Meaning, The Imago Dei, & More

Ben 0:00
Hey y’all welcome back to beyond surviving residency. I’m your host Benjamin long MD. This is a podcast dedicated to helping residents find more rest, fulfillment and clarity amidst the chaos of residency. Through this series, I hope to equip you with practical tools to move away from just surviving residency and toward flourishing despite it. Today, I had the honor of sitting down with Dr. Kristin Collier to talk about the role of spirituality and religion and physician and trainee wellness guys, you are gonna love this conversation. She is a Michiganian and through and through having done medical school and residency at the University of Michigan, where she is now the Assistant Program Director of the internal medicine residency at Michigan medicine and oversees their primary care track. Additionally, she is the director of the University of Michigan’s School of Medicine’s program on health, spirituality and religion. I’m so excited to introduce y’all to my new friend, Dr. Kristen Collier. Let’s get started.

Alright, I’m here with Dr. Kristen Collier. Dr. Collier, thank you so much for coming on the show.

Kristin 1:21
Thanks for asking me to be on the show, Ben.

Ben 1:23
So the reason why I have asked you on to be a guest on the show is specifically that you published an article called The role of spirituality and religion and physician and trainee wellness, which is exactly one of the areas that we’re trying to dig deeper in to in this podcast series. So I have kind of already introduced you to the audience. But I really would love to know how you became interested in the intersection of religion and spirituality within medicine.

Kristin 1:55
Oh, thanks. Thanks for that question. So this is definitely a newer area of interest of mine, I would say, I actually find myself somewhat surprised them interested in it now given I’ve spent most of my life really including my medical training and several years of my life as an attending, sort of waxing between being a non-theist and really an anti-theist. But several years ago, I became interested in Christianity in particular, for reasons that are sort of long and complex and outside the scope of this podcast, but in part because I was drawn to the person of Jesus who is also referred to often as the great physician, and really the promise of a future restoration of everything that’s currently broken. And so during this time of exploration, at the same time, the dean of undergraduate college of the LSA at the University of Michigan, was looking for faculty actually to teach some undergraduate seminars in the undergraduate college that were sort of a mash up of two subjects brought together. And so at the time, I was exploring Christianity, and I was reading the scriptures and really was drawn to the concepts there in that I saw every day in medicine, suffering, death, dying. And I put together a course that I ended up teaching in 2015, and 16. To the freshmen at U of M, it was called “Fearfully and Wonderfully Made themes of Medicine in the Old & New Testaments”. And so during this time of teaching the course, I was I had to time because of this now part of my professional job to teach this course to reflect upon my medical training. And I realized that I’m an internist. I’m a general internist. So I realized I was pretty well trained in diagnosing and managing physical suffering, marginally well trained to diagnosing and managing emotional suffering, and really largely untrained and how to diagnose and manage social and spiritual suffering. And so in effect, I realized I had really only been seeing and treating like half of my patient in my encounters, and to me as a general internist, that to me felt very unacceptable. And Ben, as you know, as a doctor, patients come to us in some of the moments of deepest distress they will ever experience right. And we know that in such times of distress, existential questions of meaning arise and what is known as spiritual distress occurs. And so during this teaching of the course, I became familiar with Cicely Saunders, who many of your listeners probably know is considered to be like the mother of modern day palliative medicine, and she said that patients suffer or can be well informed in your second quadrant sort of physical, social, emotional and spiritual. And this this model, actually, that we that I draw and that she uses is a circle that’s cut up into these four intersecting domains. And all these types of domains intersect so for example, we know that when patients have under or untreated spiritual distress, the end of life if that isn’t addressed, their physical pain actually can become quite refractory to pain medications and traditional therapies. And then once their spiritual distress is addressed by a closure chaplain, their pain improves and same thing with like emotional pain. So what happened during this time teaching the class I became aware of literature related to medicine that show that patients are want their religious and spiritual needs addressed in their health care, but that isn’t happening, and became very aware of my own deficiencies and how to address these concerns. And so I became very motivated, do something about that. And out of this, then grew my interest in this space, and eventually led to the program that I now directed the medical school called the University of Michigan Medical School Program and health, spirituality, religion.

Ben 5:21
Yeah, wow, man, so many good things there. I am so glad that you were doing this work and was really encouraged by the article that you wrote. But certainly, I might have some people who are maybe listening that are a little bit skeptical, or uneasy about this concept of spirituality, or religion and medicine or spiritual wellness. And, you know, I think part of that, for me, and you kind of touched on it in one of your articles that you’ve written recently, is the fact that we are so focused on this kind of scientistic worldview, that in order to describe reality, as it is that it has to be based upon observable hard facts, when you know, you start digging at that a little bit deeper, probably would find out that there are many things in our lives that we can’t test in a lab that, you know, direct our lives and give our lives meaning and purpose. That is contradicting that. So in one of your articles, you kind of said, you know, when you’re talking about spirituality as a topic for academic discourse, that maybe a systematic and quantitative approach, or even qualitative research isn’t going to be the best suited to address that. Can you talk a little bit about that tension there?

