EP. 3: THE SPIRITUALITY OF CARE

Mar 8

WITH BRUCE FELDSTEIN, MD

An emergency physician-turned chaplain explores what the role of spiritual care is in medicine.

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Episode Summary

Chaplain Bruce Feldstein, MD is the director of the Jewish Chaplaincy Service at Stanford University, as well as an adjunct clinical professor at Stanford University School of Medicine. After 19 years practicing as an emergency medicine physician, an injury led Bruce on the path of finding a deeper sense of his life’s work as a Chaplain. He now teaches an award-winning curriculum on spirituality and well-being for medical students and faculty at Stanford.

Chaplain Bruce Feldstein, MD is the founding director of the Jewish chaplaincy service at Stanford Medicine, as well as an Adjunct Clinical Professor at Stanford University School of Medicine. A graduate of the University of Michigan Medical School, Bruce was an emergency medicine physician for 19 years before an injury led him to a deeper sense of his life’s work as a chaplain. Bruce was a visiting scholar at the Stanford Center for Biomedical Ethics and completed his clinical chaplaincy training through Stanford’s Clinical Pastoral Education program. As a board certified chaplain, he developed and teaches an award-winning curriculum on spirituality and well-being for medical students and faculty at Stanford. He has served as a past president of Neshama: Association of Jewish Chaplains, which is the professional association for Jewish chaplains worldwide. Finally, Bruce writes widely on humanistic medicine and spiritual care.
In this episode, you will hear about:
• Chaplain Feldstein’s unexpected journey from emergency physician to chaplain - 3:35
• The unforgettable moment when Chaplain Feldstein first prayed with a patient - 5:00
• How to connect with patients in a spiritual way - even if they’re not religious - 18:04
• Five key relationships to foster in your life to counter compassion fatigue - 30:57
• The core teaching within Chaplain Feldstein’s class, ‘The Healer’s Art’ - 37:40
Henry Bair: [00:00:01] Hi, I'm Henry Bair

Tyler Johnson: [00:00:03] And I'm Tyler Johnson,

Henry Bair: [00:00:04] And you're listening to the Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful? Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor-patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom. Probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:01] Our guest on today's episode is Chaplain Bruce Feldstein, who is the founding director of the Jewish Chaplaincy Service at Stanford Medicine, as well as an adjunct clinical professor at Stanford University School of Medicine. A graduate of the University of Michigan Medical School, Bruce was an emergency medicine physician for 19 years before an injury led him to a deeper sense of his life's work as a chaplain. Bruce was a visiting scholar at the Stanford Center for Biomedical Ethics and completed his clinical chaplaincy training through Stanford's Clinical Pastoral Education Program. As a board certified chaplain and physician, he developed and teaches an award winning curriculum on spirituality and well-being for medical students and faculty at Stanford, including Stanford's reflection rounds, where students and faculty join with chaplains to reflect on their inner life experience. He has served as a past president of the Association of Jewish Chaplains, which is the Professional Association for Jewish Chaplains Worldwide. Finally, Bruce writes widely on humanistic medicine and spiritual care. Bruce, welcome to the program. Thanks for being here.

Chaplain Bruce Feldstein: [00:02:02] Henry, it's a delight, really.

Henry Bair: [00:02:04] So for our listeners who may not be aware, can you tell us what your work as a clinical chaplain looks like?

Chaplain Bruce Feldstein: [00:02:11] So a lot of people may not be familiar with who chaplains are and what they do. So let me just say a word about that. As I learned when it was introduced first to me, chaplains are professionals who care for the spiritual, religious, existential aspects of people and what they're going through. If I had to choose one verb to describe what we do, it's accompany. And to put it in a more operational way, as I as a chaplain in health care, go in to see a patient, I always stop and prepare my attention and my intention. And so part of what that includes is as I enter into the room, I remind myself, May I meet you, my patient in your world as it is for you and accompany you from there? May I meet you in your world as it is for you, and in a way that allows you to connect with your source of comfort, of strength, of meaning. However, that is for you bringing all of who I am, not just my training and expertise, but all of my life experience. And whatever matters most for you is what matters for me. And so may I listen for that, be with that, identify that and respond to that.

Henry Bair: [00:03:30] So you mentioned bringing your life experience -

Chaplain Bruce Feldstein: [00:03:32] Yes

Henry Bair: [00:03:32] - to your current work.

