Learning from Chaplains: The Role of Spirituality in Medical Education

By David Lewellen

Photographs by Tommy Leonardi

The young woman in the ICU was dying; there was no medical reason at all to think she wasn’t. But her family was clinging to hope. “God is good,” they told the chaplain. “It’s in God’s hands. We know he will bring a speedy recovery.” 

The chaplain listened sympathetically and said little. When she left the waiting room at HUP, Joey Bahng, then a first-year medical student who was shadowing her for the night, was surprised. “They’re delusional,” he told her. “We should say something. We should do something.” But she shook her head. “Nothing we can say now is going to make them change their minds,” she said gently. 

Bahng was getting a lesson in the power of silence. 

That recognition was helping him, and other students, learn how spirituality affects people’s lives and how to communicate effectively. First-year students who sign up for the chaplain shadowing program at Perelman School of Medicine, now in its fifth year, also get a chance to see practice in the trauma department (now at Penn Presbyterian Medical Center) and to observe how medical decisions affect human interactions.

As the evening went on, the chaplain and Bahng made several more visits to the ICU room, and the atmosphere began to change. An aunt and a cousin of the patient had a more realistic view of the situation, and the chaplain encouraged them to say what was on their minds. The family didn’t want advice so much as a chance to talk about the situation. When the chaplain left the room, Bahng listened and nodded, and that was enough. 

“Doctors and nurses have a lot to learn from chaplaincy,” says Bahng, who served as the student co-coordinator of the program, a year after his memorable night. Even within the confines of a patient consultation, Bahng has learned not to interrupt and to let patients tell their stories. And when he is rushed, he will remember that chaplains may have the time to sit and let a situation unfold naturally.

Students’ individual experiences vary – some nights are busier than others – but all of them see the impact of spiritu­ality on people’s lives and get a sense of how they can ac­knowledge patients’ spirits even as they treat their bodies. 

“The reality is, the majority of people do have some con­cept of spirituality that involves a being, an entity that they’re able to engage, through which they find meaning” says Horace DeLisser, M.D. ’85, G.M. ’91, the associate professor of medi­cine who leads the shadowing program. Many students, he points out, arrive at medical school with an “indifferent, dis­missive, or even hostile attitude” toward religion or spiritual­ity. DeLisser emphasizes that they must develop awareness of their own issues and beliefs – and respect for those of other people. “Patients are very smart,” he says. “They can pick up when you’re dismissive of them, even if you don’t say it.” 

DeLisser has studied spirituality in medicine for his entire career. As a pulmonologist, he often witnessed grief and loss in the ICU. He realized that the spiritual and emotional chal­lenges he witnessed were separate from, but related to, the medical problems he was trained to treat. “My spirituality in­forms my work,” he says. “I see my work in engaging and help­ing patients and their families in crisis as both a privilege and calling from God. It also helps me cope with the burden and stress of dealing with suffering.”

There are signs that the much of the medical world is com­ing to share that view. As palliative care has gained recogni­tion in recent years, so has the role of the 
chaplain, mandated to be a part of palliative care teams. Palliative medicine recognizes the role of “spirituality, ritual, meanings, and how families come to terms with the loss of a loved one,” DeLisser says. In addition to physical pain, patients face existential pain, and their families must cope with their own issues of grief and loss. 

DeLisser is quick to invite chaplains to par­ticipate in the decision to transition to comfort care. When the patient is actively dying, it is of­ten the chaplain who can make the time to sit by the bedside and wait. And they serve a valuable role as an independent mediator between doc­tors and families. 

Perelman students work on communications skills and empathy in normal class work, and they also learn how specific beliefs may affect medical treatment. For example, a Jehovah’s Witness re­fuses blood transfusions, and a Muslims may be fasting during Ramadan. Students learn how to talk with people in crisis – which involves much more listening than talking. “What people really need is someone who’s present and attentive, someone who says I’m choosing to be here with you,” as DeLisser puts it. For physicians, it is part of an overall maturation process from self-centered to patient-centered. “Even if I have a radically different view of the meaning of life, I can join their celebra­tion, their experience – not because I agree, but because I’m there for them, I’m supporting them.” 

Before his night with the trauma chaplain, Bahng says, “I expected it to be all about Jesus, and that was barely men­tioned. It’s so not about evangelism. It’s about being empa­thetic and establishing a bond and treating people’s soul as distinct from their body.” But even so, many students are sur­prised by the role faith plays in patients’ decisions.