Kristin 6:46
Sure. Yeah. So thanks for pointing this out, as well. So I always sort of joke that I’ve chosen a pretty difficult subject for my area of academic interest, as it’s not super easy to get published on this topic. And it’s somewhat controversial at times, and can be sort of a hard topic to sort of, quote unquote, study. So I think, you know, the first difficulty that you alluded to, and doing academic work, and the topic of religion and spirituality within medicine is that it’s a topic that many people either don’t understand, like how this topic is related to medicine, or people may actually have a distinct sort of negative bias towards the topic and actually want these types of conversations excluded from the conversations in bioethics and medicine. And the nature of the topic itself, as you, as you point out is really hard to study in the traditional ways we sue. And also, I think, you know, some colleagues may feel this topic as a sort of like maybe a soft skill that falls under the art of medicine and isn’t really worthy to be in the same space as the hard sciences. But in I think it was like 1927, Francis Peabody emphasized in his article, the care of the patient, that science and the art of medicine are not antagonistic to one another. And as we continue to advance scientifically, you know, have we begun to ignore the art of medicine, which incorporates what gives me an e to a person. And as you mentioned, in a piece that I wrote with my co authors in the Annals of Internal Medicine, in I think, was 2020. You know, spirituality may seem like an unlikely topic for academic discourse. You know, we pass judgment often times on our fellow faculty members primarily on the basis of the quality and the quantity of their scientific research. But as education minded physicians have increasingly sought to have medical education seen as an appropriate topic for scholarly study and academic sort of research. Some people have tried to place their work within the trappings of quantitative science and this sort of systematic quantitative approach and even work labeled as qualitative research, sort of maybe ill suited to the topic such as religion, a topic based on faith, right. And as faith is Osler acknowledges, falls outside of the scientific model. And, you know, we’ve talked about in that piece, you know, perhaps we ought to simply get to know our patients as human beings, whatever their system of beliefs, perhaps we ought to simply to give them the space to speak and listen to them absent sort of guidelines or checklists, or dare we say at scientific analysis, perhaps that would be the one way to bring us closer to understanding truly caring for the patients as they wish to be cared for. But given all these struggles, you know, we have been very fortunate to be able to publish in this space with pieces in JAMA IAM, Annals of Internal Medicine, J. Jim, the American Journal of hospice and palliative medicine, but again, apart we’re effectively in part trying to study like a metaphysical concept, you know, something that’s transcendent. So how does one do this? Or if it’s done, do we risk you know, stripping down something from the very nature of the subject in order to fit it into our current Limited models of scientific inquiry? And so I’m reminded of the quote from Rachel Redmond who said something like, you know, we’ve traded mystery for mastery and that we’ve paid a great price.

Ben 9:47
Wow. Yeah, that’s such a good quote. And I’m such a fan that you bring up Osler because I’m really interested in his work and his life. Are you a fan or like have read much on him,

Kristin 10:01
you know, I’m not an Osler scholar, I mean, I’m aware of his work. And we were given one of our source texts on my first day of medical school than I had no time to read because I was in medical school. So he’s on my list of stuff, people that sort of dive into his book a little bit more.

Ben 10:15
Yeah, we’re actually on this podcast. And as I work through one of his addresses that he gave back in 1913, called, “A Way of Life”. And this conversation about he talks about it as day tight compartments. And that’s kind of was part of his philosophy of just, hey, let’s focus on the now because if you’re responsible for what’s in front of you right now, then you will be in a better position for tomorrow.

Kristin 10:41
Oh, super relevant.

Ben 10:43
Yeah. Yeah. And really just interesting. And then especially since you know, this podcast is focusing in on residency was critical and the foundation of the residency system. Gatlin, the Big Four at Johns Hopkins. Oh, yeah. And I would love to hear a little bit more about how spirituality and religion since you’ve been thinking more deeply on this has impacted your practice of medicine.

Kristin 11:10
Yeah, so I spent really a considerable time thinking about this, you know, we can have this philosophy of medicine, right, that we wax about, but like, how does it really impact our day to day practice? How do these commitments really are they operationalize? And how do they affect our day to day practices as physicians and so you know, I’m a newer Christian was baptized a few years ago, and in that, in, in this area of exploration have really thought a ton about specifically what Jesus’s life and words and actions show me about, you know, his mind and his perfect vision of the good and how that relates to my medical practice. Out of this exercise, I’ve come up with what I call my theology of medicine, or if that if that term freaks people out, you can sort of consider it like a philosophy of medicine. And it centers around the core principles, but sort of consists of how I see my work as a physician now that I didn’t have before. And once folks have their own philosophy, or theology of medicine, you know, everything else sort of flows out of that. So this is affected, like my view of the patient, my view of what medicine or healthcare is, or isn’t, what research questions now that I’m passionate about, that I want to pursue and how I teach the language that I use, and what I want to sort of advocate for in some of my writing. So my theology of medicine is focused around three main principles, first of all, is that I see my patients now is being made in the image of God. And because of that, my work has inherent meaning. You know, I’m not taking c are of a bag of bones or a diabetic or a clump of cells, I’m taking care of the Imago Dei, you know, someone made by, by God and His image with inviolable dignity and inherent worth, instead of what what type of work matters more than that, you know, that’s, that gives work inherent meaning. And so the second principle, I would say, my theology of medicine is that matter matters because of the Incarnation. So bodies matter, because Jesus Christ had a body has a body and central to the Christian faith, our bodies, you know, Jesus redeemed every phase of our lives that he passed through, including our physical cells in our bodies. And so to me, as a doctor, that really resonates with me that people’s bodies matter people matter. And lastly, my theology, medicine is based on a non violent practice. And so Christians of how the commandment about not killing and we have Jesus who embodied this commandment and his work of non violence. And so it’s my opinion that killing cannot and should not be a part of medicine. So this affects how I see you know, the death penalty, physician assisted suicide, euthanasia. So I’ve been very influenced by Jesus as the great physician and his attributes that serve as really the ultimate role model for me his use of touch in the physical encounters he had, he always attended to people in the margins of society. And he always saw people in the fullness of who they are. And so this has led me practically to do work in our local women’s prison here before the pandemic where I was involved in training prisoner palliative health aides, and I oversee our underserved medicine elective and I’ve been able to write and speak about trying to reclaim a view of human dignity that speaks to the inherent value of every human being based on being the image bearers and not based on some type of, you know, value that’s attributed to them by a consumerist culture that often places value on people based on like, what they’re able to do in terms of producing and consuming. So I’ve received, you know, this gift of faith pretty late in my life, but I’m thankful for it. And this gift really has been a new way for me to see meaning in the work that I do. And on a personal level to is helped me cope with some of the really pretty awful things that that I see in medicine, you know, there is no, there’s no perfect, you know, theodicy theodicy is this concept of like, God is all good, he’s all powerful. And about you know, evil exist, right. But there’s no perfect way to make sense of that of the suffering that we see on this earth. But I am I’m really comforted greatly by the scriptures, which speak of this really not being the way things are supposed to be and there’s a promise to eventually wipe every tear away and restore what has been broken and to make all things new and so that that hope of a future like eschatological sort of restoration, especially amidst all the brokenness that often I have no you know, I can’t do anything about, to me has actually been a source of comfort for me and alleviated some of the moral distress that I’ve had over the years as a physician. And in the midst of seeing so much, so much brokenness. Really?