Chaplain Bruce Feldstein: [00:03:34] Yes

Henry Bair: [00:03:34] You were an emergency medicine physician before you were a chaplain. Can you tell us how you made that transition and why you made that transition?

Chaplain Bruce Feldstein: [00:03:42] Well, there's different ways to tell the story. Most simply, I was helping a friend move some furniture. It was August of 1997 and I felt a tearing pain in my back and came up like a three dimensional question mark. I mean, really twisted and in a lot of pain. And it turned out I disrupted two discs in my back. I tried for about eight months, but was unable to continue working. And finally was sent from one physician to the next and ended up at the spine surgeon. And Dr. Van Pedigan was his name, and I really appreciate him. He took the MRI films and he, you know, he flicks them up onto the box and he says, "Would you like to know what you've got?" And I expected him to, you know, tell me about, you know, this disk and that disk and et cetera, et cetera, in the lumbar spine. And he turns to me and he says, "Dr. Feldstein, what you have is you need to find a new work style." And that was it. So that was end of career one and sending me toward career two. But at that point, I had no idea and really could never have imagined or even dreamed that I'd be doing what I'm doing now.

Henry Bair: [00:05:00] So how did you find that this was the career path that eventually gave you the most meaning that you could have from your life? Like, was there an instance? Was there a patient? Was there a clinical encounter or life experience that made you realize spiritual medicine? The unique combination of your clinical training, combined with your interests in spirituality and your lived experiences as a religious individual? How did that come together?

Chaplain Bruce Feldstein: [00:05:22] So let me just say a word there. You use two terms that are, I think, important for us and useful to distinguish spirituality and religious - and religion. And so they're related and they are different. As I've come to appreciate spirituality as something that is a human phenomenon in the same way that we have bodies and anatomy and physiology, we also have a certain kind of spiritual anatomy, if we will. We're beings concerned with meaning, with purpose, with connectedness. And for me, that's what spirituality is about - how we express that in our lives, how we live that - and it's an individual thing. And religion that's its own thing too, but has to do with, you know, communities of people and et cetera, but they're different. So you asked about, was there something in my life? Well, I've come to recognize in many ways over decades how I would have spiritual experiences. And I don't mean, you know, magical experiences where the heavens would open up or something like that, but things that were just deeply meaningful or where I would come to have a sense of realization or knowing over time. And one of those was in the emergency department in my work itself, and I've had many in my work itself. And so it was an accumulation of these. But let me focus on one. It was six months before the injury and I'm working in the emergency department.

Chaplain Bruce Feldstein: [00:06:58] I'm a founding faculty for the Stanford Kaiser Emergency Medicine residency program, head of our Quality Improvement and Peer Review Committee. I'm very active in teaching and clinical care and all of that, and I take sign out from DR. He says, "We've got a lady, Mrs. Martinez. I'll call her in. She's over in room three and take a look at her CT scan. She's got a metastatic cancer. I just want to make sure it hasn't gone to the brain because she's was just discharged with vomiting and dehydration and we've tanked her up. Make sure the IVs are working, check her blood tests and CT, et cetera." You know, routine kind of sign out and then send her to her oncologist the next day. So I walk in and she says to me, "Doctor, what was the result of that brain test?" And I wasn't going to tell her that the cancer had metastasized to the brain. We had just discovered it because I only know her for 10 minutes. And that's not the news you give someone like, "Oh, well, you know, Mrs. Martinez, your potassium is a little low. You ought to eat a banana and then come see me in the morning." No, it's not like this kind of news. And like I said, I wasn't going to tell her, but how can I not tell her? So I sat down and I looked at her.

