With the theme “Compliance and Resistance” the Orthodox Christian Association of Medicine, Psychology, and Religion conference was held November 8-10, 2018 at the Ukrainian Orthodox Church Cultural Center in Somerset NJ. OCAMPR exists to facilitate Orthodox Christian fellowship, dialogue and education of professionals in religion, psychology and medicine.
These talks were recorded by Ancient Faith Radio in partnership with OCAMPR and are made available here for free access and download. Several talks were video recorded while others provide a combination of audio and slides.
OCAMPR welcomes interdisciplinary dialogue and is committed to exploring an Orthodox Christian understanding and perspective on a variety of pastoral issues. Toward that end, presentations and papers are offered for ongoing discussion and dialogue. The opinions of presenters do not necessarily reflect the opinions of the OCAMPR organization, Ancient Faith Ministries, or of the Orthodox Church.
Reflection on the Well-being of Caregivers and Patients and Sustaining the Healing Partnership Under the Increasing Demands of Corporate Interests
Dn. Stephen Muse, PhD, LMFT, CCMHC, Director of Education and Training and Clergy-in-Kairos Program, Pastoral Institute Columbus, GA.
December 13, 2018 Length: 1:05:49
Dr. Halina Woroncow: It’s my honor to be able to present an old OCAMPR friend, Rev. Dn. Stephen Muse, who’s a director of education and training in the Clergy-in-Kairos program at the Pastoral Institute in Columbus, Georgia. He’s board-certified in traumatic stress and has extensive experience working with combat veterans, clergy, chaplains, therapists, and physicians in trauma, stress, and wellness issues. Fr. Dn. Stephen is the author of a number of books and professional papers in this area. He’s past president of OCAMPR and currently serves on our advisory board. His topic today is “Whatever Happened to Sts. Cosmas and Damian?: A Reflection on the Well-being of Caregivers and Servants and Sustaining the Healing Partnership Under the Increasing Demands of Corporate Interests.” Father Deacon? [Applause]
Rev. Dr. Dn. Stephen Muse: Okay. Thank you, Halina. Halina gave a terrific introduction to what I was talking about, and we were already into what I think will be some of the discussion about it.
At this point in the conference the last couple of years, I’ve always been very grateful, and I am this time, for the cross-currents of so many of the speakers, which sync up from different directions, but lift up for us the spirit and the way of our faith. What I want to do here is… I was invited by our local county physicians’ group to present on physician stress. So I ended up writing a paper on this. What I’m doing is I want to give you some data from the research and then move into some elaboration of some of the theological themes that we’ve talked about in the last couple of days.
How many here are physicians? Let me just see how many we have in here. And how about clergy? Therapists? And medical personnel of other kinds? Okay, all right. So at our place, at our not-for-profit agency, as corporate interests have grown and we’ve had more and more management of managed care, our cost-per-hour of delivering services has gone up, and our remuneration has gone down. So we make less per hour 20 years later than we did before, and we have to work more to make that up, and we raised 35% of our entire budget in order to fund what we’re doing. So basically we’re funding the Blue Cross and Sigma with philanthropic dollars, and they’re raising the rates on the individual and lowering reimbursement rates and creating situations where physicians, in order to survive, charge an additional fee for concierge medicine. I’m thankful for them that they do that—that gives them a different life—but it becomes a real issue of lots of squeezing. So this is what we’re looking at.
I’d like to ask how many have experienced that electronic health records have increased your vocational satisfaction? [Laughter] No hands. I want you to all realize that. How many believe that electronic records experience have increased your quality of care for your patient? Still no hands; I’m not doing very well—one. Okay. For how many of you has it increased patient contact and rapport? And electronic health records has done this? [Yes.] Ooh, I want to hear about this. I think that’s an outlier, because that’s one out of a whole lot in here. All right. How about: Has it decreased the cost of medical care? Getting the new records is costly. How about decreasing the chances of a lawsuit? Hm-hm. And what about—we’ll talk about burnout and medical error.
Look at this. In the studies, the EHR itself is shown statistically to itself be a stress. Now, I thought Halina might actually touch this, because one of the things I like so much about what she said was, with all the data that we can get, that’s on that EHR record, if we don’t know the story and we don’t hear the uniqueness of the person, of the patient, all of that can be misapplied and misdirected, especially when you can only ask one, only have one problem per visit, and you have a certain amount of time that you’re limited to. So some people, it’s 12 minutes, and they’re… My eye surgeon—I had surgery this year—he was seeing 45 to 50 people a day, and I was just trying to say, “How can you do this?” and we ended up talking about this.
Well, how long do you think it takes for a physician to interrupt their patient when they ask him, “What are you here for?” How much? Five seconds; any others? Fifteen seconds! Well, there is a little bit of a range, but 67%, the physicians interrupted after 11 seconds. [Laughter] So we have 11 seconds to say what we think might be happening with us. The physician is the expert on certain things, but expertise without the story, without some of… especially, you know, this gets incredibly complicated when you have a 75-, 80-year-old person who’s got seven doctors and comes in with a bag of medicine. I say, “Are you telling…? Do your physicians know that you’re taking all this, regularly reviewing it?” And they, oh my gosh, what a mess that is.