Ben 15:12
Yeah. Oh, man, Kristin, I could just dig into so much of what you just said there.

Kristin 15:20
That’s sort of a heavy topic. I realize.

Ben 15:23
yeah, yeah, no, and no, it’s so good. Because this is exactly what I think is missing in so many conversations in medicine right now. And I have to touch back on the fact that you’re talking about one of your three kind of pillars is the Imago Dei, because I think of anything that Christianity has to offer for medicine, that that is so valuable, because it is easy to give dignity to patients that you like, and that listen to you, and you know, do what you think is best. But then especially when you encounter what we you know, many people would call “difficult patients”, or these like really just lives that are just dissonant to your own, it can be so easy to just kind of retract. And I think in some ways unconsciously respond in ways that we wouldn’t if the patient was kind of more amenable to how we want them to act or want them to practice or some combination of those things. And that root of this is a person who has made in the image of God, and because of that gives them inherent dignity. So even when all they have is Venom for me, and just lash out, you know, I think as a Christian, that rooting also gives an understanding that part of that is because they have not experienced so many of the good things and the grace that God has given kind of in creation. And so that’s certainly something that I want to talk about more and explore more on this podcast. So I’m very glad that you brought that up. And I think yeah, has amazing possibilities within medicine. The other thing I wanted to kind of touch on real quick, is, you know, you said that for a long time, or you’ve been a Christian for a short while. So maybe just another word or so about. Because you were practicing medicine before you were Christian. Correct?

Kristin 15:23
Yeah.

Ben 16:11
Okay. Yeah. So, so maybe a little bit about in your own inner life, what you have noticed that shifted between before and after your conversion? I guess the contrast between those two?

Kristin 17:45
Yeah. So I mean, I think the biggest contrast as it as as it relates to medicine, and the podcast topic, is really sort of what you what you touched upon, really, which has been, I mean, to be like, overly dramatic, but really, it has been a dramatic shift in my viewpoint about the inherent dignity and the worth of every human being, and how I see patients really, I mean, in there, because there are real implications to how we see patients, you know, what, like, how do we see patients so for example, there are a lot of studies that show that physicians are incredibly ableist actually, when many of us come from privileged backgrounds, we oftentimes are very able bodied, that’s how a lot of us have been able to sort of get to this place because it you know, medical education doesn’t wait isn’t fully encompassing of people who have chronic illness or disability. And so a lot of us are shaped by that culture, right. And we have this view of patients, oftentimes, as you said, but a lot of value on patients based on things that are sort of accidental traits, or that are things that are very intellectually minded. So for example, we’ll say, gosh, yeah, this this patient, this businessman, right up on the cardiology service, who’s like a productive member of society, and he’s working and fits into this also this idea of this consumerist culture that we live in producing and consuming, he’s intellectually intact, we would value him oftentimes in the way that we talk about our patients on the floor that we have policies around patients, more so than the quote unquote, and I hate this term. I’m using it only because I’ve heard it used, I just want to point it out, like the vegetable right up on ad who’s the person who may have had a catastrophic anoxic brain injury or who has end stage dementia? Right? And so how do we do we actually see the person who has unsafe dementia in the moral sphere of concern of the US in the same way that we see the businessman up on the cardiology service? I mean, and I have shame in admitting this, but I remember you know, as a medical trainee, like, I didn’t think of those two folks the same. You know, I often thought I often term you know, use terms oftentimes we’re very ableist like, you know, thinking about qualities or quality of life, which again, is very framed and shaped but what like what I thought quality of life to be but there are studies that show if you ask doctors actually about quality of life What do you think that person’s quality of life is? You know, and you have doctors judge what they think the quality of life is of a person, for example, that has intellectual, you know, injury, for example, disability or cognitive disability and stage dementia, we rate their quality of life much worse than if you ask the patients themselves and then locations at Florida. So there was a case in Texas a couple summers ago, during the first surge of the pandemic in Texas, a man named Michael Hickson, who was a black man who had an out of hospital cardiac arrest several years prior had anoxic brain injury, was in the hospital with COVID. And he definitely had significant physical and cognitive limitations because of his history of anoxic brain injury. But he was married, he had a family, his children, he were very close. And, you know, he had COVID. And his family was asking for him to get at the time. And I think it was like when destiny or something like that, and the doctor is on the wife actually videotaped the doctor, saying, like, we’re not going to give this medicine to your husband. And she was like, Well, why is that? And he said, Well, he doesn’t have you know, a quality of life. And she’s like, What do you mean, he’s like, Well, he’s not like a walking and talking person, you know. So again, this doctor, you know, the way that we view patients has real implications for the way that we triage the way that we talk about the way that we may be like, think about rationing resources and times, and there’s limited resources. So how do we see the value of human persons do we place upon them some type of value based on what they can do what they can produce? Are they able to think because if that’s how we’re placing value on patients, there are certain patients that are going to be left out of the scope of the US. And that’s going to have real implications for how we treat and see those patients. So I think the biggest shift has been me seeing every person made an image of God with inherent inviolable dignity, and not based on like, what they can do, you know, some attributed external sort of dignity that we can place upon them. Because so many of our patients, as you mentioned, we consider it to be socially dead, right? People with substance use disorder, people who are on domiciled, you know, the refugees, the immigrants, all those folks, if they’re outside of the concern of our moral sphere of concern, because of who they are in our minds, that that’s a real problem to me. So I’m really thankful, actually, for this new shift and the mentality that I’ve had around the Imago Dei.