[00:08:13] Now, Mrs. Martinez was twice my age. She was 88. Mrs. Martinez was from Mexico, originally. Mrs. Martinez, I saw, was wearing a cross. Now I'm from Detroit. Half her age, I come from a Jewish family. I'm Jewish. We're like worlds apart, but we're sitting right across from each other and I'm with her. I cannot not not tell her, so I said, "Mrs. Martinez. The test shows that the cancer has spread to your brain." And I pause thinking what I'm going to say next. And her face, the color in her face turned white. And I thought, "Now what?" I always felt that there was something that I could say to someone and being with them, even if I couldn't cure them, even if I couldn't relieve their symptoms or something, there was something that I could say to provide comfort. But what might that be? And so I didn't know, so I said, "Well, Mrs. Martinez, what's your reaction to the news?" And she told me, "It's a death sentence." And she looked away. Now, what could I say? And I thought I couldn't say I know how you feel because I don't know how she feels, I'm not on her side of her eyelids. I couldn't say, Well, you know, back in my era, in the sixties and the 70s, they had TV shows about Dr.Kildare or Dr. Welby, Marcus Welby. You know, these were the doctors who knew your patients for decades, and they could say, "Well, you know, Mrs. Martinez, we've known each other for years. It's we'll all die sometime," you know, in some philosophical... I know her for 10 minutes. I couldn't go there. And then I see that she's wearing this cross. And I'm reminded of a story that Rachel Remen, a physician who's later become not only a mentor but a friend of mine, how she tells about a doctor who prayed with a patient. And I just knew that's what I needed to do. Now, I've never done that before. They didn't teach me this in medical school, they didn't teach me this in Hebrew school. I didn't know, but I thought, "Well, that's what I need to do." And so I said, "Mrs. Martinez, are you a prayerful person?" And she said "Yes". And I figured, well, that's like taking, you know, you've got to have your indications and contraindications, you want to make sure you know that it's OK and. And I said, "Well, would you like to have a prayer together?" And she said, "Yes". And now at this point, I'm getting really nervous. My hands, I can feel it now as I'm remembering this and I take her hands in mine and bow our heads.

Chaplain Bruce Feldstein: [00:10:51] By the way, in the room was her son, and also with me was a resident going into radiation oncology. I take her hand and we bow our heads and I wait for her to begin. And then I realized she's Catholic. She's waiting for me to begin. So I think, "Well, how does a prayer go?" You acknowledge some higher power. You God, whatever you call it, you ask for something you say thank you and go home. Four steps, I could do that. So I said, "God, you who are the great healer." And then I paused thinking to what to say next? And she starts to repeat after me. "God, you who are the great healer." And then I think "be with us in our time of need," including mine, to figure out what to say next. And she says, "be with us in our time of need" and we start to go back and forth and I don't know the words just kind of come. I later learned that this is a spontaneous prayer. Well, maybe for you or for you, you understand what that is. But for me, this is something new and we get to the end of the prayer "Grant us strength, Grant us strength to do what is right and best. Thank you for hearing our prayer. Thank you for hearing our prayer."

[00:12:02] And then she holds on and she starts to say "Our father who art in heaven." I knew this prayer because I used to work nightshift at the Catholic Hospital when I first started in emergency medicine and at eight o'clock, the sister would come on to the announcements and say "It's now eight o'clock. It's time for all visitors to go home. Our father, who art in heaven, hallowed be thy name..." Well, I remembered this well, mostly. And as she was going through this, I would give her a kind of little squeeze at the end of each first and went along as best I could. And then she said a prayer in Spanish, which I later found out was a prayer to St. Jude, the patron saint for the hopeless and the destitute. And at that moment, she looks now right at me and she has a tear streaming over her cheek. And she says to me in a way that I will always remember, "Thank you, Doctor. Thank you." And in that moment, and I can't explain, there was a palpable velvetiness in the air, or there was something. It felt healing and good. And right, and then we got up, the whole thing took far less time than it took for me to tell the story. And she thanked me and I thanked her.

Chaplain Bruce Feldstein: [00:13:20] And I walk out the room and I thought... Well, actually, I set out loud to the resident, I said, "Listen, I got to tell you that's not something I regularly do. I've never done that before. It's never happened to me." And I was off my map. He said, "Well, if you were off your map, I was out of my world entirely." And then I thought to myself, "Oh my God, what did I just do? I just prayed with a patient. Yikes. Isn't there a separation between church and state? And maybe this is illegal? Oh my God, what?" I'm having this cognitive dissonance moment. What happens if I get reported? What if I get reported to peer review and quality improvement? Oh, I am head of peer review and quality improvement. It was a terrific opening. And in that moment also I felt like I saw before me two worlds. There was a world of being the scientist, the physician, the man of medicine as we traditionally understand it. And then I felt there was the spirituality, the caring, the love, and there was a bridge joining those two. Like, I had my foot in two worlds and I was bridging those two. And that was the ethics, the service. And I realized that I was standing on the bridge myself, bridging these two worlds.

Tyler Johnson: [00:14:40] So it sounds to me like even before you became a chaplain, you were at least to some degree, or at least in that experience, a spiritually minded doctor. But I'm still curious now with decades of chaplaincy inside of you. If today's you were to go back to the you from before you had the accident, who is a busy emergency medicine doctor? What would today's you want to tell that prior you about how to be a better doctor?