This was a 1999 report on deaths from medical error, so it was 98,000. This was for medical residents. You can see how extensive this was, but overall… 98,000 that year, 1999. Now the number has tripled, and this is 20 years later, so this is a conservative estimate: 200,000 to 300,000 deaths annually. So 700 people a day, and that would make medical error the third leading cause of death in the U.S. Steve Swensen at the Mayo Clinic—do you know Steve? no—he says something important here. Most of those have a second victim, and it’s the nurses, doctors, social workers, managers, and pharmacists that are involved in their care. One of the issues is between the changes in healthcare that are turning physicians and now therapists into production units, with the increased stress as medical error goes up, personal issues increase, and so the suicide rate is huge.
Look at this now. After serious medical error. This is a 2017 medical survey. 66[%] of the physicians were concerned about, naturally, another error. Half of them lost confidence, half of them had sleeping difficulties, half had reduced job satisfaction. 80% expressed an interest in counseling, but look at this other number: 10% said that they received adequate support from their organizations in coping with it. So we have a systemic issue of not getting support, but we also have the medical culture that doesn’t want to admit a problem because of all sorts of potential complications that come from that, from stigma to licensing.
This was 1984 to 2001, of burnout among practicing physicians. This is a psychological test from Maslach. You need three categories to qualify in burnout: emotional exhaustion, which then leads to not having the emotional buoyancy to actually be with people, and that’s de-personalization. You’re just starting; you go from waking up, glad to be alive, wanting to be with people, to suddenly having to do more than you can do at your emotional level, so you can say you can begin to manage stuff out of your mind and your will.
You can force your body to go for a while, but at that point you’re already… that’s symptomatic, and it has implications in terms of our Orthodox faith, because in terms of spiritual warfare and watchfulness and prayer, what I’m beginning to do is to leave reality behind and I’m going into functional atheism, in which I am participating in a world that’s not in my natural rhythm. I’m stretching into something that is humanistic and my own will and mental power rather than an organic relationship with the world around me.
One of the stresses of the healthcare system and our particular economic industry right now is that it’s constantly forcing this. It’s tempting us, it’s testing us to do this, because we can do it for a while. But if you keep doing that, the de-personalization, then you’re just managing people and you’re not there for them. The patient and the nurses and the people that work with you feel that.
Then if you keep going—this is just physical stress at this point, so you start getting some symptoms from that, which I’ll look at in just a second—if you keep pushing yourself past that, then it starts to go toward the soul and now, inwardly, distortions of the self begin to where “maybe I chose the wrong profession; maybe I ought to leave medicine; I shouldn’t be a priest.” This is a delusional state. This is a state of altered consciousness in which we don’t have an accurate read on reality or ourselves, and that’s harder to heal when you get to that point, to get out of this if you catch it at the physical stress level.
So you could have emotional exhaustion and de-personalization and still have a very good sense of personal accomplishment, so at that point you’re not in burnout, but you’re symptomatic of something that needs attention. If you were—we don’t want to be our own doctor at one level, but we have to in another level—I need to analyze myself and see: Am I doing something that… That’s like my blood pressure. When I’m depersonalizing people and I’m operating out of my will and my body strength, I’m starting to show symptoms.
That was 1984-2001. So JCAHO said all hospitals must have a process to address physician well-being. That was in 2001, so the data got attention. So what happened? 17 years later, we’re at least as bad or worse than back then. These are the three main areas that have the highest burnout: critical care, neurology, and family medicine. One group in California invited me out for consultation because they had so much stress in the ER units that the physicians were screaming at each other and blowing up. I remember I had them doing a lot of things, even, if you can believe, sitting on the floor with balloons and papers, building a bridge together with their team; they finally got to do that—to see what they were doing; how did they manage stuff.
Well, one person stood up and said, “This is a bunch of B.S.” He said, “What we do is life and death, and if somebody doesn’t move immediately to what I’m asking, there’s no excuse for it.” After I ask him if a couple of things went wrong in your life, does this give you the right to go home and be abusive to your wife. He said, “Mm. No.” So then he got on board. So this group, after two and a half days of consultation, got their group practice together and decided to put 10% of their profits in a sort of escrow fund and make sure every one of them got a three-month sabbatical on a regular basis. If you didn’t use it, you lost it. That was, to me, a group of people that originally objected, then soaked it in, made a rational decision and made an active change in their practice to address it.
These three have the most difficult conditions in some ways. In 2017, the National Academy of Medicine decided that the issue is systemic. So they looked at cumbersome IT systems, excessive work hours and workloads, and then organizational culture that began to go into dysfunction from that. The more top-down control there is and the less control you have over your schedule, we know psychologically this is a problem. The top monkey has less stress than all the ones underneath who have to be… have no say. And then the loss of meaning, which is a part of that burnout.
Now this is a shift from 25 years ago, when they were looking at the person of the physician. What is it psychologically about physicians that might contribute to the stress? So then they started looking at systemic issues.