Ben 22:11
Yeah, yeah. And I think you’ve pointed out so poignantly, another arm of this podcast, too, is that moral formation occurs in medical education, and that in some ways, medicine is a moral enterprise. And there are so many judgments and, you know, discussions of value. And the problem is that there’s such a shift towards the scientific, that physicians are coming into the profession, not well prepared, even to have discussions or even be aware of, oh, I am making a truth claim or a value judgment or something here, that is not actually medicine as far as a biomedical decision. And you know, so much of that, I think, is within medical education, what and probably what we’d call the “hidden curriculum” that we are just encountering in everyday life. And so I think that’s why your article is so important here of about why we need people who will champion trainees spirituality and religiosity to help people bring their full selves to medicine, because not only of the diversity of patients that we are serving, but then in your article, you talked a little bit about the increasing diversity of identities involved in the medical profession, as well as the potential as a maybe a protective factor against burnout. Can you speak a little bit more on that?

Kristin 23:43
Sure. So you know, thankfully, there has, there’s been an increased focus in many areas, including medicine on diversity, equity inclusion, rightly so, you know, we’re not going to be a strong profession unless we have diversity amongst all our ranks at all levels, and have a workforce that really represents the people whom we are treating. And, you know, religious diversity is part of diversity, but it’s a very under recognized under discussed aspect of diversity. So one study that we quote, in one of my manuscripts you know shows that up to like 30% of physicians enter into the vocation of medicine, in part because of their sort of either religious or spiritual commitments. But then what happens is, you know, they get here into medicine, and we make it seem like they have to check their faith at the door to practice medicine, to be considered like a legitimate scientist, you know, and then what happens then is the one great pathway they had to meaning-making and the vocation and a huge part of themselves is shut off from their professional identity, which we argue in one of our pieces was really counterproductive. So you know, like many complicated issues, burnout is a multifaceted problem and deserves a multifaceted approach. But, you know, we know at least in part, burnout can be prevented or at least alleviated by having a sense of meaning making and living work that you do. And for many physicians, they make meaning in their vocation through the lens of their religious and spiritual commitments. There was a recent NAMS report on clinician burnout, and one of the recommendations they make in the huge report moving forward. And around burnout is to provide pathways of meaning making for physicians in order to combat burnout. So, you know, we shouldn’t make a religious or spiritual physician feel like they have to be a religious person on Sunday, for example, and then they can be a physician Monday through Saturday. But instead, for those other interested, again, have this identity that someone has been marginalized, I think we should help them understand how they can be, for example, a Jewish physician, let’s say, with an integrated personal professional identity, all these are the weak, because as you said, we can’t expect our physicians to take care of whole persons, if they themselves haven’t been treated and seen as whole persons who can’t bring the entirety of themselves to work. And in our conversations around Dei, you would be total hypocrisy for us to say that we welcome the diversity of physicians in all the ways they can be diverse, except for religious diversity, that just wouldn’t make any sense. We really should be calling that out. But I have faculty, students and staff at various institutions across the country, reach out to me who tell me that they feel like their religious and or spiritual identity is really a marginalized part of their identity. And they’re afraid, for example, to put their involvement for example, in their synagogue or organizations like, you know, Christian Medical Dental Association, or to wear their, you know, his job, you know, in their heirs photo or put these things on their Eris applications because of fear of backlash or discrimination. And that’s frankly, unacceptable.