That is exactly why DeLisser values the program and would like it to expand. Watching a chaplain in action gives students “a little glimpse of how they themselves can do spiritual care,” he says. A first-year student shadowing a chaplain may be en­countering death for the first time and seeing its effects on others in the room as well. According to DeLisser, “The first order of business is to establish that they care. . . . I’m here to listen, and I can wait.” The communication skills may be basic, but they are nonetheless necessary. 

A small example that DeLisser offers: When patients or family members mention prayer, he will ask them to pray for him and for the medical team. It shows respect, affirms their belief, gives them a way to participate, and functions as care for the spirit. 

Should doctors lead prayer with patients? DeLisser’s answer is “Yes, if.” If prayer feels authentic to the physician; if the pa­tient welcomes it; and if the goal is “comforting, consoling, af­firming,” never about influencing. At a secular institution such as HUP, he points out, meeting all of those conditions is rela­tively rare. On the other hand, “If they’re inviting you into their lives,” he continues, “I can’t see that as bad.” 

As far as participating in prayer led by someone else, DeLisser says that he more often feels comfortable with it as he has become “a more culturally competent physician.” A doctor who feels uneasy in that situation should “respectfully step out of it.” 

Margaret (Meggie) Kobb, M.Div., a staff chaplain at HUP, took five or six medical students around with her in a recent year, and she remembers the questions they asked afterward: How do you know what kind of prayer to offer? How do you learn to be comfortable sitting in silence? Were you intimi­dated when that family was so angry with you?

In her answers, she tells them that a chaplain has to learn to “dive deep quickly.” As she emphasizes, “There’s no time for small talk about where they’re from or the weather or how the Eagles are doing. In moments of crisis, people are so receptive to having that lifeline.”

The situation that Bahng saw, when the family is praying for a miracle, is one of the trickiest that a chaplain faces. “Very often, I’m the bridge between the medical team and the family,” Kobb says. “I love family meetings. They’re incredibly stressful for everyone, but it’s also an opportunity for every­one to be heard.” 

Kobb’s memorable case was the matriarch of a West Afri­can Catholic family who was on life support. The medical team was ready to remove it, the family wasn’t, and “they spent days avoiding each other.” When a meeting finally took place, everyone agreed that they did not want the patient to be hurt, and she was eventually discharged to long-term care. “It didn’t feel like a win for either group,” Kobb reports, “which told me it was a good compromise.” 

Based on her occasional contacts with the students who have shadowed her, Kobb believes that the program is having a lasting impact. “They carry that impression with them,” she says. Physicians are trained to make decisions quickly, and “knowing when to sit in silence is a skill. It’s counterintuitive to what doctors are about.” 

Once students shed their misconceptions, they learn that spiritual care offers “a listening ear and presence, being atten­tive to the patients’ stories and concerns and fears,” DeLisser says. What the medical students may be surprised to learn is that one of the stops the chaplains make on their rounds is at the department’s security desk. In fact, it is often the first stop, when they are informed of any delicate situations affect­ing the families of patients or any possible disruptions, which can happen when trauma is involved. Much of the chaplains’ work with families is spiritual – but a fair amount of it is ad­ministrative as well, easing the families’ stay at the hospital. When patients and families are enduring the worst day of their lives, a chaplain can identify the resources they can make use of for coping — their own religious tradition, family and friends, music, nature, etc. — and may suggest other alterna­tives. But they also offer and share what DeLisser calls “their authentic selves.” 

The shadowing program began in 2012, when student Andrew Perechocky, M.D. ’13, took notice of chaplains’ inter­personal skills during his palliative care elective. He arranged on his own to spend an evening with a chaplain and found it to be a great experience for his own education and career de­velopment. When other students then showed an interest, Perechocky helped set up the program’s first year. Subsequently, he was the lead author of a paper in Journal of Surgical Edu­cation (2014) on the program. (DeLisser and two HUP chap­lains – including James Browning, M.Div., coordinator of clinical pastoral education for Penn’s Health System – are among the authors.) The article notes that spirituality typi­cally receives little attention in the curricula of most medical schools. “Particularly lacking is formal instruction in effective communication with patients and families experiencing grief, loss, or death of a loved one.” Although the sample size was small, the medical students who took part in the shadowing and responded to the survey were overwhelmingly positive. All recommended that the experience be part of the medical school curriculum. According to the article: “Hospital-based trauma chaplains undergo extensive training in providing emotional and spiritual support for patients and their families in crisis, enabling them to be effective role models for medical students who wish to strengthen their interpersonal and communica­tion skills.” For his part, Perechocky found that the providers of spiritual care are “experts in active listening, being a sup­portive presence, and navigating family dynamics.” 