Just so we know in terms of stress and burnout, let’s just review these symptoms real quick. Stress, and what became labeled as compassion fatigue, is physical. So what do you see? You’ve got someone who’s working more than they should, out of balance, so their energy goes down. There’s fatigue, sense of the tyranny of the urgent going in 60 million directions, loss of vitality. We each have our own way of experiencing this. If I get too much in my mind—if I have too many patients, and I’ve got books started and different things in the back of my mind—my image is, if it gets up to about here I start to get anxiety, because I begin to think, “I can’t do this.”
This is disturbing my state, and then there’s a certain terrain that appears to me that will be temptations and tests for me if I fail to address this in a realistic way, because what will happen is there’ll be some form of avoiding reality. There’ll be a slight dissociative mechanism. It could be as simple as eating ice cream and watching movies, but it can get worse. It can be addictions, it can be compulsive things, it can be marital problems, but you can’t stay in a condition in which you’re overloaded without either going toward a change that will bring you into organic relationship with yourself and the world, or you will avoid reality. Those are the only two possibilities that there are.
If that isn’t addressed, if I fail to take my temperature and also fail to get connection with someone to give me some feedback, from consultants to peer supervision to… The doctors in one study, they don’t eat lunch any more. So they were saying, “You have to have a mandatory coffee break.” Well, why would you have a mandatory coffee break? So that you could sit for a moment and not have to be the doctor, and you could get your colleagues to have a moment of solidarity. Can you imagine that? That was the best they came up with to get to help with this, to have a mandatory coffee break while you continue to overwork.
If that’s not ignored, then the burnout, you can see what that does: it goes deeper into us. It goes into the internal sense of self. Here you can be driven to hopelessness, which I think of as spiritual grief. So much of what we have undiagnosed, not just in medicine, but all around, is spiritual pain. I would say, in one sense, that spiritual pain is related to what several of our speakers have said, but what Renos was talking about yesterday. Spiritual pain is, at one level, the failure or the inability to move from a human-centered functional atheism to faith in God at the level of a deep surrender and acceptance.
If you took what Renos said last night in a simplistic way, it could be like the army that tells people, “Suck it up and get over it. Just bear it. Bear it in the kidneys.” Or it could be like the woman who came to me and said, “I had to come talk to somebody, because there’s signs up at my church everywhere that says, ‘God is the mind regulator, and if you faith you have no problems. You should overcome anything.’ ” That is a misunderstanding of the deep sense of facing reality with the helplessness that we have to manage it and change it, which opens the door to God’s help in a way that is vitally necessary to us, which is where I’m headed.
I like to show this. Some of you have seen it before. 24 hours without sleep is the equivalent of legally drunk. It’s 0.1 alcohol level. Traffic deaths come from this all the time, but think about medical error and this and what happens. Here’s one study the army did, and this looks at the deterioration of mental and physical capacities when you don’t sleep. If you’re firing artillery, at the end of 20 days, the group that got seven hours of sleep had 98% peak efficiency. That’s pretty good, seven hours. Now look what happens when you get six. You lose one hour for 20 days: you’re at 50% efficiency in that. At five hours of sleep for three weeks, 28% peak efficiency. And group four that only got four hours of sleep, they had 15%. So the deterioration, these were like… so they’re drunks who can’t move their body and can’t operate their mind at the way that you would need to in order to… Now that’s artillery.
If you’re managing a scalpel or making decisions medically and you’re getting past the point where you can do that and you’re not sleeping and you’re starting to drink a couple more glasses of wine or whatever it is that you’re doing, then this thing is going to move toward something dangerous.
300-400 physicians suicide annually, and the rates for the male physicians are 70% higher than the norm, and for the female 250-400% when you compare to the general population, so this is a huge issue. Suicide is usually associated with severe depression, anxiety, and cognitive narrowing to a myopic hopelessness regarding options, so it’s a distortion of the mind: “I have no other possibilities.”
If you look at the interpersonal theory of suicide, three factors show up. Belongingness is lost: a person is feeling isolated. There’s a perceived sense of being a burden to the people around them. People will say, “They’ll be better off with my insurance. I can help my family by dying.” So I don’t belong, I’m a burden, and I have the capability of doing it—when those three are in the ascendant and you’re in an altered state of consciousness, it’s very dangerous.
I wonder… I’d like to know, just for a minute—how much time do we have, Halina? Are we doing okay? [We’re doing okay.] I’d like to get a couple of thoughts on this, what you think about, first of all, the gap between the male and the female physicians’ suicide incident rate here, and then what’s your reaction to this is, because that’s a doctor a day. Yes?
Q1: Women access mental health services more frequently than men
Dn. Stephen: The ones who access mental health services.
Q1: Women access mental health services much more frequently than men.
Dn. Stephen: You know, that might be true, but I don’t think what I’m aware of in the research bears that out, because the stigma of that may… It shows that many of the women who had a diagnosis hid that from the licensing board and from each other, because they had to work harder, in a sense, within that sort of male environment. There were a lot of issues there, so I don’t know if that holds up. Yes?