Ben 26:33
Yeah, absolutely. And there’s just such this idea that religion and spirituality is going to be antagonistic against progress in medicine. And I’m still exploring that. And I do think there are certainly a lot of historic and sociological reasons that are contributing to that. But I think a big part is just the fact of how it has been discussed. Typically, when I’m kind of trying to take a spiritual history or something, usually I just start off with just like, is spirituality or religion important in your daily life? And just let that kind of open the door to see kind of what people say, you know, yes, no. And if it’s no, then that shuts the door. But you know, if that changes, they know that I’m a person that they can talk to about those kinds of things. But I’ve seen, or I’ve had discussions with patients and families, where I have to kind of come away and wonder, would they have disclosed those things if I had not opened that door, about spirituality and religion, because they have so many things that are going on in their lives, and, and socially, but so many of those things touch back to their faith. And so maybe part of that story would have been revealed, but I certainly felt like I have a better picture of who they are as a whole person with that. And unfortunately, for people who aren’t in an institution that kind of focus on this, or don’t have a personal interest themselves, I think so much of it is kind of like, okay, how does your your religion impact your care? I mean, I think that’s one of the things that I’ve seen just even on a variety of different kind of documentation or forums at the different hospitals that I’ve served at, through the years of my training, have an even I’ve had people when I start asking, like, how is this you know, is important your daily life? And people will say, like, “oh, yeah, but it doesn’t impact my care”, or like, you know, automatically jump to, you know, the the totem of a Jehovah’s Witness who doesn’t want to have a blood transfusion. And I think, unfortunately, that has been kind of the, the frame that so many people think and they don’t realize kind of what we’ve touched on is, there is a wealth of data that shows that involvement in religious communities, and that these things are linked to not only this kind of better meaning and purpose, but also health outcomes and health factors as well. And so I think that does seem to be kind of that first step of just being able to take a step back, if you have that response of kind of like, Oh, we don’t need this just thinking, Okay, why do you have that response? Have you know that this isn’t a place for this kind of a discussion?

Kristin 29:32
Yeah, yeah, we’ve totally we’ve totally, you know, our patients come to us. You know, if you look at the Pew Research and such so many Americans, us Americans endorse a belief in God, some of them endorsed belief in God. You know, according to the scripture, some believe in sort of more about a higher power, divine power, if you look at specific subsets of the population, specifically blacks. To patients that people who have who are also populations we really are called to serve in medicine, if you look at global health or even in immigrants refugees, a lot of those folks have strong religious and faith commitments, and they’re not just deists, not believing that like God’s, you know, up there and just we’re sort of like round the clock and said it. And there’s like, he’s not involved, like you look at that actually religious sort of beliefs of some of these subsets of the population. They believe God’s like intimately involved in their lives. And so our patients come to us with this framework, their faith informs the way that they view their illness, their path for wealth for getting better for healing, they oftentimes have spiritual distress around this belief, like, why is Why is God allowing this to happen to me, they don’t feel a sense of peace, they oftentimes will say, you know, what’s gonna happen when I die, they’re gonna use their faith in terms of how they view end of life, sort of decision making and decision making, you know, just in general, oftentimes, in Muslim families will rely on certain sort of decision makers within the community, because our patients have these beliefs they have these needs. And if we’re not aware of these, and incorporating the patient’s most deeply held values, like in their care plan, like our care plan is going to be impoverished. And I agree on that a lot of it is you sort of I think, maybe you’re hinting at is because of a bias, you know, like, whatever your thoughts are about this topic, you know, your patients deserve to be seen in the fullness of who they are. And if we’re going to be practicing care that is around, it’s not paternalistic, what we decide is fast, but we’re actually going to incorporate patient’s most deeply held commitments and values in the care plan, then guess what we’ve got to ask whether mostly if we have commitments, which for a lot of patients actually, is around a faith or a religious worldview.

Ben
Yeah, absolutely. And, and I think part of that is just that medical education is not equipped to be able to necessarily address that bias directly. And I think that’s, that’s a concept that I’m wanting to explore that I’ll have introduced on the podcast before this one about specifically thinking about physician spiritual wellness. And my current description of that is that physician spiritual wellness is this this journey for meaning and purpose, and that has to address our own biases as well, that’s amidst our day to day life as persons within medicine. And it’s this interaction of our inner life with kind of the rough and rugged stretches of our path. And for it to be wellness, its destination has to be becoming a good physician. I’d really love to hear kind of your response to that description and kind of feedback you have on that.

Kristin
Yeah, I was able to read the description you sent me as well. And I love that you’re thinking about this, I think, I mean, I finished residency in 2005. And I still feel like I have legitimately some source of soul trauma from that about how hard it was. And I was totally unprepared to handle like, you know that the big questions that we see in medicine, like why is my again, like not that you will have a fully ever an answer to this. But these things weren’t even like talked about why was my 35 year old mother of four dying from like metastatic ovarian cancer and like, I can manage her medical symptoms, but like, if there wasn’t any conversation around the effect about on me and like, how do we think about suffering in medicine? And what are the goals of medicine, just these traumas that we see. And I think you went into medicine, most of us went into medicine, I would say to help people, right?

Ben
Yep.

Kristin
And then you feel like right off the bat, you know, your first day of medical school, you’re focused on, you know, studying diseases, then you study sort of disembodied organ systems. And then you find yourself studying receptors, and then you eventually find yourself like endlessly replacing potassium out of your 2am page. And again, not that replacing potassium isn’t important, right?

Ben

Right.