Now an emergency medicine resident at Boston Medical Center, Perechocky says that even in a high-volume, high-pressure setting, “you can establish a rapport and form a connection in a short amount of time. It’s something you need to work on.” Even the simple act of sitting down helps calm the atmosphere. In general, he continues, such skills are better learned from watching other people than from reading a text. 

“Patients can benefit from speaking with a chaplain in mul­tiple situations,” Perechocky says, “even if it’s not life-threatening and the patient’s not religious.” 

“When I went to medical school, I didn’t know what a chaplain was,” says Amy Westcott, M.D., G.M.E. ’08, who was a mentor for Perechocky’s research and an author of the jour­nal article. More than a decade after her own education and her work in palliative care and geriatrics, she now recognizes the importance of treating the whole person and paying atten­tion to how each person copes. As a profession, Westcott says, medicine is “moving toward treating patients as whole persons.” Now an associate professor of medicine, geriatrics, and palliative medicine at Penn State Hershey Medical Center, she found spiritual care integrated throughout its system when she moved there in 2014. 

Interprofessional work has always been one of Westcott’s interests, and now she is seeing wider acceptance of the team model. “Sometimes the physician leads, sometimes she’s a member of the team. It’s going to vary depending on the situ­ation,” she says. “Sometimes it’s the chaplain running the fam­ily meeting, and my job is to listen. Or if I’m in the room, the certified nursing assistant is going to coach me on how to help turn the patient. They studied for that; I didn’t.” 

Westcott praised Perechocky’s initiative in seeing a need and acting on it. As she puts it, “Things really come from the stu­dents these days. They know what’s missing better than we do.” 

It’s usually 30 to 40 students, from a class of about 150, who have participated in the shadowing program during the fall. The program is now expanding to spring, in order to accom­modate word-of-mouth recommendations from students to their peers. The feedback has been so positive that DeLisser would like to see the program become mandatory. That, of course, might change the experience, and more logistical sup­port would be needed, but he feels the benefits would be more widespread. Students who sign up now are probably self-selected for being open to the experience, and DeLisser hopes that those who skip it because of indifference might learn something. 

The next step in formally recognizing the growing integra­tion of medicine and spirituality will come this summer, when DeLisser enrolls the first cohort to receive a certificate in spir­ituality, similar to ones already offered in community health, women’s health, and global health. The six-week summer pro­gram, he believes, would push students “growing in their own spirituality, their sense of who they are, and empower them to be better doctors.” 

As part of that program, fourth-year students may again shadow chaplains. But in addition, they will track patients and families over consecutive days and present verbatim accounts of their experiences to peers in order to evaluate their com­munication and the relationship with the patients. Group ses­sions will deal with common fears and desires, and partici­pants will practice meditation and attend seminars on such topics as theology and medical ethics, 12-step spirituality, and near-death phenomena. 

Watching chaplains at work has been a lesson in interper­sonal skills to Adam Mayer, who had been a student coordinator along with Bahng. “Even in five minutes, you can make people feel heard,” he says. “They’re not just a heart failure or a cancer – they’re a person, with hobbies and things they care about.” 

Mayer knew something about chaplaincy going in, be­cause he had volunteered at a nursing home. But that setting was almost all Jewish, and seeing patients of all faiths at the hospital has broadened his horizons. In his rotations now, he often suggests calling the chaplain into a conference with family members. 

He recalls the experience of being at the bedside of a woman who was dying. Mayer held hands in a circle with family members as the chaplain prayed. The family was Christian, and Mayer was wearing his yarmulke, but, he says, “I felt a connection with them, and they felt a connection with me. They said thank you and that it helped them process things.” 

Mayer has seen the role spirituality plays in patients’ lives – even nonreligious people frequently ask for a chaplain be­cause “they just need someone to talk to.” 

He was particularly moved when he witnessed his first patient death, a woman whose mother was still alive. Partly influenced by his memory of spiritual care in action, he called the mother afterward and told her he’d always remember her daughter, so “her memory is going to live on in my memory. It was a very special moment.” 

For the lasting benefits involved, Mayer says, giving up a free evening to shadow a chaplain “is totally worth it.”