Q2: Perhaps it is due to women’s natural tendency toward nurturing; when they have failure, they take it more personally?
Dn. Stephen: That’s a very interesting thought. Women in their nurturing capacities would be thwarted more in the system the way it is now. So that would be a deep spiritual pain, to be out of phase with your deepest capacities for nurturance in your vocation and possibly in your personal life, not able to go to get help, and then possibly self-prescribing. So isolation is huge. Yes, Father?
Q3: We know that in general, males present more externalizing than females, who tend to present internalized.
Dn. Stephen: How would you see…? So the internalization of the female is connected to suicide; what are you thinking of?
Q3: This is a rationale. It is a movement towards the world, towards… that makes manifest the disturbed.
Dn. Stephen: So you’re suggesting the man might…
Q3: Maybe the female equivalent is more psychosomatic or…
Dn. Stephen: Okay.
Q4: Women in general, across all professions, have to work harder than men for recognition, for equal pay, for respect.
Dn. Stephen: Yes, so there’s something we call in family therapy “intersectionality,” where privilege and power cross and exponentiate the pressure that a person is dealing with. I think you’re pointing this out.
Q5: Women are often also moms, too, and have not just a professional career but also at home.
Dn. Stephen: Yes, and I think that the deep pain that a mother carries for not nurturing her children because of the conflict of giving herself to her vocation is a spiritual pain. This needs attention in order to help deal with it, and it may well be an attention like what Renos was inviting us to. But this is a deep, full askesis that’s in a faith context, because there isn’t really yet any kind of systemic solution to that.
One more I think was in the back. Did someone have a hand up? No. All right. Let me see.
One Christine Moutier did a study. There was a university medical system, and they were having a lot of suicides in it, in the professors; I think they had 11 or so over 15 years. So what she did was they instituted an anonymous way that the physicians could do a survey and begin to talk about what was going on with them and possibly to be connected to someone to talk about it. After she did this, the next 11 years there was only one suicide, so it made a huge difference to be able to speak, because what she found out was they weren’t talking about this. They didn’t have a way to deal with it. Again, we’re talking about isolation.
Douglas Graham suggests five areas, the top five physician soul-killers, and I think each of these can be an aspect of spiritual pain.
Another thing that Dr. Christine Moutier reported in a psychological autopsy of the suicides was that physicians who die from suicide were 20-40 times more likely than the general population to have taken benzodiazepines, barbiturates, or anti-psychotics prior to their death, and they were three times more likely to have been experiencing problems at work. Often those were self-prescribed. So they weren’t… Again, you’re not in care with a person giving you a read on what you’re doing.
This is an interesting study, and this was all the medical residency training programs in the United States. It was 1998, so I hope things are much better, but look at this: 86% of the respondents, medical students, reported being humiliated at least once during their year of internships; 53% shamed three times or more, 38% were slapped, pushed, kicked, or hit. 30% reported being sexually harassed, 31% had their reputations or careers threatened, and 25% reported racial or ethnic discrimination. When I see these statistics, one thing I think of is how family generational systems pass down what happened to them to their children. So if you came through a system that was top-down hierarchical, “you do what I say”… One psychiatrist told me, “We don’t branch out past what we were taught, because the way we were taught is: The person that taught us knows what they’re doing, and we follow it.” So it’s very hard to go past what you’ve been taught, because the system didn’t really… its ethos didn’t support that.
So if you have a system that’s shaming the people that are becoming doctors and the ones who will teach the doctors, then it’s easy to pass this on.
I carry a little pain in my heart from when my grandfather was getting really sick in his 90s. I was on the medical staff of our local hospital as a psychotherapist. He was there with some congestion and some other problems. He had been in and out of the hospital, and he had a stroke, and he was worn out. I had to take him to the ER, and I heard the doctor screaming at the nurse in the background, and when he came out, he was very brusque and ordering about, and he wasn’t taking the time to see if my grandfather, what was really going on with him. He was going to put him in there and wear him out with a bunch of more tests and things. So I said to him, “I’m not going to let you take care of him.” I said, “I’m on the medical staff here, and I’ve heard how you treated that nurse, and you’re not going to do that to him.” And I wheeled him out.
I still think about that one, but the system… We reproduce with one another our internal state. So don’t think that you can practice good medicine, or psychotherapy or anything else, when you transmit the disease of your own fragmentation and irritation to the others.
Peter Moscowitz suggests it’s the John Wayne school of medicine: Because we’re trained to solve problems ourselves, we unconsciously believe it’s a sign of weakness to ask for help. In my experience, most physicians don’t like to talk about their feelings. So this is partly an enculturation, but it’s also a selection process. I remember Jay Haley, one of the founders of family therapy, talking at York Hospital to the physicians. He was talking about how, in those days—this was back in the ‘80s—they were systematically weeding out people with empathy in the medical schools by only selecting the brightest who didn’t do anything in their life but study. So what you were getting were a whole crop of people who weren’t as empathic.