Chaplain Bruce Feldstein: [00:15:11] I came to see a number of things that I now teach others. It's part of what I call spiritual fitness, and I wish I had known this and I teach it now to medical students. So, one of the things is that before our commitment to medicine, and this was something that relates to burnout. Burnout is... it undermines our commitment to action and our commitment to medicine. You know, and it leaves us exhausted and cynical and and I've been through that a couple of times. But the antecedent of our commitment is meaning. I learned that along the way, including from my teacher, Rachel Remen, and I wish I had recognized that. And one of the ways of finding and keeping meaning strong is several things. One is recognizing that when I go in to see a patient, it's not just about the CC - the chief complaint, but it's the CC - the chief concern. It's not what brought you in today, Mrs. Martinez or Mr. Smith. It's what is it about this that prompted you to come in? Now, in that morning, in that moment? And by the way, this is not a matter of time. It's a matter of something else. When I ask that question, what prompted you to come in? What is it about this that prompted you to come in? I'm modulating into a different realm, a realm of meaning, a relational realm where I am here with you. You are not alone. It's a realm where I've come to see it is good that you exist. I am glad that you are here. And then when I listened for what prompted you to come in, the chief concern in this other context, something new shows up a kind of caring and an opportunity for healing, even as I go through and ask the same review of systems and present illness kind of questions. We're in it differently. And I wish I had known that explicitly at the time.

Tyler Johnson: [00:17:02] Just to clarify for our listeners, chief complaint is a moniker that doctors use to refer to the main complaint that brings a patient into the emergency room or into the doctor's office. And so I think the point is a really beautiful one that there's the couple of words that you might write down on their admitting sheet, right? Abdominal pain, chest pain, trouble breathing, or whatever. And then there's what that means to the patient or why that concerns.

Chaplain Bruce Feldstein: [00:17:28] Oh, exactly. So, common one in the emergency department - ankle injury. So we come in and there's a swollen, bruised ankle and the X-ray shows the same thing. Maybe it's a little chip fracture in one person. What it means might be I'm a fullback for the high school team. When do I get back to play? Like, that's what really matters. Sure, in the next patient, they've been married for 50 years and are getting ready, "Doctor, will we be able to go on their cruise? The one to celebrate our 50th anniversary?"

Tyler Johnson: [00:17:58] Sure.

Chaplain Bruce Feldstein: [00:17:59] Two different worlds and realms of being together.

Tyler Johnson: [00:18:03] Yeah.

Henry Bair: [00:18:04] Yeah, I think that's an interesting point that you because early on you distinguish between spirituality and religion and you make the point that spirituality, as you've defined it, is a universal human experience. And I was going to ask you, what do we do for patients for whom religion is not a particularly important part of their lives? And I think you just answered that question, which is it's really not about -

Chaplain Bruce Feldstein: [00:18:28] You're right.

Henry Bair: [00:18:28] It's not about faith in a higher power, necessarily. It's really just about -

Chaplain Bruce Feldstein: [00:18:32] How it shows up. This is really great because here's how it shows up at the bedside in a very practical way. Let's say you come in with something that's been really stressful for you, and maybe it's your chief complaint is a headache. And then after I go through all the analysis, it turns out it's not an acute aneurysm, it's not meningitis, it's not a brain tumor. It's not any of these really terrible things. But it's, you know, a muscle tension headache, and that can be disabling. And so I say, this is really, you know, been a really hard time for. You know, you've been under a lot of stress and it's not any of these other things. Tell me what sustains you in the past when you've been through some really difficult times? This is a great question for everybody. So I ask them and I'm listening for what they say. But then I listen for what they don't say, and then I say, Well, is there anything else? Are you a spiritual or religious person? Do you have any spiritual or religious customs or practices that are important for you that sustain you? What is important for you? So that's true for everybody. And then it's a way to flush it out and to say it in a neutral way. Not to say, "Well, tell me you're religious? How often do you go to church?" You know, it's not like that.

Tyler Johnson: [00:19:45] One of the things that I was struck by that you said is... One of the underlying impulses for this podcast is to try to help address the epidemic of burnout in the medical workforce. And I think that both Henry and I have an intuitive sense that at least part of the reason for that is that we have - we speaking collectively as a medical profession - have lost touch with the meaning behind medicine. And I'm curious if you were a practicing doctor again, what would you do differently to try to stay more directly in touch with the deeper meaning behind the care that you were providing?

