" in which justice will dwell ("But in keeping with his promise we are looking forward to a new heaven and a new earth, where righteousness dwells." 2 Peter 3:13). He concluded:
"What I am proposing is that the New Testament image of the future hope of the whole cosmos, grounded in the resurrection of Jesus, gives as coherent a picture as we need or could have of the future that is promised to the whole world, a future in which, under the sovereign and wise rule of the creator God, decay and death will be done away with and a new creation born, to which the present one will stand as mother to child... What creation needs is neither abandonment nor evolution but rather redemption and renewal; and this is both promised and guaranteed by the resurrection of Jesus from the dead. This is what the whole world's waiting for." (page 107)

"I am neither an optimist nor pessimist, Jesus Christ is risen from the dead!" - Bishop Lesslie Newbigin

Seven Woes against Hypocrisy and Mere Apologetics

Today I read Matthew 23. What was so striking about this story was Jesus' anger towards hypocrisy and those who practiced it. I can think of only another instance when I see Jesus' "righteous anger" so vividly displayed and that is found in the story of Jesus clearing the temple (Matthew 21:12-17). There he told the merchants who were doing their business in the temple court:
 “It is written,” he said to them, “‘My house will be called a house of prayer,’[a] but you are making it ‘a den of robbers.’[b]” (verse 13).
He was then quoting [a] Isaiah 56:7 and [b] Jeremiah 7:11. These passages speak of God's passionate love for His temple (His tent or His people where He had chosen to make his abode). He wants to have a relationship with believers, through prayer and worship but instead, some have "robbed" that relationship for personal gain.

The Seven Woes on the Teachers of the Law and the Pharisees (representing those who were knowledgeable of God's word and were in position of leadership in the church) are summarized here with my personal reflection. I am quoting from the Message translation which uses the phrase "you are hopeless" instead of "woe to you" and calls the teachers of the law and Pharisees as "frauds":

1. "You’re hopeless, you religion scholars, you Pharisees! Frauds! Your lives are roadblocks to God’s kingdom. You refuse to enter, and won’t let anyone else in either." (verse 13) Oh don't let my preconceived ideas of personal holiness to blind me of the true delight of God's Kingdom on earth. If I miss the boat I will lead others away from God's true intention for mankind.
2. "You’re hopeless, you religion scholars and Pharisees! Frauds! You go halfway around the world to make a convert, but once you get him you make him into a replica of yourselves, double-damned." (verse 15) When I present the good news to others I should be mindful of telling the good news of Jesus instead of telling them a list of do's and don'ts.
3. "You’re hopeless! What arrogant stupidity! You say, ‘If someone makes a promise with his fingers crossed, that’s nothing; but if he swears with his hand on the Bible, that’s serious.’ What ignorance! Does the leather on the Bible carry more weight than the skin on your hands?...A promise is a promise. God is present, watching and holding you to account regardless." (verses 16-22) I am reminded of the importance of personal integrity in my dealings with believers and non-believers alike.
4. "You’re hopeless, you religion scholars and Pharisees! Frauds! You keep meticulous account books, tithing on every nickel and dime you get, but on the meat of God’s Law, things like fairness and compassion and commitment—the absolute basics!—you carelessly take it or leave it..." (verses 23-24) These verses helped me understanding the meaning of tithing better. It's not just 10% of my income (before tax or after tax?). It is about using what has been entrusted to me to further God's kingdom of justice and compassion.
5. "You’re hopeless, you religion scholars and Pharisees! Frauds! You burnish the surface of your cups and bowls so they sparkle in the sun, while the insides are maggoty with your greed and gluttony. Stupid Pharisee! Scour the insides, and then the gleaming surface will mean something." (verses 25-26) Do everything out of God's love and not just to look good.
6. "You’re hopeless, you religion scholars and Pharisees! Frauds! You’re like manicured grave plots, grass clipped and the flowers bright, but six feet down it’s all rotting bones and worm-eaten flesh. People look at you and think you’re saints, but beneath the skin you’re total frauds." (verses 27-28) This one looks similar to (4). I guess it puts more emphasis on sincerity and transparency. Admitting to missing the mark should always be part of my testimony.
7. "You’re hopeless, you religion scholars and Pharisees! Frauds! You build granite tombs for your prophets and marble monuments for your saints. And you say that if you had lived in the days of your ancestors, no blood would have been on your hands. You protest too much! You’re cut from the same cloth as those murderers, and daily add to the death count." (verses 29-32) Wow, I really need to be aware of my criticism and judging of others, especially those who belong to the household of God. It amounts to murdering their faith!

These are good warnings for me. It's amazing how life can be if I pursue the Eight Beatitudes instead of being pulled back by the Seven Woes.

The lesson this morning ties in with the book I finished reading this past week. "Mere Apologetics" by Alister McGrath reminded me of the importance of personal narrative/stories in the post-modern age. Let me quote a few helpful passages here:
"An image I have long found helpful is to think of each person potentially being on the road leading from doubt or unbelief to faith. For some, that path is smooth and easy, having few roadblocks of any importance. For others, that path is long and difficult, with many potholes and other obstacles to faith along the way. The problem is that an external observer doesn't know what someone's road look like; the apologist has no idea whether the difficulty raised by the person she's speaking to is the one and only remaining barrier to faith - or whether a whole series of difficulties remained to be engaged. All the apologist can do is to give a good answer and trust that a seed has been sown - and that one less barrier to faith remains. Our job is to move people along by one step." (page 159 last paragraph).

In dealing with questions and concerns, some basic points (pages 160-161):

• Be gracious.
• What is the real question?
• Don't give prepackaged answers to honest questions.
• Appreciate the importance of learning from other apologists.

The Seven Woes would be a good reminder (of What Not To Do) when I engage others in matters of faith. My life should be a reflection of God's gracious redemption and words that come out of my mouth should be like the living water that overflows out of thankfulness of our heart. Like the story of Jesus reaching out to the Samaritan woman:

Jesus answered her, “If you knew the gift of God and who it is that asks you for a drink, you would have asked him and he would have given you living water.”
 
“Sir,” the woman said, “you have nothing to draw with and the well is deep. Where can you get this living water? Are you greater than our father Jacob, who gave us the well and drank from it himself, as did also his sons and his livestock?”
 
Jesus answered, “Everyone who drinks this water will be thirsty again, but whoever drinks the water I give them will never thirst. Indeed, the water I give them will become in them a spring of water welling up to eternal life.” (John 4:10-13)