Sirisha Narayana, MD

We spoke with medical social worker Laura Shea, MSW, LICSW on her role at our tertiary care hospital. Laura’s reflections on the struggles and rewards of her job may resonate with those of us who search for balance and meaning in work.

Laura, tell us about yourself. What made you want to be a social worker?

I couldn’t really picture doing anything else. I got a degree in psychology and loved counseling. Social work was a natural fit because of the social justice component and the look into larger systems. I knew I had the skill set for this, and for those most marginalized, to be a supportive person for someone who doesn’t have that.

I also have a family member with major mental illness and chronic suicidality who I supported for a very long time. In many ways, I was a personal social worker advocating on their behalf while growing up. I remember being in high school when they overdosed, and going to the ER in the middle of the night. The next morning, I was back at school. I was a total do-gooder—President of the student council and on top of my grades. I tried dealing with this while keeping up the appearance that everything was ok, even though it wasn’t.

As I got older, there were middle-of-the-night phone calls professing suicidality which were so painful. I learned a lot about compartmentalizing and resiliency. It has given me an incredible amount of empathy for family members of patients. I have learned that it’s not always simple, and decisions aren’t easy, and solutions are complicated and can feel incomplete. We often hear, “Why hasn’t the family stepped in?” Well these issues are hard for families too, I know from firsthand experience.

At the end of the day, as challenging as the work is, I get something from it. I feel honored to bear witness to some of people’s darkest moments and also some of the most beautiful moments—the joys of coming out the other side of their process and journey.

How much of your personal story do you reveal to your patients?

I rarely do. However, to some families that are particularly devastated, I do share some of my family story. I try to affirm their challenge and acknowledge that family and friends can’t always “solve this.”

We have a culture that reveres going above and beyond, however I really honor those family members who can set boundaries. Sometimes caregivers need space, that doesn’t make you a bad person. It’s actually brave and really hard to do. You can’t give from an empty well.

Laura, tell us about your typical day.

Well, it begins with responding to e-mails. Then I meet with patients and obtain collateral to prep for multidisciplinary rounds (with physicians, RNs, case managers). I usually consult on 20-30 patients a day. In the afternoon, it varies -- maybe three patients are leaving that may need my help with things like providing substance use information or shelter resources. Typically, I’ll have a few complicated long-term patients, who may have challenging family dynamics, ongoing goals of care discussions, or behavioral difficulties. These patients keep me just as busy, it’s not quite as time sensitive but I have to keep chipping away at the work.

Seems like a busy day. Do you get a break at all?

When possible, I take a walk in the woods behind the hospital on my lunch break. There’s a beautiful path, it’s an important part of my day -- getting outside and taking a step back. I bring my pager, so I am still connected.

I used to feel like I didn’t have time to take a break, and I would work through lunch. But now I find if I take a break, I am more productive the rest of the day because it makes me more mindful. It quiets me a little, gives me perspective on the stress and stressors of working in the hospital and allows me to better connect to my job and others around me.

What does a successful day look like?

Well, one involved a homeless gentleman and a search for his family. He was in his 40s, though he looked much older, and recently had been assaulted at a shelter. He presented to either the ER or was admitted to various hospitals 14 times over the past month – typically for intoxication and hypothermia. He kept saying “I just need to find my brother” though no one was taking this request too seriously. We spent a lot of time looking for his brother with the Office of Public Guardian’s help, and we actually found him! The patient hadn’t seen his brother in four years and as it turns out was searching for him too. The brother thought the patient had passed away. With his brother’s support, the patient is now housed, going to alcohol treatment, reunited with his family, and taking his medications. His whole life changed. So that was amazing, and a reminder of how rewarding this job can be.

What is most challenging about your work?

The biggest challenge is grappling with the limitations of the system, and discharging someone to the community when the community has limited resources for these patients.

Though it’s not just the limitation of resources, some patients have been through the system so many times that as a coping mechanism and to protect themselves they do everything possible to push you away. They have walls firmly up, because of prior negative experiences with providers. I am not fazed by being yelled at, but it’s hard trying to connect with someone who has learned not to let you in. These are often the patients that need the support the most, and yet I want to respect their ability to have control or to say no. It is a tough balance.

What’s fun about your job?

I love meeting new people. I met a woman a few weeks ago who was talking about being a hippie in the ‘60s in San Francisco, and how great it was and how soft millennials are. She actually put meth in her coffee because she needed a pick-me-up to clean her house. You can’t make this stuff up! It’s just really fascinating how people live their lives, and to have a window into their world and perspective is a privilege.

