The Christian Physician in the Halls of Academia

1. The Christian Physician in the Halls of Academia Élise W. van der Jagt, MD, MPH Professor of Pediatrics, Critical Care, Hospital Medicine URMC/GCH

2. Acknowledgements and Background • World-War II/Immigration from the Netherlands to Canada-U.S. • Generations of strong Christians; Reformed tradition/Calvinism/Christian worldview • Weekly instruction in Bible, Doctrine, Church History/Catechisms • Mealtime prayers, devotions 3x/day • Strict Lord’s Day Observance/no work • Exposure to art/philosophy/ music/theology/ history/politics/non-English languages • Emphasis on learning/discourse; father an author of church history/youth books • Neighborhood Bible studies • Coping with serious illness Anton and Elizabeth van der Jagt

3. Education and Military Experience • Univ. of Rochester (late 1960s) • Vietnam War; ; civil rights movement • sexual revolution; women’s lib; drugs • Prof. at RIT/Elder at church insured church attendance; participation in college/career fellowship • Univ. of Maryland Med School (1970s) • Christian Med Student Fellowship • Inner City Mission work • Sundays at home • US Navy General Medical Officer x 3 years post pediatric internship 1st Tour: Okinawa/Japan/Pacific • Navy Chaplains – Passero/Darcy • Overseas Christian Servicemen Ctr • Ship – USS Juneau, • Protestant Lay leader 2nd Tour: Va Beach/Norfolk/Portsmouth • USS Inchon to Africa/South America • Christian Reformed Church; OCSC

4. Objectives Describe an academic medical center, its changing perspective on patients, and both the challenges and benefits of being there as a Christian physician Give specific insights in how a Christian academic physician might live out his/her Christianity in a secular, academic environment Share specific examples from my own experience

5. The Academic Medical Environment WHAT IS IT LIKE?

6. The Academic Medical Environment • TheAcademic Physician’sprimary allegiance is to the Institution and its mission/values in return for the privileges and opportunities the institution provides in education, research, clinical care and leadership • TheAcademic Institution has a responsibility to the academic physician to provide opportunities for deployment of his/her skills in ways that would optimize them for both the individual and the institution including the provision of remuneration and other benefits to enable this to happen. • TheAcademic Physician and the Academic Institution are interdependentand are usually formally or informally contractually related.

7. Education/Teaching • Education/Teaching (required for all faculty) • Medical Students/Residents/Nurses/Other • Peer Faculty • Lectures/Seminars, during clinical care, experiential learning; problem based learning, provide current resources • Faculty Development • CME requirements either on-line, locally or at conferences (MOC); tied into compensation • Other Requirements • Promotion requirements (instructor, assistant professor, associate professor, professor) – education portfolios, publications, national-international presentations, grants • Involvement in Resident and Medical Student selection • Involvement in faculty promotion committees

8. Research/Scholarship • Discover new knowledge using observation, testing hypotheses, analysis, • basic science, translational, clinical practice, clinical trials, health services, quality improvement science, educational • Presentations/Collaborations: regional/national/international (PAS, SCCM, etc.) • Publications (peer-reviewed journals) • Obtain funding (intramural, NIH, foundations, etc.) • Promotion Requirements

9. Clinical Care • Provide inpatient, outpatient, specialty and sub-specialty care according to training and interest; • Provide full spectrum of care including primary/secondary, tertiary, quarternary) • Referral center for the region • Trainees (fellows, residents, med students) involved in almost all care; apprentice model; always teaching while providing care • Team-based, interdisciplinary; almost never by oneself; • Involvement in quality improvement/safety required; Quality Improvement project participation required and tied to compensation • Maintenance of certification in specialty/subspecialty

10. Administration/Leadership • Accountable for revenue generation – either clinical, research funding, other • Direct programs, divisions, departments as requested • Mentor and support faculty, especially if leader • Provide fiscal oversight if leading an area • Improve/develop the medical center’s health care process (committees, workgroups, task forces) • Optimize interface with physicians outside the medical center, other institutions • Leadership in local/national/international academic societies • Leadership and medical expertise in community and governmental health agencies

11. Transitions in Medical Models spiritual spiritual spiritual Spiritual Biological Psychological Social biological biological biological social psycho social psycho psycho social Flexner Report 1910 Engel - 1977 TJC 2001-Present Before 1900