Kristin

And that the study of diseases isn’t important, but they are operationally disconnected from any larger source of meaning making in any real way. And so what’s flowing out of this shift and like the clinical gaze that Foucault talks about, Jeff Bishop talks about in his book and Anticipatory corpse is that, you know, medical education has become progressively more materialistic and sort of reductionistic in nature. And when you focus, you know, just sort of solely on the biomedical aspects of illness and disease, you know, that creates, I think, a moral distress for patients and physicians and learners. Again, many people came into medicine to treat and accompany persons through illness and suffering. But then in medical education, they are taught and you sort of mentioned this, like in the hidden curriculum, but sometimes explicitly in the formal curriculum, that life is really no more than molecules in motion. And we study disembodied organ systems, and you learn to see your patients in a fragmented way. And you aren’t taught to see people in the fullness of their humanity. And what happens is, that type of education leads us to see our patients is sort of like a bag of blood or bones or a clump of cells or molecules in motion, and this causes a moral distress. And I think, you know, medical educators, I think, thankfully have taken note of this of late and there are efforts to bring a type of humanism back to medical education, but there’s so much more work to be done. You know, we’re not we’re not technicians taking care of complex machines. We are human beings taking care of the image bearers. There was a clinical scholar at our place at Michigan Nauzley Abedini, who now is a geriatrician out at university of Washington. When she was at Michigan, years ago, she published a really cool piece that I love. It was in JGME, 2017. And she looked at different aspects of burnout. And she says in the piece, which I had never thought about before that actually there are two types of burnout, right? So circumstantial burnout and existential burnout. And so for people who are interested, the pieces titled, “It’s Not Just Time Off”: A Framework for Understanding Factors Promoting Recovery from Burnout Among Internal Medicine Residents”, so categorizing people’s burnout, I think just circumstantial versus existential experiences, I think may serve as a helpful framework for formulating interventions, you know, circumstantial burnout is around things like your, your schedule, you have no control over that your time off. But existential burnout is a really real thing, too. And this comes down to me making burnout I think, is expected when we haven’t prepared the students or residents or faculty to anchor their practice and any values or meaning or context, but we educate only in content. And you mentioned this before, you know, do we recognize that proper medical education doesn’t and shouldn’t just teach content, but engages and I guess, dare I say is involved in the formation of person. So this concept of formation, it’s been, I think, very under developed in medical education. So you know, Aristotle wrote that there are these three types of knowledge you know, knowledge of the that which is the epitome knowledge of the how, which is like techni and then this other type of knowledge just like applied wisdom of like what to do, should we do it? Why are we doing it and he calls us phronesis,

so you know, Med Ed is really good at providing the knowledge of the “that” – the episteme and, and the “techne”, but really not as capable in the domain of preparing us about the “should” the “why”, you know, this phronesis, you know, these types of questions of meaning making really can’t be explored in a technical model. But the technical model is really, I think, comfortable for a lot of people, right? It’s like, we can like talk about it. It’s like, values neutral. But there’s nothing that’s value neutral, folks. Like, everything is value laden, especially medicine, right?

Ben
Yep.

Kristin
And so I think, you know, not to sort of throw Med Ed under the bus. I mean, there’s so many I am a medical educator, I understand the tensions, and I understand the limited time and the curriculum and such. But I think without a values model, Incorporated, we really are robbing our students of a proper understanding of the telos are the goals, meaning and purpose in medicine. And so I think as a result, many people, including myself, feel that my dad really is falling short of providing the resources necessary for students to find, you know, meaning in their vocation.

Ben
Yeah. Oh, my gosh, I need to just like put it out there that I didn’t, you know, like, didn’t say, like, bring up Aristotle or. But it’s so funny that you, you did because the guests that I have lined up right after you is Warren Kinghorn

Kristin
Oh from Duke! Yeah! awesome!

Ben
Yeah. Yeah. And so specifically his article on the like, Aristotelian perspective on moral formation in medical education. So thank you for making just a perfect, yeah, transition to that next episode.

Kristin
I don’t know if you’ve read Abraham Nussbaum’s book. He’s uh- I believe- he’s a psychiatrist in Colorado, he wrote a book called “The Finest Traditions of My Calling”. And just something you said reminded me of his book, like, you know, he says in the book, if no one ever asked you about something, you learned that it’s not important. And if we never, like ask our patients about their deepest health commitments, or we don’t like, you know, God is basically absent from the hospital, the patients realize, like, gosh, this isn’t something that like my doctors feel that’s important, or that that this whole system recognizes, but the same thing too. And you sort of mentioned it earlier is like, if our learners never see us as attendings, right? Ever model that. They’re gonna think like, Oh, yea that’s something I just learned in med school, but like, that’s not what real doctors do, right?

Ben
Yep.

Kristin
So we have to be able to have these things vertically integrated across the curriculum, but also like in practice, because if we don’t ever see like, our attendees, ask patients questions that like, extend beyond the biomedical symptom questions like, Are you at peace, or if you use like a FICA, which is the faith, sort of spiritual history tool? You know, you people are never going to do it, because they’re not going to think that this is something that like real doctors do, because people a lot of people learn their skills from like, the apprenticeship of the role model, but they see their attendings do but yeah, Abraham Nussbaum talks about some of these things as well. And he’s fantastic. But yeah, Warren is great as well. That’s so cool.