In my research and in my doctoral studies, I was looking at the capacity for clinical empathy for therapists and their religious integration. I didn’t have enough subjects, so I ended up getting the business school graduate school students in there, and I found an interesting little detail. The business graduate students were a full standard deviation below the psychologists and the pastoral counselors in the capacity for clinical empathy. I wonder about that in terms of some of the other areas.
But that was some time back, and so the medical schools began to look for people who were more well-rounded. I know that that was something, and part of that comes from the research that I want to share with you. Let me share this: In a survey of 2100 female physicians, one-third reported receiving a formal mental health diagnosis since they were in medical school, but only six percent disclosed this to the state licensing boards. Most tried to manage their problems on their own, including writing their own prescriptions rather than seeking professional support or consultation. So there’s that isolation that I think helps us explain why there were so many more suicides.
What simple little things can be done? because we hope for the deep transformation of an ongoing spiritual life like we were talking about, but there are some things. One thing is that we know that now for every 30 minutes of focused attention, the brain needs five minutes of unfocused attention. One whole area of psychology that’s arisen is what’s called the psychology of restorative environments. You can have a focused attention, which is required to work, and if you’re in emergency mode using your will and your body, that focused attention is what you’re drawing on, so you have a tautness that’s not relaxing—and this is exhausting.
Being able to find a way to let go of that, even for a couple of minutes, is important. I will walk outside—now we have to write in those records, so I don’t have as much time between patients—but I’ll walk outside through our prayer garden—it might only take me three minutes—crunch a couple of acorns, smell the air, realize that the birds and the ants don’t follow man-made laws and they’re actually free right in the midst of the world I live in that I forget that all the time. And that helps me.
So sometimes I do crazy stuff. One time my patient came in, and I picked a leaf up off the ground and I said to her, very seriously, “All right. Your task is to put this back on the tree.” And our session was about that. If you looked at this at the standpoint of trying to give this a conceptualization, I would say: what we’re doing is making a play space. It’s a restorative environment in which a person can come in and be out of that tension that they’re in, and they can have the very thing that Winnicott realized was needed between the mother and the child. If you have this and can play, if you are free enough to trust yourself and the place you are and the person you’re with to play, you can do all kinds of things.
It’s very interesting from psychotherapy research that theory isn’t significant, and medicine, explanation, from a psychotherapy standpoint, account for one percent of the change. What’s happening? Well, we’re in another arena, and I think medicine can benefit from this, because if the physician is alive in a way with you—not that he’s going to play with you in an obvious way, with Silly Putty, but in a way that isn’t just business and it isn’t just a manufactured “Well, how are you today?” like they say at the grocery store: “Did you find everything that you want?” because they have to go by that script. If you’re not going by that script and it’s real, you’re inviting restorative environment right there, just by the fact that you show up. But in order to show up and practice medicine, you have to be showing up in your life, and that’s back to what Fr. Sean mentioned: the “night work,” as the monks call it. The night work.
Here’s an interesting detail.
Nobel laureates in science are often polymaths: 22 times more likely to perform as actors, dancers, or magicians; 12 times more likely to write poetry, plays or novels; seven times more likely to dabble in arts and crafts; and twice as likely to play an instrument or compose music.
They’re not Johnny One-Note. These are very… These people know how to play. Einstein would play the piano or his violin when he got stuck. I think his sister or someone said, “He’d be playing, and all of a sudden: I’ve got it!” and then he’d go right back to his work, but he had to switch. And he said he discovered things through the intuition that arose while he was involved in the act of music and listening. That’s different parts of the brain as well.
We look at that and we say: Okay, humanities: empathy and resilience. Among the medical students, regression analysis showed that when they were exposed to humanities—literature, music, art—it was a significant correlation—that’s not causal, but a correlation—with a whole lot of factors that are seen as part of resilience. One of them that I’m lifting out here is that exposure to humanities predicted significant decreases in physical fatigue—think back to what we were saying about stress—emotional exhaustion, and cognitive weariness.
Increased empathy correlates with higher clinical satisfaction and less burnout, increased medical effectiveness and overall communication between doctors and patients, more accurate diagnoses, increased treatment adherence—there’s a new term instead of compliance, yes—improved patient outcomes, and a clear emotional communication originating from a physician’s sincere empathic goal to care for the patient builds the trust.
“The personal bond”—here’s a quote from Dr. Peabody in Harvard, 1906. Did you study him? [Inaudible] Good. All right.
The personal bond [with the patient] forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
If we put that in a larger context, this is what Martin Buber, Levinas, Metropolitan Zizioulas, drawing on the encounter with the other, is getting at. In a sense, our brother is our life. We are brought into being through communion, so it is the act of responding to the other that’s essential to the formation, development, and healing of our being.
The Third General Council of Constantinople affirmed that Christ had two wills. As Dr. Theodoropoulos spoke about in her talk, compliance with the natural will of Christ to the Father is: Christ only does what he sees the Father doing. You can think about St. Silouan’s response to Fr. Stratonicos, about how do the perfect speak and what is perfect obedience. Remember what he said, anybody? This is a test. [Laughter]
A1: Only when God speaks to you.
