Abstract
A
Early in the morning, I found my way through the bowels of the hospital—down a long, unfamiliar hallway with many twists and turns, weaving my way past service entrances and storage rooms, past staff rolling clattering carts, and nurses rushing to their posts upstairs—to meet Tom in his office, a windowless room at the end of a windowless corridor. Tom was an unassuming man, middle-aged, reddish-brown hair thinning on his crown, thicker on his chin. He had broad shoulders and thick, capable hands, the kind of man who looked like he'd be equally at home making furniture or reading Bonhoeffer. There were books on the shelves, CDs on the table, and a guitar in the corner. He rose quickly to greet me.
“Welcome, come on in.” His voice was soft, his mannerisms gentle. “Please, have a seat. I hope you found my office okay.”
I sat down in a chair with orange vinyl upholstery, circa 1970s. I expressed my hope, as a palliative care fellow, of gaining insight into the spiritual side of healthcare, and Tom shared a bit of his story. After years of service as an army chaplain, he did some additional training and became a hospital chaplain. He had been doing this for several years and felt that he was in the right place. He was also a grandfather, occasional preacher in his church, and a musician. After 10 minutes or so of conversation, he stood up.
“Well, I think we can get started. I have four patients on the Palliative team I'd like to see this morning.” From his rear pocket, he pulled out a short stack of crisp index cards. “Why don't we start in the ICU? I need to follow up on someone there first. You can leave your white coat here, if you'd like.”
I shed my vocational robe and followed on his terms. He led the way out of the office, walking with his square shoulders hunched slightly forward, like a deferential linebacker. We made our way through the morning bustle, went up four floors on the elevator, and found ourselves at the ICU, visiting a man I'll call “James.”
James was in his 60s, with unkempt gray hair framing gaunt cheeks, and he was suffering from an aggressive lymphoma. As soon as he saw Tom, his wild eyes found their home. In one fluid motion, Tom met his gaze, moved to the bedside, and took his hand.
With little preface, James poured out his heart: “Chaplain, I am afraid to die, I am afraid. I do believe and trust that God is good, and yet I am afraid.” Coming from such a frail, debilitated frame, his voice was surprisingly stentorian and formal.
“Afraid of the unknown?” asked Tom gently.
“Yes, it is the unknown.”
“Yes, James, we're all afraid of the unknown. But we know that God will provide. He will meet you on the other side with open arms.”
“I do know this, in my very heart of hearts, and yet I am afraid. I have lived a hard life, and done things I am not proud of.” James went on, sharing stories with the urgency of a prophet: stories of the war, of leaving men behind; stories of his family, of leaving loved ones behind.
I deposited myself in the corner, relieved to be on the sidelines, and studied Tom closely. He stood at the bedside and held James' hand, nodding and periodically breathing in deeply, as if sighing in reverse. I waited for him to speak the platitudes that sat on the tip of my tongue, for the sermonizing, the words of comfort. But for what seemed like dozens of minutes, Tom held his tongue, held James' gaze, and held the space.
By holding the space—and not filling it with words—he allowed one man to pour out his very soul to another.
“Yes, I have sinned,” James uttered, face etched with angst, “and I do not know how I will be received. I am afraid, I am afraid.”
Just when the pain felt almost unbearable, when the man seemed to be lost in his suffering, Tom broke his silence. In a quietly urgent voice, he began to speak.
“James, Jesus will take one look at you and say, ‘These sins—they are erased.’ Remember in Psalm 103, it says: ‘As far as the east is from the west, so far has he removed our transgressions from us.’ ” Tom followed with more Scripture from memory, interspersed with brief comments of his own, seemingly hand tailored for James. This was chaplaincy as art form. For a precious moment, James was quiet, his eyes were closed, the tension in his brow relaxed.
Then the doctors arrived.
The team—senior resident, two interns, and two medical students—entered, carrying with it the hustle of morning rounds. They wore crisp white coats and rumpled blue scrubs and moved, with authority, toward the bedside. Quickly and discreetly, Tom gave way and faded to the corner. Clipboard in hand, seasoned look on her young face, one intern assumed the lead.
She smiled. “Good morning, James. How are you? Is your breathing feeling any better?”
James said no. His brow was furrowed again, turbulence in his eyes.
“Are you having any pain? How about nausea?” The intern asked a few more checklist questions, then reviewed recent laboratory work and the plan for the day, which included rechecking a chest X-ray. She was professional, competent, businesslike.
And everything she said, in light of what had just transpired in the room moments ago, was ultimately irrelevant.
She finished her piece, then asked whether James had any questions. He shook his head, mouth clamped down. Then, just as quickly as they had come, the team exited en masse.
I was stunned. A most significant, profound conversation had been interrupted by one that was absolutely peripheral to what the patient most cared about. And it was the interaction with the chaplain, not the doctor, which was central.
Of course, I've stood on the other side. All too often I live and work on the other side. The intern was doing her job, at least as it had been taught to her. She was managing abnormal laboratory values, working through the problem list, and explaining her plan to the patient. I saw myself in her, organized, and oh-so-efficient. And I recognized that, in the face of a man who knew he was dying and was wrestling with his mortality, this approach completely missed the boat.
I looked at Tom. He was back at the bedside, holding James' hand and praying in a flowing cadence, James' eyes closed and head nodding in rhythm, as if the words were a river bearing him on its current. I saw the chaplain in a different light, saw how he—not the doctors—had positioned himself to help the man at the very crux of his suffering. He was in the right place. And the clearer the light, the sharper the shadow. For the first time, I recognized that for many patients, we doctors, whether we perceive it or not, live in the chaplain's shadow.
The experience also forced into the light the hierarchy I have internalized. It is a hierarchy never explicitly taught, yet one communicated and reinforced through everyday interactions from training to practice. This “hidden curriculum” taught me that there is a pecking order in the hospital, where doctors sit in the upper echelon, above nurses and orderlies, janitors, and technicians. How many times have I barged into a patient's room, regardless of whether a social worker or chaplain might be there, and hijacked the conversation as if it were my God-given right? I like to believe that I embrace the concept of “patient-centered care.” But how can my patients and their values be paramount unless I get my ego out of the way?
I came away with a new perspective of the hospital and my role in it. As a doctor, I have much to learn from my interdisciplinary colleagues. The better I understand and appreciate their roles and skills, the better we can function together as a team, with the patient—not the doctor—at the center. A little time shadowing can go a long way. From Tom and James, I gained insight into the importance of spiritual conversations and compassionate presence. I am learning how to hold my tongue and hold the space, both with my patients and my colleagues. Refrain from interrupting the patient and, by all means, think twice before interrupting the chaplain.
Footnotes
Acknowledgment
The author thanks Chaplain Thomas C. Hartmann, MDiv, BCC (retired).