13. world. He may not be convinced of this or that form of church doctrine, or interpretation of Biblical teachings, but he should ever hold the subject open for further evidence, and always show a readiness to hear all sides of the topic

14. The majority of medical men have long ago taken this position, and where they do not become active members of some regular church, are reverential believers and supporters of the fundamental principles of Christian religion. It is only the minority, which happily are growing less every year, who are skeptics, and who hide their weakness under the pitiful expression of Agnosticism. These men are always urging the idea of conflict between science and religion, which every true student of science denies, and every new truth of nature flatly contradicts. Learned theologians and scientists find no conflict or clash of the great truths of nature and theology;only the small, weak, half-learned men ae troubled by such possibilities. JAMA 1891

15. The clergyman is coming nearer the physician, and both are pointing out and applying the higher laws of physical and spiritual life, and urging men to live in accordance with them. The highest form of theology points out the realm of the spiritual, from the physical, and shows the laws and forces which govern the life here and here after; and the highest form of medicine indicates the reign of physical laws, their scope and influence, over organic and tangible life. JAMA 1891

16. The Flexner Report – 1910 • Based on model of German medical education • Established the biomedical model as gold standard of medical training • “Embraced scientific knowledge and its advancement as the defining ethos of the modern physician” • All physicians were to be trained as physician scientists, had a responsibility to generate new information either in the laboratory or clinically.

17. Transitions in Medical Models spiritual spiritual spiritual Spiritual Biological Psychological Social biological biological biological social psycho social psycho psycho social Flexner Report 1910 Engel - 1977 TJC 2001-Present Before 1900

18. Christus und Hippokrates GemeinsameZentralprobleme in Medizin Und Theologie W.KohlhammerVerlag 1958

19. Biopsychosocial Model 1977

20. Transitions in Medical Models spiritual spiritual spiritual Spiritual Biological Psychological Social biological biological biological social psycho social psycho psycho social Flexner Report 1910 Engel - 1977 TJC 2001-Present Before 1900

21. 1998 AAMC Medical School Objectives • Ability to elicit a spiritual history • Ability to elicit a cultural history • An understanding that the spiritual dimension of people’s lives is an avenue for compassionate care giving • Ability to apply understanding of patient’s spirituality, cultural beliefs, behaviors to clinical contexts • Understanding/respect for role of clergy and other spiritual leaders, culturally based healers and care provider and how to communicate and/or collaborate with them on behalf of patient’s physical and/or spiritual needs • An understanding of their own spirituality and how it can be nurtured….and the basis of their calling a a physician.

22. The Joint Commission - 2001 Hospitals: requires practitioners to conduct an initial, brief spiritual assessment including as a minimum: • Denomination or faith tradition • Significant spiritual beliefs • Important spiritual practices Provides sample questions to ask such as: • Who or what provides the patients with strength or hope? • How does the patient express their spirituality? • What is the name of the patient’s clergy, ministers, chapains, etc. • What does suffering mean to the patient? • Has belief in God been important in the patient’s life? • Others…

23. Transitions in Medical Models spiritual spiritual spiritual Spiritual Biological Psychological Social biological biological biological social psycho social psycho psycho social Flexner Report 1910 Engel - 1977 TJC 2001-Present Before 1900

24. Biopsychosocial Model Biological Model Biopsychosociospiritual Model

25. Spirituality A quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any god. The spiritual dimension tries to be in harmony with the universe, and strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness or death. (Murray & Zentner 1985) Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs values, traditions and practices. International Consensus Conference 2012

26. NON-CHRISTIAN VALUES/IDEAS Christians are Anti-Intellectuals Atheism (no God) Scientism Sexual Expression a Right Situational Ethics Secular Humanism Evolution Utilitarianism Individualism Primary Value Autonomy as Primary Good Pragmatism Gender Fluidity Uncertainty Unacceptable Eastern Philosophies Feminism Euthanasia Materialism Diversity (selective?) Agnosticism Religion is a Crutch Non-Traditional Marriage Anti-Christian Thought Relative Truth Abortion

27. Quality of Care Truth- telling Concern for Poor Christian and Non-Christian Shared Values Kindness Education Peace Good communication Learning environment Compassion Spirituality SHARED VALUES Fair reimbursement Honesty Commitment Accountability Team based Care Science Burn-out Concern Science Cost Concern Respect Efficiency Listening Patience