Dn. Stephen: Yes. The perfect say only what the Holy Spirit tells them to say. Imagine that—compliance, out of joyful humility and being in harmony.
The human will is compliant—his human will, Christ’s human will—it does not resist or oppose, but rather submits to the divine and almighty will. It was necessary that the will of the flesh move itself, but also that it be submitted to the divine will.
So here is both the potential problem for us, and to the fall and the destruction of our being, as well as the gateway to the potential transformation and healing of us, which at the deepest level may be the real solution to the situation, because we will never be in a politically perfect or economically perfect environment. From the beginning to the end of time, alpha to omega, there will be the poor among us, and there will be wars and rumors of wars. There is no solution to the human dilemma that comes politically or economically, so that Christ frees us, whether we are in the gulag, like Fr. Roman Braga or Fr. Arseny; he can free us while we die of cancer, as a beautiful story… How many of you have heard of Elder Zacharias’ story of the woman who approached him in Stage 4 cancer, no more treatment; she had six months to live? And she said, “Will you visit me?” How many of you know this story?
Okay, this is an addendum to Renos’ comment. This is on the personal level rather than on the trauma of refugees. Her personal… Okay, the event was cancer, but the effect was not traumatic for her. Here’s what happened. Fr. Zacharias said, “Yes, I will come, if you will say, ‘Glory to God,’ for the rest of your time, all day long. ‘Glory to God.’ ” So when he went to see her, he said she was a stick. There was nothing left of her except her face, and she was crying. And he thought, “Oh!” And she noticed this; she said, “Father, no, no. My tears are because I don’t feel worthy of the grace of having this cancer.” Think of the transformation that that tells us.
Later, Fr. Simeon, one of the other monks at Essex, was in the church with Fr. Zacharias, and he was crying—Fr. Zacharias was crying. Fr. Simeon said, “What’s the matter?” He said, “I hear inside: She is saved. She is saved.” He hadn’t heard yet. This was a noetic premonition for him.
So here is an example that Christ frees us, potentially, anywhere we are, in any condition. We are not dependent on something getting perfect on the outside, which is also why my wife doesn’t have to be perfect for me to love her. I need to forgive her, and then I can show up. If I don’t forgive you for being human, and I don’t see you eschatologically for what you will be like, so to speak, at least give you the benefit of the doubt that the Holy Spirit will fill you one day, and your uniqueness is standing before me, not all the things that I gripe about—if I can begin to realize “forgive them,” I’ll risk showing up. But if I don’t forgive you, I cannot show up, because what I’m doing is in the judgment: I am protecting myself. It’s inescapable. It’s just a question of what degree it is.
Here’s the doorway. How can we approach the One who is approaching us? This is kind of a paradoxical thing. “What must I do? What must I do, Lord, to be saved?” He says, “Oh, Stephen, you’ve collected so much. Why don’t you let go of that and really depend on me?” “Oh. I was trying to get you to give me a monological pill that I could do without having to show up and risk transformation with you every time you’re looking at me, because the love and intimacy with you is too much for me. I’ve got to have some control.”
Jean-Claude Larchet orients us to something very important here.
Each body is unique. The body does not only express the person; to a certain extent it is the person. The person does not merely have a body; he or she is a body, even though the person as such infinitely transcends bodily limits. This is why everything that involves the body involves the person as a whole. By refusing to consider the spiritual dimension of human persons when we seek to alleviate their physical ailments, we do them immeasurable harm.
Fr. Luke gave us a wonderful talk yesterday and mentioned how the anesthesiologist, when he comes to the patient before the surgery, and instead of going through the things that will prevent him from having a liability issue, he says, “Thank you for entrusting me with your body, which I will take very good care of through this.” This is medicine, of a very different kind. But of course, he has to be there to say that.
Another thing I want to say, Larchet says in another place; he distills another patristic little gem; he says, “There’s no such thing as pure human nature. Human being is either man-god or does not exist.” This points to our real personhood which is only created and lives in and through the gate of the Theanthropos, in and through Christ. Outside of that, we fall into non-being; we don’t exist. So this has big implications for the practice of medicine and psychotherapy.
By returning to the perspective which Orthodoxy invites, we return to the whole person, care exemplified by those whose hearts are being transformed by love into unmercenary physicians, whose care engenders another’s healing, that first embraces the person of the other before attempting to address any symptoms. That’s the first one.
Interesting. The literature, without dealing with Orthodoxy at all, is now suggesting again: We’ve got to look at the person of the physician. Damon Dagnone came up with three principles which I really like, and I think they lend themselves very much to Orthodoxy. The first is that encounters with patients primarily occur between two people. I would say it’s always three because it’s always Dia-Logos; it’s always in and through Christ, whether recognized or not, but definitely it is person-to-person; it doesn’t occur in monologue.