Do you take work home with you or do you disconnect?

I try to disconnect, however there are days when something sticks with you and you really worry and wonder about a patient. As I mentioned, you can’t give from an empty well—so I try to acknowledge this. I find that trying to have a rich life outside of work is an important part of self-care as well. Social work is a big part of my identity but it’s not entirely who I am. I focus on friends, family, travel, yoga, and things that sustain me. I can’t do my job effectively if I am not taking a step back regularly.

What advice do you have for other providers and for patients?

The hospital is so overwhelming for our patients, more so than some providers realize. I could be in the room with a patient for 45 minutes and six different providers may come in. I try to maintain that this is the patient’s bedroom I’m walking into. It’s a private, and a sacred space for them. That’s where they sleep. This is where they are trying to recover and grapple with what brought them into the hospital.

Laura, thank you so much for telling us about your work. Anything else you’d like to share with us?

Some days I’ll go home completely exhausted and wiped out, and at first, I don’t feel like I did a single solitary thing. Some of the things that I’m trying to help people work through ...it never occurred to me that someone could, for whatever reason, find themselves in such challenging situations. I don’t have a magic wand to provide someone with housing or sobriety, but maybe in that moment I can begin to make a connection. When I just listen, I am beginning to build relationships – which for some patients is something they haven’t had in a long time. It’s in these moments of being present, without an agenda, walking with them in their challenges, that I feel most connected to the work.

Thanks, Laura.

We spoke with medical social worker Laura Shea, MSW, LICSW on her role at our tertiary care hospital. Laura’s reflections on the struggles and rewards of her job may resonate with those of us who search for balance and meaning in work.

Laura, tell us about yourself. What made you want to be a social worker?

I couldn’t really picture doing anything else. I got a degree in psychology and loved counseling. Social work was a natural fit because of the social justice component and the look into larger systems. I knew I had the skill set for this, and for those most marginalized, to be a supportive person for someone who doesn’t have that.

I also have a family member with major mental illness and chronic suicidality who I supported for a very long time. In many ways, I was a personal social worker advocating on their behalf while growing up. I remember being in high school when they overdosed, and going to the ER in the middle of the night. The next morning, I was back at school. I was a total do-gooder—President of the student council and on top of my grades. I tried dealing with this while keeping up the appearance that everything was ok, even though it wasn’t.

As I got older, there were middle-of-the-night phone calls professing suicidality which were so painful. I learned a lot about compartmentalizing and resiliency. It has given me an incredible amount of empathy for family members of patients. I have learned that it’s not always simple, and decisions aren’t easy, and solutions are complicated and can feel incomplete. We often hear, “Why hasn’t the family stepped in?” Well these issues are hard for families too, I know from firsthand experience.

At the end of the day, as challenging as the work is, I get something from it. I feel honored to bear witness to some of people’s darkest moments and also some of the most beautiful moments—the joys of coming out the other side of their process and journey.

How much of your personal story do you reveal to your patients?

I rarely do. However, to some families that are particularly devastated, I do share some of my family story. I try to affirm their challenge and acknowledge that family and friends can’t always “solve this.”

We have a culture that reveres going above and beyond, however I really honor those family members who can set boundaries. Sometimes caregivers need space, that doesn’t make you a bad person. It’s actually brave and really hard to do. You can’t give from an empty well.

Laura, tell us about your typical day.

Well, it begins with responding to e-mails. Then I meet with patients and obtain collateral to prep for multidisciplinary rounds (with physicians, RNs, case managers). I usually consult on 20-30 patients a day. In the afternoon, it varies -- maybe three patients are leaving that may need my help with things like providing substance use information or shelter resources. Typically, I’ll have a few complicated long-term patients, who may have challenging family dynamics, ongoing goals of care discussions, or behavioral difficulties. These patients keep me just as busy, it’s not quite as time sensitive but I have to keep chipping away at the work.

Seems like a busy day. Do you get a break at all?

When possible, I take a walk in the woods behind the hospital on my lunch break. There’s a beautiful path, it’s an important part of my day -- getting outside and taking a step back. I bring my pager, so I am still connected.

I used to feel like I didn’t have time to take a break, and I would work through lunch. But now I find if I take a break, I am more productive the rest of the day because it makes me more mindful. It quiets me a little, gives me perspective on the stress and stressors of working in the hospital and allows me to better connect to my job and others around me.