28. Key Relationships Christian Academic MD

29. Christian Beliefs and Threats Christian World View Threats Secular humanism Atheism/agnosticism Religious scepticism Plurality of ways to God No absolute truth Individualism/Autonomy Compartmentalization of spirituality/religion Self-realization is dominant No proselytizing; religion is private • There is only one God • Sin is inherent in all people and prevents a relationship with God • Jesus Christ only way to God • Life after death • Christian beliefs affect all areas of life; cannot be compartmentalized • Behavior must reflect Christian beliefs of loving God and neighbor • Christians are not to isolate themselves but live in a caring community with one another • Mandate to spread the gospel wherever God has placed us

30. Physician Responsibilities and Threats Responsibilities/Values Threats Technology Data overload Fragmentation into ever more sub-sub-specialties Separation of care and cure Increased complexity of patients including medical, social, mental and spiritual complexity Lack of time Consumerism Reimbursement/financial issues Social stresses – lack of family/marital issues/debt Burn-out • Care for the entirepatient – body, mind and spirit • Give care to the patient in the context of their social environment • Cure where possible; provide caring when cure impossible • Provide highest quality and most current care possible using highest level of skill • Patient responsibility is primary; all else is secondary • Use all resources important to the care/cure of the patient

31. Academic Responsibilities and Threats Responsibilities/Values Threats Emphasis on generating revenue EHR, technology, data overload leading to dissatisfaction/burnout Less time for patients and academic endeavors because emphasis on revenue and clinical operations Educational objectives changing since complexity and type of health problems changing Personal needs and balanced life-style more and more dominant Decreased funding sources • Educate/train next generation of MDs, researchers, RNs/health care workers and faculty • Explore, increase and disseminate knowledge of disciplines that relate to medicine/health using basic, clinical, translational, quality improvmt research. • Obtain funding for research/education • Provide highest level of clinical care and disseminate successes/failures so that continuous improvement can occur • Support faculty/trainees for success • Interface with community/governmental agencies to provide expertise to help promote population health

32. SECULAR How do I care for individual patients? How do I teach/mentor trainees in medical knowledge, patient care, academic pursuits? ACADEMIC How do I interact and meet the responsibilities of an academic system? How do I interact with the health care system? How do I maintain my integrity and avoid burn-out? ENVIRONMENT

33. Attributes of a Christian Physician • Strong Faith(based on knowledge/fact) • Solid Hope(redemption/eternal life/glory) • Self-Sacrificial Love(for God and for man, act like Jesus) • Compassion/Mercy • Honor/Respect • Honesty/Truthfulness • Knowledgeable/Skilled in Medicine/Holistic • Sacrifice/Commitment (patient centered)

34. ChristianAcademicPhysicianWays to Impact • Integrationshare ideas, common ground, not isolated, in the world but not of the world, participation • Demonstrationdemeanor, clinical care, actions • Educationformal education/mentoring/modeling/ethics • Explorationexploration of God’s creation, discover new knowledge, new ways of doing things, new opportunities • Publication disseminate knowledge and experience for the benefit of others/further knowledge • Preservationwellness (self and family), health both physical, mental and spiritual, balance

35. “I am the Way, the Truth and the Life”John 14:6 • Know, Speak and Attest to the truth • Behave/Act in accordance with the truth “Walk as Jesus did” • “Guard your heart”; continue to grow in the truth

36. Speaking the Truth Know the truth and seek to increase it! A Christian academic physician must be very well informed (1) to engage properly the ideas of non-Christian academics and (2) to help patients/people in their struggles • Personal Scripture study/Church Services/Sermons • Books/Journals/Internet - Biblical perspective on all of life: bioethics, government, arts, philosophy, education, life/death issues, science, history, technologic advances, culture, social issues • Courses/Study groups with other Christians

37. Goal: Increase Understanding about Christianity • Christianity is a faith that is based on witnessed/observed and well recorded facts, NOT an unfounded “leap of faith”, or a subjective feeling • Christianity is about a relationship with God/Christ; the implications of that are reflected in our actions • Christianity is NOT anti-intellectual but seeks to understand and interact with all knowledge, ideas, philosophies, taking its legitimate place in the marketplace of ideas

38. Goal: Increase Understanding about Christianity • Christianity is NOT a mere list of moralistic decisions, but a view of our entire world driven by our understanding of God. • Christianity is NOT a privatized belief, only valid for that person, but true for all individuals • Christian physicians are especially suited and called to be involved with all dimensions of the patient – bio-psycho-socio-spiritual to provide the best care