The power of being vulnerable is the second one, of opening up—now listen to this; this goes so far against John Wayne medicine—the power of being vulnerable, of opening up and letting patients and colleagues see your imperfect humanity, apologizing, having tears, sharing moments of pain, cannot be overstated and further reinforces the physician as person. If you’re in burnout or stress, you aren’t going to cry in that way. You don’t have the emotional buoyancy to; you’re not there, and you’re in iatrogenic armor. Where the EMTs are in the military? You learn to survive, to stay in the battle, and you don’t have the luxury of having feeling and mind-body connection, or you’re dead or somebody else is dead. That’s the way it is. But in the practice of medicine within the consulting room, there’s more room for feeling.
I want to use Dr. Leonard Goldner as a… I want to lift him up. My mother got rheumatoid arthritis right after her divorce from my father, who had paranoid schizophrenia, and he was violent, so they said, “You’ve got to get out of this.” But I’ve always wondered about the emotional connection. It just destroyed her; it ravaged her, and I watched her go from soaking her feet and hands in paraffin, which is what they did back then to try to help it, through operations at Duke Hospital over and over: knees and hips and arms and tendons out. Gangrene in her feet, cutting off her legs. Her bones sticking through her back. This I just watched like Sherman’s march through Atlanta.
But Leonard Goldner was her physician, an internationally known orthopedic surgeon. So I’m a little guy, growing up during that time. When he found out that my grandfather sold the family home to pay for her medical bills, he refused to charge her for the rest of her life for any of his professional services. She ended up in a nursing home. She couldn’t turn over in the bed. She had one tooth that touched. She couldn’t do anything except with a little stick to try to touch her body. It was really pitiful. I could give a whole ‘nother seminar on what it took to work through the spiritual pain of that and get myself out of feeling responsible for that.
But what I have continued to do… One of my friends, who read one of my books where I mentioned Goldner, gave me his obituary. I hadn’t heard from him in 30 years. He came to my mother’s funeral back in 1985. In his gentle self that I remembered from many meetings, he said, “Jean was the sickest person we ever treated at Duke Medical Center, and it broke my heart that nothing we ever did helped her.” Now, his wife would visit her in the nursing home, and he became her psychiatrist. He would tell her, “You scream as loud as you want when you feel like it.” And he began to support her and bear the helplessness, the shame, and the defeat of not being able to do anything for her.
In some of his articles that he has written and in his obituary—and I want to read you a little paragraph, because I cried when this person gave me this. I read it, and I wept, because it’s the man that I remembered—very gratefully. He says:
“You owe your patients full-time care, but you also owe time to yourself and your family. You must be able to analyze your feelings, your fatigue symptoms, your physical and emotional capabilities. You must also recognize that occasionally your patient’s problems are not solvable, but what a patient can expect is to receive your personal interest, your undivided attention, a courteous, positive response to questions, and a hands-on examination…”
And he meant literally touch the person.
“...and an explanation with a tentative diagnosis.”
Dr. Goldner proved that a warm and compassionate engagement with the patient was 90% responsible for gaining the respect of the patient, even if a precise diagnosis was not made. He demonstrated that appropriate facial expressions, body movement, calm voice, a friendly attitude were the main ingredients of a good and lasting doctor-patient relationship. He never appeared hurried or rushed, and his colleagues never heard him speak in an angry or harsh voice to a patient, a nurse, an attendant, or anyone around him.
I thank you, Dr. Goldner.
So as Dr. Goldner said, sometimes we cannot heal the patient. So the Spirit said to St. Paul that the dynamis of God reaches its telos, its perfection, through what? Asthenia. My asthenia gravis, where you lose, you’re helpless and you die in your own body that can’t move. The Dynamis of God is made perfect in the asthenia of our own human created being. Now what is this—I’ll translate this as helplessness—what is this? because St. Paul was Harvard-educated, and he was the top of his class, and he had a resume that wouldn’t quit. And what did he do with it? He executed people. Instead of being a good physician, his learning on the basis of human will and humanist supremacy syndrome led to the execution of anyone associated with Christ, just like the Sanhedrin did.
Think what danger it is for us to get the best education and fail to grasp what St. Paul is talking about here. How much damage we can do, because we’re right, and we’re zealously right. We don’t need to show up and be vulnerable. Wow! Extreme humility. Christ says something so strange to his disciples: “When I be lifted up, I will draw humanity to myself.” What in the world? “When you be lifted up as the king in glory, I want to sit on your left and your right.” “No, no, not at all.” The essence of the healing partnership is the willingness of the human being to accept extreme humility as the foundation upon which anything we learn will be used in conjunction with God, Dia-Logos.
So now, like the woman with cancer or the woman that Renos spoke about last night, the cross, which becomes our joy, is the presence of God in humanity’s experience of God’s absence. St. Isaac the Syrian said, “God’s marvelous love is made known to man when he is in the midst of circumstances that cut off his hope,” that slice in half the supremacy syndrome that we get in the garden.