Ben
Yeah, yeah. And I have not read that yet. So I’ll definitely have to put that on my list. And I know, I’ve heard you say this, that you’re kind of equated for people’s hesitancy to kind of address this specifically with patients because like, we now ask about sexual health history. And previously, that was kind of like, oh, we can’t ask about that. That’s too intimate. That’s too taboo, kind of a thing. And that now, like spiritual health, is this last taboo, that we you know, we need to like overcome and allow our medical educators to be empowered to ask these Question so that they can model that for the next generation of physicians to see that, hey, this is an important part of life for many of my patients. And regardless of how I feel about that, it isn’t taboo for me to bring that up. And there, I think there are some specialties where you get that more I certainly see that as a sleep medicine physician, when I’m asking questions about spirituality and religion. And because I am a Christian, I think I have more comfort with kind of diving into that with people who say that they are from a Christian background. And so certainly, I would think you would agree that we’re not asking people to become pastors or chaplains, or things like that, for sure. But then, in your biomedical knowledge, you’re going to have strengths and weaknesses in certain areas, like I, even though I’m a pediatrician, I hate rashes, I am not good at the random little bumps that like pop up and then are gone by the time you get to me. But you show me the picture. And you’re like, what are these? and I’m like, “I don’t know! It’s gone. Don’t worry about it!” But in the same way, in this realm of kind of moral knowledge, and spirituality and faith, there are going to be natural strengths that different people have. And I think we should want clinicians to be able to utilize the tools that they have in their toolbox for those strengths to help patients. So for me, in my practice, you know, when I have someone who says that they are Christian, and I’m talking to them about their insomnia, or something, natural part of Sleep Medicine is to get a sleep history. And part of that’s your bedtime routine. And it’s so interesting that I found that so many people who say that they’re Christian, and they have religious routines at bedtime to include prayer and Bible reading. But then when I asked, okay, so how does that impact your winding down? How does that impact your ability to fall asleep? And it’s just like this light bulb. And they’re like, “I’ve never really like thought about that”. And if I asked him, you know, how do you pray? What does your faith tradition, talk to you about prayer, and especially people who maybe come from more of an evangelical background, and I see a lot of those too that they just like, well, I have a very spontaneous kind of conversation style, where I’m just kind of walking through my day with God. And so it just gives me an opportunity to kind of open up, hey, you know, other faith traditions in Christianity have different, maybe more contemplative practices for prayer, and different ways of understanding prayer. And we know that in the literature, that meditation and things like that help to kind of decrease your sympathetic response. And so let’s try and integrate this into your plan because you’re already doing it. So I don’t have to, to start something new. But let’s think about this as someone who struggles with insomnia and you’re trying to kind of wind down to fall asleep. And so So certainly, that same approach would not necessarily be as applicable if you are like an interventional radiologist. But there are probably moments and things within every person’s practice of medicine, where we are encountering people and relationships, and we just don’t know what we can discover of how we can help our patients unless we ask and try, you know.

Kristin
Correct, I know we talked about in our piece that we got published in American Journal of hospitalized medicine, like last year, I think it was, it was a qualitative piece that we looked at our ICU docs up the adult palm crit care physicians at Michigan medicine, and we talked to attendees and fellows and ask them, you know, what are the barriers to you, you know, addressing religious and spiritual patients, and one of them, which you sort of alluded to, in in your and your comments, that came up as one of our themes and that analysis was that physicians are less likely to bring this up if if with a patient if the patient and themselves had like discordant religious views, you know, because like physicians don’t like love to like, look like they don’t know what they’re talking about, or to put their physicians who were like, you know, Jewish religion, if they had a patient or like, they were less likely to bring up because they said they, they didn’t want to say to say the wrong thing, or put their foot in their mouth or like offend someone. So they sort of ignored it, which again, is like, not super helpful. But as you said, we all have like these different strengths and weaknesses. And so especially, like, you know, all the rage, thankfully now of interprofessional. Teamwork, right. And we thankfully and I know a lot of a lot of folks have have these folks have their places. We have a very strong spiritual care department. We have community clergy, we have our chaplains, you know, again, like you mentioned, like, if I have someone who has like, I’m able to handle a lot of stuff in my practice, right as a general internist, but if I have someone like Brugada syndrome, I got to pick it up. And then guess what, I’m going to have my cardiologist get involved, right? So just the same, like, if my patient has spiritual distress, like I’m going to get my Chaplain involved, but I have to at least recognize it right, I have to be able to be able to pick it up because it’s, if I don’t, they’re going to suffer with it silently and like that’s not great, you know. So, again, look, you’re going to use your interprofessional team and your community stakeholders if you have patients who have their clergy and they’re connected within the community to be able to come in but you know, if I don’t even like legitimize that this is a real source of suffering for them or to be able to recognize it. And to get them the help that they need whatever domain that may be, whether it be social work, Chaplain, your cardiologist, your like consultants, right? You’re not doing a whole person care, which I think we’re all trying to do.

Ben
Yeah, absolutely. Well, I’m so thankful for this discussion. So far. We’re kind of closing a little bit here. So I like to end every interview on the on surviving residency with two questions. So the first one, what’s one thing you’re doing to move toward flourishing instead of just surviving right now?

