First-year medical students Melanie Cargle (left) and Gabriel Mendoza (right) learn about the spiritual side of medicine.
The patient’s eyes lift and brighten when Chaplain Andrew Couch walks into her room at Ronald Reagan UCLA Medical Center. Her mouth widens in a smile — it is small and tight, but a smile nonetheless. The woman has been in the hospital for nearly two months, waiting for a liver transplant.
“How are you feeling today?” Chaplain Couch asks.
“Today is a difficult day,” her husband quickly responds. He rarely has left his wife’s side since she was hospitalized. “We are strong and trying to keep positive,” he says.
“Why is it a tough day?” Chaplain Couch asks, looking to engage directly with the patient. It’s clear he has developed a strong rapport with the couple during his frequent visits, and today he senses more emotional distress than usual.
“It’s the waiting,” she says. “It just takes so long.” With that, she breaks down and sobs. After a few minutes, her tears subside. “Why the tears?”
Chaplain Couch asks in a comforting tone. She says she wants to go home and feels trapped in her room. Although she has been given permission to go outside, she has chosen not to. “Why?” She says that she’s afraid that if she does go outside, “I would want to keep walking and not come back.” Chaplain Couch talks to the woman and her husband about their faith, and later he asks if they would like to pray with him. They welcome his offer, and the three gather together in a circle. Afterward, the patient’s husband tells the chaplain: “When you come in and pray with us, it gives us a sense of reassurance and hopefulness in our hearts.”
Medical student Melanie Cargle (left) wipes away a tear as she and fellow student Gabriel Mendoza (right) observe UCLA Chaplain Andrew Couch as he visits with a patient.
SUCH MEETINGS WITH PATIENTS ARE DELICATE AND USUALLY PRIVATE, taking place beyond the eyes of medical staff. But on this day, two first-year students in the David Geffen School of Medicine at UCLA — Melanie Cargle and Gabriel Mendoza — join Chaplain Couch to receive a rare glimpse into the role that spirituality plays in patient-centered care. They are participants in UCLA’s Doctoring 1 course, which requires first-year medical students to spend time with a chaplain on his or her rounds.
This also is the pair’s first interaction with a patient, and the visit catches them off-guard. They are visibly moved — Cargle discreetly wipes away a tear when the patient starts to cry. “I can only imagine what she’s going through,” she says. “She has the option to stand up and walk outside and feel the breeze, but there are strings attached. It’s almost like a prison, and Chaplain Couch and God are her liberators.”
Before entering the room, Chaplain Couch spoke with the two students about what they might see and hear. Both students bowed their heads slightly, standing outside the intimate circle, as he prayed with the couple. Afterward, the students briefly talked with the couple. “For them, the spiritual care was as important — or perhaps more important — than the medical care,” Mendoza later reflected in the personal essay he wrote for Doctoring 1. “From their verbal and nonverbal display of gratitude, it was clear that Chaplain Andrew had been a crucial part of their care at the hospital.”
For more than 15 years, UCLA medical students have participated in chaplain rounding, spending a half-day shadowing a chaplain as he or she meets with and comforts patients. The experience, the students say, is eye-opening, if not life-changing. Participation in the rounds and writing a short reflection on their experience are a mandatory part of their doctoring course – a unique feature of UCLA’s curriculum that opens a window on how other forms of care contribute to healing.
“Chaplain rounds are an extraordinary opportunity for medical students in their first year to put human faces and human stories to the illnesses and diseases they are learning about,” says the Rev. Karen Schnell, director of UCLA’s Department of Spiritual Care. “As the chaplain explores the impact and meaning of the patient’s diagnosis on that person’s life, spirit and soul, the medical students cannot help but be profoundly affected as they observe.”
While Chaplain Couch meets privately with a patient who requests a one-on-one visit, the medical students take a breather in the corridor. Cargle is the daughter of a pastor, and she grew up going to church four-to-seven times a week. She says she is spiritual but no longer religious, and she initially viewed this assignment as “a burden or annoyance that I was required to check off of my weekly to-do list.” But her preconceived notions dissolved this day with her first patient encounter. “I never thought a doctor would, like, write a prescription for a chaplain,” Cargle says. “But Rev. Couch told us to use him like a tool in our tool bag — like medicine to take care of that emotional/spiritual side that so many people rely on through difficulty and adversity. It’s, like, give me 55 ccs of Rev. Couch stat!”
Meghana Attaluri (foreground) and other first-year medical students listen during a chaplain introduction meeting as part of their Doctoring 1 course.
And she notes that the pace of such meetings was much slower than the usual pell-mell rush of a medical student. “It was nice to be on that slower wavelength and tune in to where people are emotionally and spiritually,” she says.
ANOTHER PATIENT DURING THE ROUNDS also is having a difficult day and calls out to Chaplain Couch as he passes by her room. “I’m on a pill boycott today,” the patient says. As the chaplain and medical students enter her room, she sends her husband to bring her a piece of pepperoni pizza from the cafeteria. Surely that’s not on her approved diet, an astonished Mendoza whispers in a quiet aside. The patient recounts other antics of noncompliance, but she then becomes curious about her two young visitors, asking them questions about medical school and their personal backgrounds. But her remarks aren’t focused, and Chaplain Couch tries to center her.