Chaplain Bruce Feldstein: [00:20:33] Hmm. What just flashed through mine is a whole series of practices that I do to find and sustain meaning.

Tyler Johnson: [00:20:42] Let's talk about that

Chaplain Bruce Feldstein: [00:20:42] I'm going to outline those, but before I do, I want to say that you're asking the question What does an individual do? But also to recognize you take any good, well-meaning individual who's practicing medicine for the most noble reasons and you put them in an organizational system, a way of practicing medicine that is unrelenting, that encourages an unreflective busyness. And you can hear my disdain for that. Then what you get are burned out physicians and it could be anybody. It was me. Maybe it's been you, too. And for many people, it can be avoided, but it requires paying attention and organizing our way of coordinating together and our, you know, our economy, our, you know, sociology, all these kind of things inside of which I, as a physician, practice medicine. So I'm not going to address that, but I just want to say I understand that question in this broader way. But what can I do as an individual now?

Chaplain Bruce Feldstein: [00:21:48] So one way of finding meaning is recognizing what counts for meaning for me. When I addressed the chief concern about someone, it viscerally feels right to me. It's meaningful for me and for you -

Tyler Johnson: [00:22:03] Yeah

Chaplain Bruce Feldstein: [00:22:04] What matters most? So what is the practice for listening and speaking that allows for revealing meaning? And again, it's not about time. So what is it about this, Dr. Tyler, that prompts you to come in today? What is it about this that prompts you to ask that question that points back to me?

Henry Bair: [00:22:23] Yeah

Chaplain Bruce Feldstein: [00:22:23] I can listen for that. I can be a reflective practitioner in action. This is an idea I borrow from Donald Shum from the 1980s and educator. He was at MIT, the reflective practitioner. As we progress and form in our professionalism, we become reflective practitioners. We don't make decisions based on "this is what I'm going to do. That's what I'm going to do." We just act, and we can observe ourselves while acting. So how can I be a reflective practitioner in action? Not after the fact, but in the midst of the fact, while I'm with people, be aware of how is this for you? How is this for me? What's our governing context? What are my options? What are the ethical values on which we're sitting on? While at the same time, not being distracted from being with you. So, being a reflective practitioner and ability to design care, what I'll call ontological design. Now, they don't teach this in medical school, that sounds like a big philosophical word. And you know why?

Henry Bair: [00:23:30] Why is that?

Chaplain Bruce Feldstein: [00:23:31] Because it is. It is. So ontological has to do with being. And now that I think about it, I wish I knew what I learned now in studying with philosophers and so many different people about what it means to be human, and reflecting on my own humanity. I mean, we go to medicine, we take care of human beings. What do they teach us in in medical school? We go to anatomy class, so we learn about the body, we go to physiology, we learn about that. We go to pathophysiology and learn about what happens when it goes wrong. We learn about all those things that allow us to understand the person, maybe even as a bio psychosocial spiritual person. And we learn about meaning and love and connectedness. But what about being itself? What is the anatomy? If we were to use that word of being, what does it mean to be being? Wouldn't that be something if we knew about that? Because every person that we take care of is a being just like we are beings. And if this sounds foreign to you. It certainly was for me, and it led me to like "a ha", a great perplexity. But right now, now it's operational. It's not even about thought. And I wish I could have told my old self what I knew about then.

Chaplain Bruce Feldstein: [00:25:52] Here's another thing. And this really ties to burnout. When I'm with somebody... To be with somebody who is sick or comes into the clinic, it's to be with someone who has lost, or feared that they lost some capacity of themselves. As the the Roman Celsus would say, it was Functio Laesa. You know, there were cardinal signs of inflammation. There was dolar and rubor and calor and Functio Laesa signs of inflammation. But when somebody has loss of function, Functio Laesa, that means they've lost something. And what is the reaction to loss? Grief. It's an energetic one, but somebody doesn't come in and say, "Doctor, I feel sad. Doctor, I have anxiety. Doctor, I'm feeling really uncertain. Doctor, I'm in anguish." No, they say, "I hurt my ankle. Will I be able to go on that trip? Will I be able to play?" So to be able to sit in the the field, there's an energetic field of grief that we encounter with every single patient. Grief isn't just when somebody dies or the big loss, although it's certainly there. So it's pervasive and inescapable. I wish I knew that, and I wish I knew all the ways to grieve that I've learned along the way.