Kristin
So many things I’m trying to do. I guess one thing I’m really excited about now is I’m currently reading Professor Carter Sneed, he’s a, he’s a professor of law and political science. He runs the genetic Law Center for Culture and ethics at Notre Dame, he wrote a book, the book is called, “What It Means to be Human: The Case for the Body in Public Bioethics”. So I’m currently reading his book, because my program and health spirituality and religion is co-hosting a seminar series with him, we’re co hosting it with a new educational foundation. I’m also part of at the U of M, called the Baroque foundations, we’re hosting a seminar series with Professor Sneed on this topic of what it means to be human. And we’re going to work through his book. So the book was named as one of the top books of 2020 by the Wall Street Journal, and it talks about like reclaiming an embodied anthropology, which again, to me is just like, I love thinking about this topic. So you know, it’s important for all of us, especially in medicine, in my opinion, to deeply reflect on this question, you know, what does it mean to be human, like, who counts as a person in our society, you know, gives us I talked about earlier, these decisions affect our policies and our practice of medicine, so, and anyone just, by the way, anyone who wants to join us on this seminar series by Zoom is totally welcome. And so I’m really excited about that project and working with this Baroque foundation to sort of help encourage undergraduates to think about sources of meaning and what it means to flourish as an undergrad and not just sort of, you know, have a technical sort of mindset as you go through your vocational training. But also, I’m also working on writing a book with my husband, Tim, that’s going to be on something called feel biology, again, sort of more musings on big questions that helped me see my own life and vocation more clearly. So that’s, I guess the two things I’m pretty excited about right now.

Ben
Awesome. And I realized we I don’t think we’ve kind of dived into it. Can you tell us a little bit more or fill in any more details about the University of Michigan School of Medicine’s health, spirituality and religion?

Kristin
Yeah, thanks for asking me about that. So yeah, so I direct a program at my place called the University of Michigan Medical School program on health, spirituality, religion, and we’re pretty unique, and that we’re the only public medical school in the country that has a program such as ours that really isn’t affiliated with like a divinity school, or isn’t some isolated research child, but it’s actually under the medical school umbrella. So this program came about, as I sort of mentioned before, after I was teaching this undergraduate course. And I became very motivated to think about how our curriculum at the medical school was at, you know, being able to address what the AAMC calls these sort of spiritual competencies in learners. And at the same time, you know, I brought this up,the Med School was undergoing this huge curricular redesign. So I went to the dean and said, Hey, as you redesign the curriculum, can I help think about incorporating some curriculum around spiritual and religion and patient centered care. And it was amazing because at the same time, he’s holding a family, a private family had approached the medical school, wanting to sort of fund an initiative around religion and spirituality. So I was invited out to like a dinner with the deans and like the family, the development office, and some other stakeholders, and we discussed like what a program could look like and Michigan in the space. And then a few days after that, the Deans called me and said, they wanted me to start this program. And I had some reservations at first as I really didn’t have any experience in starting a program, but after a lot of conversation and thought I accepted their offer. And then I was able to sort of go on this like listening tour and talk to other relevant stakeholders at our institution at what a program could look like. And many colleagues across the country who do similar types of work, were able to be very generous with their time with me and share their wisdom. And then an academic year 2017 We started the program and I ran the program, actually with a resident and because I wanted resident involvement and learner involvement in the program, so Dr. Jeremy bruke, who was a resident in Department of Psychiatry, and who had done previously some rabbinical training, and now we have two core faculty who help direct our efforts. Dr. Phil Choi, who’s a Pulm Critical care doc and Dr. Adam Baruch, who’s a obstetrician gynecologist, and our program really has four goals. We run curriculum for our preclinical and clinical students. We support students and trainees in their research projects in the domain of religion, spirituality medicine, we mentor students about their professional identity as relates to this topic. And we also run a monthly speaker series on the intersection of religion, spirituality medicine. And our larger goal too, is to, as we’ve talked about, is to sort of publish and write and talk about this topic to sort of add to the academic discourse as This topic can be legit legitimate and relevant to the really integral to the practice of medicine, which is I’m very thankful for the support of my place and the dean’s office and our donors, and with the engagement of our place with our program over the past few years.

Ben
Wow, absolutely. That sounds like such a great program and an amazing opportunity. Our last question would be, so one aim of this podcast is exploring what it means to be a good physician. So can you tell me about a good physician you personally know in medicine?

Kristin
I know, I’m so fortunate to get to know so many doctors who are beyond amazing. I guess one person that comes to mind is one of my colleagues at Michigan Medicine, Dr. Sarah Hartley. She is the current ACP, governor of the state of Michigan. She’s a fabulous hospitalist she’s so incredibly smart. But more importantly than that has, I think, this concept that we talked about this phronesis, you know, she’s incredibly wise. And she’s really the person that I would always go to if I have a tough decision to make. And she’s always so thoughtful and thinks about things from every angle. And she’s patient. And she really is, which I think is a very integral part of being a good physician, She’s curious and loving towards other human beings and her patients, her students, her colleagues, her friends, and I’m really truly lucky to know her. She’s one of those people who you always come away from having been been bettered by um in a way.

Ben
Absolutely. Wow. Thank you so much for your time and contributing to this kind of exploration and digging deeper. And it was just amazing to be able to sit down with you.

Kristin
Yeah, this is truly a pleasure, Ben. I think this type of podcast is really I wish this type of podcast that it existed when I was we didn’t have podcasts when I was a resident, but if I had been a resident where the time and costs have existed, this is totally needed. Thank you for your hard work on it.

Ben
Thank you. I appreciate that.

Alright, y’all! Man! That was such a good episode! I think my favorite quote from that was when Dr. Collier said that we are not technicians taking care of complex machines, but rather we are human beings taking care of image bears. Mmmn – So good! Hey, if you enjoyed this show then I’d love to connect with you and I’d love to know your thoughts about this interview, feedback, comments, whatever. You can connect with me on Instagram @thewholeheartedMD. Or if you don’t have social media, then you can also reach out to me through the website, thewholeheartedmd.com Looking forward to more on this in the future and can’t wait to connect with y’all. Hope y’all have a great week. Bye, everybody.