“Why are you having such a rough day? Tell me what’s going on,” he asks. Grateful for the company, she says that she’s not receiving as many visitors as she’d like and feels lonely. She also says she feels anxious and has enormous guilt about decisions and actions that she believes may have led to her current medical status. And she worries about the burden she feels she may be to her family. They talk about a biblical reference that the patient brings up, and Chaplain Couch then begins to counsel her on how one must love oneself before others can love them. In the end, Chaplain Couch prays with her, and she asks him — and God — to help carry the burden with her. By the end of the visit, she is visibly more calm and focused — and medically compliant.
Top: Dr. Margaret Stuber notes that, in a survey of students published last year, a majority indicated that spiritual care needed to be addressed to fully treat the patient. Bottom: Dr. Sheila Naghshineh says that students participating in the chaplain rounding program see firsthand the role that spiritual care plays in the healing process.
“It’s interesting that a patient may be more likely to take medications or follow doctor’s instructions if they utilize spiritual care,” Mendoza says later. “I think physicians can maybe learn from a chaplain in terms of boundaries and how one can get closer to a patient while keeping those boundaries.”
OUTSIDE THE PATIENT’S ROOM, Mendoza asks Chaplain Couch if physicians request his services for patients. Yes, the chaplain responds, however, it is more often the nursing staff who call for a spiritual consult.
In his essay later, Mendoza wrote: “The physicians that I have observed rarely have mentioned spirituality when talking to their patients and have been more focused on the biological causes of the disease. Nonetheless, after seeing how much the patient valued Chaplain Andrew’s presence … I believe many patients would benefit and that their outcomes would improve.”
In fact, a study published last year in Academic Psychiatry analyzed 166 essays by students and found that medical students noted an increased willingness to refer patients to a chaplain following their experience on rounds. “Chaplains provide a lot more than performing last rites, baptisms and other religious ceremonies,” one student wrote. “They really offer valuable counseling services to all patients, regardless of faith (or absence of faith).” Another student wrote directly: “I definitely plan to utilize chaplains and their services when providing my patients with whole-person care.”
Other themes found in the qualitative study were clustered into four categories, says Margaret L. Stuber, MD (RES ’82, FEL ’84), assistant dean of student affairs for well-being and career advising and co-author of the study. The most prominent theme focused on the importance of spiritual care; 63 percent of the students wrote that spiritual care needed to be addressed to fully treat the patient. Forty-three percent observed that meeting spiritual needs was therapeutic for the patient, and a third of the students noted that “all doctors should make spiritual care available to all their patients.” The other prominent themes included the significance of the chaplain’s role in the clinical setting, personal introspection and doctors and compassion.
Addressing spirituality in medical school can be challenging, as students may have preconceived notions or not understand how it fits into the context of patient-centered care, says the Rev. Schnell, who also is a co-author of the study.
But having students shadow the chaplain during rounds appears to have a profound effect on the students going forward. “Hearing the chaplain-patient conversation often elicits compassion for the patient in the medical student,” she says. “The overall experience reinforces the first-year medical students’ internal determination to give compassionate care in their calling as physicians.”
Exposure to spiritual aspects of care is not limited to Doctoring 1’s required chaplain rounds. Other courses, like the semester-long selective “Living and Dying: Medical, Psychosocial and Spiritual Approaches to End-of-Life Care,” address these issues.
During the chaplain rounds, students also learn about interview technique. The Joint Commission, which accredits healthcare organizations in the United States, recommends that a spiritual assessment be part of the admission process for patients in hospital settings.
“The impact of a spiritual assessment is huge because a lot of students don’t see spirituality as a medical component when interviewing patients when they first arrive,” says Sheila Naghshineh, MD (RES ’10), chair of the Doctoring 1 program. “They think medication is important, family history is important, genetics is important. But getting a spiritual history also is important in terms of how it affects a patient’s health. Do they find it motivating to pray? Does it affect chronic pain? Do they have the support of their community? Or is it a deterrent in taking certain medications such as antidepressants?”
Adds Dr. Naghshineh: “The unique part of the chaplain rounding is that students are put in this space when people are thinking, feeling, crying, reaching out to whomever they believe in and seeing firsthand how the chaplains are, in a sense, meeting the patient where they are and helping them through the healing process.”
THE NEXT PATIENT ON CHAPLAIN COUCH’S ROUNDS is a man who has received his liver transplant and is hoping to be released soon from the hospital. However, there’s a rare complication. “I know whatever happens, I am at peace,” he tells the chaplain, whom he is meeting for the first time. They then pray together, and the patient asks Chaplain Couch to come back the next day.
“I realized that the healing these patients needed in those intimate moments could never come from a doctor,” Cargle later wrote in her personal essay about the day. “The chaplain is perhaps the only person that the patient can truly be honest with because they are the right balance of ‘keep fighting’ and ‘what will be will be.’ They straddle the line between family friend and perfect stranger. If we are to treat patients holistically, then chaplains must be like balms of Gilead and indispensable resources to the field of medicine.”
Marina Dundjerski is a regular contributor to U Magazine.
“Chaplain Rounds: A Chance for Medical Students to Reflect on Spirituality in Patient-centered Care,” Academic Psychiatry, June 2015