39. Speaking the Truth Look for opportunities to engage and speak it • With patients in the role of physician • Spiritual history • Listen carefully for indications of spiritual state • Crisis intervention if patient open to this • Always speak truth about the patient’s condition and care required, including spiritual care • Pastoral Services Interface (carefully) • Clinical Pastoral Education (CPE) • Collaboration surrounding specific patients • Ethics Courses/Ethics Committees • Resident/Med Student Education/Case Conferences • Discussions of policy/procedures with ethical aspects

40. Speaking the Truth Speak it and do not be afraid • “Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you. But do this with gentleness and respect…(1 Peter 3:15) • Good and continual preparation is essential since the academic environment thrives especially on discourse abilities, facts, data and a bias towards anti-Christian thought • “Whatever happens conduct yourselves in a manner worthy of the gospel of Christ…..contending as one man for the faith of the gospel without being frightened in any way by those who oppose you” (Phil 1:27) • A Christian’s opinion is just as valid as anyone else’s

41. Behave in Accordance with the Truth James 2:17 “In the same way, faith by itself, if it is not accompanied by action, is dead.” Phil 4:5 “Let your gentleness be evident to all” Eph 4:29 “Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs.” Gal 6:9 “Let us not become weary in doing good for at the proper time we will reap a harvest if we do not give up. Therefore, as we have opportunity, let us do good to all people, especially to those who belong to the family of believers.” Gal 5:22 “The fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness , gentleness and self- control” Col 3:24 “Whatever you do, work at it with all your heart, as working for the Lord, not for men, since you know that you will receive an inheritance from the Lord as a reward. It is the Lord Christ you are serving.

42. Godly Behavior • Godly communication: no unwholesome speech; use gentle, clear speech and only that which builds up others, both patients and those around you • Compassion for those who are learning • Patience with student/resident presentations (e.g) • Adult learning methods (e.g. open ended questions, self-learning) • Compassion when errors get made, give support • Support jr faculty as they strive to move upwards academically

43. Godly Behavior • Provide holistic, compassionate clinical care with expertise, gentleness,, kindness, patience always putting patientsand their families before your own needs. • Seek to do good and improve the system of care, or system for research, or system of education so that good would be promoted • Seek to remove those things that are unjust, that do not promote God’s definition of good, and that do not demonstrate love for people • As a leader, seek to improveyour area rather than maintain your area

44. Guard your heart; Continue to grow in the truth • “Above all else, guard your heart for it is the wellspring of life.” Proverbs 4:23 • “But grow in the grace and knowledge of our Lord and Savior Jesus Christ.” 2 Peter 3:17 • Personal, daily devotions/time for God • Keep informed re: the world and a Biblical response to it • Use support from spouse/family • Lead your family/spouse spiritually (blessings in return) • Strong and consistent involvement with other believers • Church attendance (Heb 10:25) • Small groups • Keeping the Lord’s Day (one day in seven)

45. The Lord’s Day (4th commandment) • God’s way to give you rest from your physician and daily labors • allows opportunity for personal devotions, prayer, worship with other believers, fellowship, Biblical meditation, increasing knowledge, enjoying creation • Physical rest; mental rest; • Prevent medicine from becoming an all-consuming idol • Takes discipline – start early and be strict about it • Rest does not mean idleness/laziness or a day of simply leisure. It is meant to be refreshed by God’s grace using the tools he has given us

46. PERSONAL EXAMPLES

47. Education/Mentoring (examples) • Praying with residents • Teaching ethics to medical Students • Mentoring medical students • Showing hospitality • Open door for stressed students, residents, and young faculty

48. Patient Care (cases) • Listening to Patients for opportunities to interact around their faith • Praying with patients (life/death/trials) • Handling conflicts re: ptcare (sanctity of life) • Partnership with pastoral services • Responding to patient/family concerns

49. Integration (examples) • Professional Advisory Committee (CPE Program) (CPE Training Program) • Clinical Ethics Conferences (URMC) • Joint Committee on the Quality of Care (Brain Death Policies)

50. Administration/Leadership (examples) • Not serving on national committees that consistently require meetings on the Lord’s Day • Not serving on organizations that have develop policies not consistent with Biblical/Christian principles • Serving on organizations that are based on Biblical/Christian world-life view (ACPeds, CMDA)