What does a successful day look like?

Well, one involved a homeless gentleman and a search for his family. He was in his 40s, though he looked much older, and recently had been assaulted at a shelter. He presented to either the ER or was admitted to various hospitals 14 times over the past month – typically for intoxication and hypothermia. He kept saying “I just need to find my brother” though no one was taking this request too seriously. We spent a lot of time looking for his brother with the Office of Public Guardian’s help, and we actually found him! The patient hadn’t seen his brother in four years and as it turns out was searching for him too. The brother thought the patient had passed away. With his brother’s support, the patient is now housed, going to alcohol treatment, reunited with his family, and taking his medications. His whole life changed. So that was amazing, and a reminder of how rewarding this job can be.

What is most challenging about your work?

The biggest challenge is grappling with the limitations of the system, and discharging someone to the community when the community has limited resources for these patients.

Though it’s not just the limitation of resources, some patients have been through the system so many times that as a coping mechanism and to protect themselves they do everything possible to push you away. They have walls firmly up, because of prior negative experiences with providers. I am not fazed by being yelled at, but it’s hard trying to connect with someone who has learned not to let you in. These are often the patients that need the support the most, and yet I want to respect their ability to have control or to say no. It is a tough balance.

What’s fun about your job?

I love meeting new people. I met a woman a few weeks ago who was talking about being a hippie in the ‘60s in San Francisco, and how great it was and how soft millennials are. She actually put meth in her coffee because she needed a pick-me-up to clean her house. You can’t make this stuff up! It’s just really fascinating how people live their lives, and to have a window into their world and perspective is a privilege.

Do you take work home with you or do you disconnect?

I try to disconnect, however there are days when something sticks with you and you really worry and wonder about a patient. As I mentioned, you can’t give from an empty well—so I try to acknowledge this. I find that trying to have a rich life outside of work is an important part of self-care as well. Social work is a big part of my identity but it’s not entirely who I am. I focus on friends, family, travel, yoga, and things that sustain me. I can’t do my job effectively if I am not taking a step back regularly.

What advice do you have for other providers and for patients?

The hospital is so overwhelming for our patients, more so than some providers realize. I could be in the room with a patient for 45 minutes and six different providers may come in. I try to maintain that this is the patient’s bedroom I’m walking into. It’s a private, and a sacred space for them. That’s where they sleep. This is where they are trying to recover and grapple with what brought them into the hospital.

Laura, thank you so much for telling us about your work. Anything else you’d like to share with us?

Some days I’ll go home completely exhausted and wiped out, and at first, I don’t feel like I did a single solitary thing. Some of the things that I’m trying to help people work through ...it never occurred to me that someone could, for whatever reason, find themselves in such challenging situations. I don’t have a magic wand to provide someone with housing or sobriety, but maybe in that moment I can begin to make a connection. When I just listen, I am beginning to build relationships – which for some patients is something they haven’t had in a long time. It’s in these moments of being present, without an agenda, walking with them in their challenges, that I feel most connected to the work.

Thanks, Laura.

We spoke with medical social worker Laura Shea, MSW, LICSW on her role at our tertiary care hospital. Laura’s reflections on the struggles and rewards of her job may resonate with those of us who search for balance and meaning in work.

Laura, tell us about yourself. What made you want to be a social worker?

I couldn’t really picture doing anything else. I got a degree in psychology and loved counseling. Social work was a natural fit because of the social justice component and the look into larger systems. I knew I had the skill set for this, and for those most marginalized, to be a supportive person for someone who doesn’t have that.

I also have a family member with major mental illness and chronic suicidality who I supported for a very long time. In many ways, I was a personal social worker advocating on their behalf while growing up. I remember being in high school when they overdosed, and going to the ER in the middle of the night. The next morning, I was back at school. I was a total do-gooder—President of the student council and on top of my grades. I tried dealing with this while keeping up the appearance that everything was ok, even though it wasn’t.

As I got older, there were middle-of-the-night phone calls professing suicidality which were so painful. I learned a lot about compartmentalizing and resiliency. It has given me an incredible amount of empathy for family members of patients. I have learned that it’s not always simple, and decisions aren’t easy, and solutions are complicated and can feel incomplete. We often hear, “Why hasn’t the family stepped in?” Well these issues are hard for families too, I know from firsthand experience.