Chaplain Bruce Feldstein: [00:27:10] And there's different styles of grieving. You might be an emotional griever. I can be that way. You know, on the weekend, I come home and I open up the paper when I'm alone. I read a tender story and I cry. I don't just cry, but I sob. I just love. Oh, I just let it out, you know? There's some parasympathetic something that goes on and it's good, you know? But some of us are not those kind of emotional grievers. Some of us are action grievous. They're going to go outside and chop wood or go run or exercise or. But how do we grieve? What are your grief skills? What do you know about grief? It's what they didn't teach us in kindergarten, let alone medical school. Come on. And another thing to be alive is in medicine is to be alive means there might be a moment when somebody might die. And with oncology patients, I know that, you know, that's every single time it's in the room.

Tyler Johnson: [00:28:06] Sure

Chaplain Bruce Feldstein: [00:28:06] Right? Every single time. So how can we desensitize ourselves to the things that make us run away from and not be able to encounter death and dying? Or let me put it in a positive way - How can I prepare myself? And this is learning, I have learned this. How can I prepare myself to be with someone in their world with the possibility of death before me? You know, we can deconstruct this. We can teach this. We can prepare ourselves.

Tyler Johnson: [00:28:37] Let me let me ask - of all of the things that you've said, one of the words that has struck me the most is this idea of accompaniment. Accompanying a patient. And I think you would have to ask a lot of doctors, you know, if you said to a doctor, "When you go into the room or to see the patient in the emergency room or whatever. What is the verb to describe what you're going to do?" You would hear a lot of examine a lot of diagnosis, a lot of treat, perhaps. But I think you'd have to ask a lot of doctors before you got to the verb, accompany before you got to a doctor who said, "I'm going into the room to accompany the patient." I'm not sure you'd ever ask a doctor who would say that. But if again, if you were to go back to being a medical doctor and yet you took with you as your foundational idea that every time you're going to see a patient, though you are going to be diagnosing them and treating them and everything else. But if you took with you the idea that at least as important as all of those things is your responsibility to accompany the patient as their physician. How do you think that would transform the experience of doctoring?

Chaplain Bruce Feldstein: [00:29:47] I want to go back and say that maybe there's another verb before accompanying. There's something that prompts me - that's already prompted me - that I've said already yes to and being a physician to walk in the room or to be with you. So it's about being with and joining. So I want to look at that and maybe that's about care. Sure. So maybe that's the verb. And we can take like, maybe there's a family of just several verbs here that are really operational. So one is there's the care. Yeah, and out of care and being of service and care has to do with love and we may not recognize it as such. It's one of those funny kind of Four-Letter words. We don't like to use Four-Letter words in medicine too much, but that's one of them. So there's care and then out of that care, I meet you in your world as it is. I join with. So it's to be with. And a way of being with us to accompany. And then comes, which way shall I accompany you? Diagnose, treat, listen, interact. Be an advocate, be a teacher. So these are some of the things that I'm thinking about there. What a great question.

Henry Bair: [00:30:57] How would you respond to those who may say that it's really difficult to be immersed and accompany the grief of patients without feeling fatigued from doing this over and over again? The word I'm thinking of that people have used these days is compassion fatigue.

[00:31:17] Mm hmm. I would agree. It really is. Especially if we're open hearted and we really want to join with people explicitly in these kind of ways. It can be hard. People say to me, "Well, how can you do this?" You know, I'm the guy that's called in when someone's acutely grieving. So first of all, it's something that can be learned how to be in a way that is resilient. I know for me it was in finding meaning that allowed me to say yes to this in the first place. You know, if you would have asked me, Henry, you know, following the injury and said, "Oh, you know, you're going to be, you're going to become a chaplain, you're going to be the guy that's called in to be with people in their in their worst moments in life and their time of grief." I would have said, 'That's ridiculous. I can't do that. " I said, Look, I know I always took pride as a physician that I would be the one when we could not resuscitate a patient successfully and they died. I would be the one to go in and give the news as the senior physician and with a lot of experience, I would do this time after time and I can remember one family vivid. Italy from the Middle East, and I walked in to give the news that their husband, he came in with a heart rate, no pulse.