So we’re back to the healing partnership, the unmercenary physicians. Jesus said, “Heal the sick, raise the dead, cast out devils. Freely you have received, therefore freely give.” Who can cast out devils and raise the dead? Who heals? Right there, the job description for ministers and for physicians, we step up and we want to be like Peter and say, “Yeah, I’ll do it. I’m all in.” But we’re all in on the wrong foundation. We’re all in, as Saul was in, as Peter was in, and we make the mistake that he told Moses not to make, which was: When you get into the promised land, when you get your degree, your medical degree, when you’re ordained—don’t say, “My arm hath done it.” Don’t make that mistake. If you do, you’ll burn out, and you’ll hurt my people!
Unarguably this is not about not taking money. Yes, it’s about… I mean, in a way Dr. Goldner revealed that to me, but it’s deeper than that. What it says is: The healing vocation, the pastoral vocation, and the priestly vocation are not given by this world. They come from another domain. They operate in this world, but they’re from another domain. So when Christ says how to pray, he says: First orient yourself to your uncreated Father, your uncreated Origin that’s beyond this world, because if you don’t do that, you miss everything else. First do that. Now we don’t have time to go into the Lord’s Prayer, but the first four petitions are all about that, and of course we’re up against something impossible. If you think you’re going to solve it by having your bread that you eat daily, you’re believing the wrong English translation of the prayer we say all the time, because it’s not about daily bread.
It’s about the Theanthropos, and the only way to move from the uncreated Father is to go through the Logos, and when you come out on the other side, all you do is forgive everyone in the world everything, and begin to bear the temptations that come to you, hoping in God that you won’t fall to the devil. That’s it. That’s the solution. Now, is it easy? No! Because rendering unto Caesar what is Caesar’s, and rendering unto God we want to do in a rational way, but its depth work. Oops, I missed one; where is it? Hold on a second. All right. I’ll have to tell you this; I left a slide out.
Okay, Jacob at the Jabbok River. What happens to him? He goes from humanistic supremacy, a self-made man, to being thrown out of joint and renamed as someone who got the blessing of struggling with God, being defeated, and overcoming his human problem by beginning to live in a communion of struggle, because “Israel” means “one who struggles with God.” I would say to you that that’s also what “Bethlehem” means. It’s not “house of bread,” because there’s two words, two meanings for “lehem.” One is “kneading of dough” and the other is “hand-to-hand combat.” Both of those show us that what it’s about is struggle. So Israel and the Savior of Israel—Yeshua, Jesus—is born in the house of struggle. He’s born bringing the cross to and for us.
Job in the whirlwind moves from a religion that offers him, “Hey, do what we say and God will bless you like a slot machine.” He says, “I won’t have any part in it.” Remember the testing. God said, “You cant take everyone away from him, but you can’t take away his freedom to respond to me as a thou.” So Job is stripped of everything that could be taken from a human being, everything, but he says, “I won’t settle for any theology that denies the reality of the otherness of God who loves me—in spite of what’s happening to me all over the place that tells me he’s asleep in the boat!” He doesn’t give up. He goes in the whirlwind, he comes out on his face, and he’s renewed. Did his children come back to life? Not them. He still has all his grief, all the pain, all that he had before, but he’s reformed.
Peter’s lesson, denying God. He said, “I’m unlike other men. Unlike all my brothers here, I will never, never fail you.” Jesus says, “You’ve got to learn this, Peter. You have to see your helplessness before you can be my minister and strengthen the brethren. You can’t strengthen them or heal them or help them on a humanistic supremacy syndrome. You will burn out and kill people.” But so painful that is. None of us want to see that. It’s taken me 40-some years to move slowly like an ant through birthing rage into my body, thinking it was with God, running it through temptations, to realize I was enraged with my own helplessness. Think how much pride and vainglory and falseness was in all this? And it still continues. It’s not over, but at least I say, “Whoa.”
It’s hard to love, even as a child loves their parent, let alone as we love God, and be helpless. But it’s not a helplessness of identification with the sickness; it’s a neptic helplessness that actively bears the relationship with the defeat so that God can reveal how devils are cleansed, how people are cleansed, and show the strength of the person that we’re blind to when it all depends on me to fix you. The other shows up crystal-clear, as I vanish in my supremacy.
What did Fr. Sophrony say about Christ’s hypostasis shortly before he died? One very important statement he made was: The content of the hypostasis of Christ is the total self-offering of God the Father. So when we are before Christ, we are before an emptiness of presence that invites us to be so visible his life becomes ours. This is the direction of healing and development. I call this prayer the Dia-Logos prayer to remind me. You can change the word “world” for “patient” if you want, or “spouse.” Christ is going to come through us.
Lord, love the world through me—love the patient through me;
Let me love the patient through you—with my head on the ground before you, empty of needing to fix them, and, God help me, not abandon them, but to stay present.
And let me be loved by you through the patient—I don’t need the patient to love me. My boundaries are determined by what you wish to bless in the relationship.
So at our shop we say, “God sends us the patients we need,” because, as Fr. Luke said yesterday, “They’re our guests in the beginning, but they become our hosts because Christ gives us communion, through the penitent and through the patient, by inviting us to decrease so he may increase.” I think I’m supposed to stop. Okay. [Applause]