At the end of the day, as challenging as the work is, I get something from it. I feel honored to bear witness to some of people’s darkest moments and also some of the most beautiful moments—the joys of coming out the other side of their process and journey.

How much of your personal story do you reveal to your patients?

I rarely do. However, to some families that are particularly devastated, I do share some of my family story. I try to affirm their challenge and acknowledge that family and friends can’t always “solve this.”

We have a culture that reveres going above and beyond, however I really honor those family members who can set boundaries. Sometimes caregivers need space, that doesn’t make you a bad person. It’s actually brave and really hard to do. You can’t give from an empty well.

Laura, tell us about your typical day.

Well, it begins with responding to e-mails. Then I meet with patients and obtain collateral to prep for multidisciplinary rounds (with physicians, RNs, case managers). I usually consult on 20-30 patients a day. In the afternoon, it varies -- maybe three patients are leaving that may need my help with things like providing substance use information or shelter resources. Typically, I’ll have a few complicated long-term patients, who may have challenging family dynamics, ongoing goals of care discussions, or behavioral difficulties. These patients keep me just as busy, it’s not quite as time sensitive but I have to keep chipping away at the work.

Seems like a busy day. Do you get a break at all?

When possible, I take a walk in the woods behind the hospital on my lunch break. There’s a beautiful path, it’s an important part of my day -- getting outside and taking a step back. I bring my pager, so I am still connected.

I used to feel like I didn’t have time to take a break, and I would work through lunch. But now I find if I take a break, I am more productive the rest of the day because it makes me more mindful. It quiets me a little, gives me perspective on the stress and stressors of working in the hospital and allows me to better connect to my job and others around me.

What does a successful day look like?

Well, one involved a homeless gentleman and a search for his family. He was in his 40s, though he looked much older, and recently had been assaulted at a shelter. He presented to either the ER or was admitted to various hospitals 14 times over the past month – typically for intoxication and hypothermia. He kept saying “I just need to find my brother” though no one was taking this request too seriously. We spent a lot of time looking for his brother with the Office of Public Guardian’s help, and we actually found him! The patient hadn’t seen his brother in four years and as it turns out was searching for him too. The brother thought the patient had passed away. With his brother’s support, the patient is now housed, going to alcohol treatment, reunited with his family, and taking his medications. His whole life changed. So that was amazing, and a reminder of how rewarding this job can be.

What is most challenging about your work?

The biggest challenge is grappling with the limitations of the system, and discharging someone to the community when the community has limited resources for these patients.

Though it’s not just the limitation of resources, some patients have been through the system so many times that as a coping mechanism and to protect themselves they do everything possible to push you away. They have walls firmly up, because of prior negative experiences with providers. I am not fazed by being yelled at, but it’s hard trying to connect with someone who has learned not to let you in. These are often the patients that need the support the most, and yet I want to respect their ability to have control or to say no. It is a tough balance.

What’s fun about your job?

I love meeting new people. I met a woman a few weeks ago who was talking about being a hippie in the ‘60s in San Francisco, and how great it was and how soft millennials are. She actually put meth in her coffee because she needed a pick-me-up to clean her house. You can’t make this stuff up! It’s just really fascinating how people live their lives, and to have a window into their world and perspective is a privilege.

Do you take work home with you or do you disconnect?

I try to disconnect, however there are days when something sticks with you and you really worry and wonder about a patient. As I mentioned, you can’t give from an empty well—so I try to acknowledge this. I find that trying to have a rich life outside of work is an important part of self-care as well. Social work is a big part of my identity but it’s not entirely who I am. I focus on friends, family, travel, yoga, and things that sustain me. I can’t do my job effectively if I am not taking a step back regularly.

What advice do you have for other providers and for patients?

The hospital is so overwhelming for our patients, more so than some providers realize. I could be in the room with a patient for 45 minutes and six different providers may come in. I try to maintain that this is the patient’s bedroom I’m walking into. It’s a private, and a sacred space for them. That’s where they sleep. This is where they are trying to recover and grapple with what brought them into the hospital.

Laura, thank you so much for telling us about your work. Anything else you’d like to share with us?

Some days I’ll go home completely exhausted and wiped out, and at first, I don’t feel like I did a single solitary thing. Some of the things that I’m trying to help people work through ...it never occurred to me that someone could, for whatever reason, find themselves in such challenging situations. I don’t have a magic wand to provide someone with housing or sobriety, but maybe in that moment I can begin to make a connection. When I just listen, I am beginning to build relationships – which for some patients is something they haven’t had in a long time. It’s in these moments of being present, without an agenda, walking with them in their challenges, that I feel most connected to the work.