Chaplain Bruce Feldstein: [00:32:32] We tried everything, but we just couldn't get that heart started and I explain that to the family and I said, I'm really sorry that your husband has died. And they began not just to cry, but to wail and wail upon wail and grip each other in the room and in within 10 seconds, 15 seconds. I was emotionally overwhelmed. It was all I could do to say, I am so sorry for your loss. The nurse will come in to be with you, and I ran the hell out of that room so fast. Well, there were no chaplains at the time. That's why I said the the nurse. This was in the 1990s. And what did I end up saying yes to when I could no longer practice medicine? I'm now the guy that's called in, and yet I didn't have the body. The ability to respond, the response- ability to be able to go in and be with people in this way. And so it's learnable. I learned it in a clinical pastoral education. This is the residency training program. I also learned that there's key relationships to keep me buoyant. I discovered this along the way. I'd already spoken about the practice of grieving and how important that was, and the practice for finding meaning.

Chaplain Bruce Feldstein: [00:33:46] And this, again, is something I wish I knew as a medical student, as a practicing physician. Key relationships to keep me emotionally buoyant. The first was a relationship with myself, and it recognizes that in this body, in this being of who I am, I can do more. I have more ability and possibility than I can even begin to imagine. On the one hand. On the other hand, I only have so much time. I have only so much that this flesh and bones can do, and a body needs, absolutely, rest. After every heartbeats. There's diastole, the heart stops. It rests to fill up after every breath we stop. And then we breathe in again, we rest after every time a nerve fires, what do they call that? The refractory period?

Henry Bair: [00:34:38] Yeah

Chaplain Bruce Feldstein: [00:34:38] The nerve rests, but I don't live that way, so I need to know about rest and to allow for that. So that's a relationship with myself. Need absolutely time for rest. Second is to have a soul friend. What's a soul friend? A soul friend is someone with whom I can be, who will listen to me and be with me and embrace me no matter what, without judgment. And there's actual research on this in the realm of positive psychology and epidemiology. People who have a soul friend live longer than those who do not.

Henry Bair: [00:35:12] So what is a soul friend?

Chaplain Bruce Feldstein: [00:35:14] It's the person. It may be a spouse. It could be a friend, a relative. It could be a stranger who you just find yourself being able to say anything to, and you have a sense that they are with you. They appreciate what you're saying, even if they may not understand it. There's a quality of embracing and love, as I say that to you. Can you think of a moment in your life or people like that who've been a soul friend for you?

Henry Bair: [00:35:39] Yeah, I think I can. Yeah.

Chaplain Bruce Feldstein: [00:35:41] So that's a soul friend. A third is a therapist. And I broaden. It could be a mentor or a spiritual director. People who they love the messiness of the emotional state. The fourth is a colleague, and I can't say enough about this. Colleagues are people with whom we have a shared... And it's a really intimate thing because we share a shared commitment. Our colleagues in medicine, we have a shared commitment to be physicians or to be nurses or to be health care practitioners. We're the people who go in to face the pain and suffering where others may go the other way. So colleagues. And the fifth is the transcendent. These are experiences. It could be what's beyond our self. Like we belong to family and community that's bigger than who we are. We belong to nature. When we're out in nature, that is sustaining. It's also experienced in religious practices, and so many other ways - art, music, sport. So, these are five.

Chaplain Bruce Feldstein: [00:36:44] And the question then I have is how many of these five do you have going for you right now? This kind of self-acceptance with oneself, a soul friend, a therapist, a mentor, a coach, a colleague, forth. Or ways to take time and connect with the transcendent. And the wisdom is to have at least three of these going for us at any time. That's like you're sitting on a stool with three legs. That's stable.

Henry Bair: [00:37:16] I know that you teach a class at Stanford School of Medicine called 'The Healers Art.' It's a class that is all about meaning in medicine. You teach medical students how to be reflective and how to approach their clinical experiences and patient care with the mindset that we have been discussing through the course of this conversation.

Chaplain Bruce Feldstein: [00:37:40] Yeah.

Henry Bair: [00:37:40] What would you say are the key themes that you try to impart on your students in this class?

Chaplain Bruce Feldstein: [00:37:47] This course I learned and was given from its originator, Dr. Rachel Naomi Remen at UCSF. I introduced it here at Stanford in 2001, and starting later next month I'll be offering it for the twenty first time. One of the premise of this course that I found so lovely is, as Rachel puts it, whatever you bring to medicine, whoever you already are is just as important as anything we're going to teach you here. It doesn't mean instead of, but just as important. So it means, who we are in our humanity and our life experience already is a well of wisdom, as I see it. So the course starts by recognizing that. And that human being of who we are already brings a capacity for healing. We look at what we wish to keep strong as we train, as we become physicians. And these are essential practices for resiliency. These are antidotes to burnout and set in a positive way. This is the... The nourishment, you know, for leading a good and fulfilling life. We learn about grief and that it is inescapable. We've already experienced it. So what is grief? And how do we grieve? What works? What doesn't work? We look at that. We take a good look at that.

Chaplain Bruce Feldstein: [00:39:17] And then we recognize that our science is amazing. Knowledge is amazing, but there is other realms of existence which are profoundly important that we can't. Understand. Mystery. There's things that we don't understand, we can't explain, but we can experience. And it's good. And it can be healing, and it's around us all the time. I'll give one - love. Love is one such thing. You can't explain it. There's poets and writers and musicians and artists for millennia who try and express love. We can express it, but we can't wrap our hands around it. There's a mystery about that. There's an esthetic about that, and it's beautiful. And then there's something in The Healer' Art, where having examined all this. We can stop and say, How now shall I serve? Having taken a look, well, who am I in this way? Then how shall I serve? When we look at service and examine that. Kind of pledge ourselves to ourselves and to our commitment and to our future. And we do this in small groups and large group, and in the company of other people. It's a different kind of learning. It's not about accumulating knowledge and having all the facts. It's about something else. It's an experiential kind of learning. It's a way that sets us up for learning to learn in a certain way. It's fun, and it's being with like minded people.

Henry Bair: [00:40:42] Do you hear from past students who are now in practice about how what you've taught them in those classes have impacted the way they approach patient care?

Chaplain Bruce Feldstein: [00:40:55] Oh, absolutely. One of those is Nitya. She's now finishing her residency at Pediatrics in Pennsylvania. She's going to go to Harvard for fellowship and wrote me how this one class is something that has stayed with her, imprinted itself on her, and I can see it in the many things that she's written and published, and that she teaches. One of the best examples of The Healer's Art course. It's not the one that I taught, but it's one that Rachael taught. In the beginning, there was a student from Yale who came to take the class, heard about it, flew across the country, took the class and then said, This is so good, I'm going back to Yale. So it goes back to Yale, talks them in, and that was the second place they introduced The Healer's Art, by the way, Stanford, myself and Dartmouth. We were the third and fourth places. It's now at over 90, or maybe even over 120 medical schools worldwide. Just amazing course. Well, this student who took it back to Yale went on to become surgeon general of the United States. Vivek Murthy. And when I now look at his way of being a physician, the way he conceives of policy and being with and what is the role of health in this country, it all goes to the roots of Healer's Art. When he talks about the epidemic of loneliness - This is the kind of thing that we would just recognize immediately as we're going through Healer's Art. As we recognize the loneliness in you I recognize because I know the loneliness in me.

[00:42:26] We look at... Oh, here's another notion it's called the wounded healer. Rachel writes about this. Carl Jung seemed to coined the phrase in the 20th century. It's based on a Greek myth, but the wounded healer says that the wounds, the traumas that I sustain and have endured and healed through. These wounds imbue me with a capacity for being with you who is wounded and may not know it. It imbues me with a capacity for being with you in a way that you know that I know and that you are not alone. And this is all unspoken. This is what's so amazingly cool about it, you know? The loneliness in me that I've experienced recognizes the loneliness in you. A depression that may I may have gone through. Or, you know, you listen to what people have gone through a divorce that I have gone through. People who have been alcoholic and have gone through. They're able to then meet and see what people in these kind of conditions are going through without necessarily disclosing their own history. But that person knows and gets and can trust. So it's a notion of a wounded healer. And it also says that these wounds that may be in society, people say, "Oh, shame, you know that we want to hide." Oh, no, maybe this is the source of certain capacities for healing and being with people and accompanying them. And I know this to be certain

Henry Bair: [00:43:55] It's a wonderful sentiment. Really beautiful. Thank you very much again for your time, Bruce. You know, these are entire dimensions of care - of medical care - that I think we don't hear enough about in practice.

Chaplain Bruce Feldstein: [00:44:06] Well, thank you, Henry.

Henry Bair: [00:44:10] Thank you for joining our conversation on this week's episode of The Doctors Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed that episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:44:29] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments. I'm Henry Bair and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.