Thanks, Laura.

We recently spoke with Denah Joseph, a clinical chaplain who works with the Palliative Care team to provide spiritual services to patients with serious illness. In addition, Denah leads efforts to address burnout among healthcare providers.

Denah, tell us about yourself.

My first career was actually in clinical psychology, but I’ve been a Palliative Care chaplain for 15 years. I also teach skill-building for providers around burnout and resilience.

What brought you to Palliative Care?

I’ve lost three sisters and a partner to breast cancer, and my dad died when I was quite young, so I’ve had a lot of exposure to loss. The other big thread in my life has been my spiritual practice. My father was an Orthodox Jew, but exceptionally ecumenical for his time. His first wife was Irish Catholic, and my father used to go to church, sit, kneel, and say the rosary, and light candles for his Catholic friends. Three hundred nuns from the local diocese all came to my dad’s funeral. It was really remarkable.

I’ve been a practicing Buddhist since I was 19. When I went back to school to become a chaplain I wanted to bring more of my spiritual interest into counseling work, so chaplaincy seemed like a really interesting way to do that.

Tell us more about what a chaplain actually does.

As a field, healthcare chaplaincy is relatively new. The old model was if a person was religious, somebody would arrange for a rabbi or an imam or a priest to come into the hospital and take care of the pastoral needs of that patient. In the last 10 to 15 years, the consensus guidelines for quality patient care now include addressing the spiritual dimension of patients’ lives. Instead of relying on volunteers from the community with no quality assurance, it’s required that any hospital over 200 beds have spiritual care available. In order to be a board-certified chaplain, you need to be endorsed by a faith community, and have an advanced degree in either Pastoral Counseling or Theology.

Everybody has spiritual needs even if they don’t use that word “spiritual.” We define it in terms of meaning, relationships, impact on one’s life, hope, fears, reconciliation issues, legacy issues, etc. Approximately 80% of patients want their physicians to understand a little bit about their spiritual/existential/emotional world, and only 20% of doctors ask—so there’s a really big gap. This can be a 5-minute conversation about who are you, what’s important to you, what’s the biggest struggle with your illness that is not medically oriented.

Can you share a patient encounter where you learned something?

Recently I cared for a patient whose wish was to survive to see his only son graduate from college. His wife and son both were like, “You’ve got to hang in there, Dad. You’ve got to hang in there.” He had very advanced pancreatic cancer, and the chances of him making it to graduation were exceedingly small, but nobody was dealing with this.

During the hospitalization, I went to the patient and his wife and I said, “We’re all hoping that you’re going to make it until the graduation but in the event you don’t, would you like to write a letter to your son?” In the Jewish tradition, it is called an ethical will. It’s the idea of legacy work. Just like you would make a will for your material possessions, an ethical will expresses what you value, what you hope for and dream for your beloved. He wanted to do it. His wife said, “Absolutely not, that’s like believing you’re not going to make it.” He was a very gentle guy. He would generally completely defer to his wife, but this time he said, “No, I want to do this.”

So I met with the patient and asked questions like, “What are the things you would hope to be remembered for? What are you most proud of that you want your son to know? What would you want your son to know if he became a father?”

I had him just talk, while I took notes. Later on, I wrote it up on official stationery and gave it to the patient.

What was his reaction when you gave the letter to him?

He started to cry. He said it was perfect. I usually read it to them so they can make edits if they want to. It sort of brings the grief forward when you imagine talking to a beloved that you’re leaving behind.

A few days later the patient died in the hospital surrounded by family members.

His wife, who had advocated so strongly against the letter, hugged me. She said, “That letter is the most important thing that happened here in the hospital.” I was shocked she said that, I had no idea he even shared it with her.

If people have the opportunity to share what’s important to them, particularly generationally, it could address a very deep need to be remembered.

Reflecting on it, I actually see myself as a healer and all my work is in healing, whether it’s working with physicians or working with patients or working with students or working with people in my private practice. It’s a theme that runs through everything. It’s not a word we hear often enough in medicine.

Why not?

The culture of medicine has lost its roots, in that sense. I hear a lot of people say, “There’s nothing we can do medically, so we’re just supporting them through this.” Supporting people through the experience is often seen as less valuable, but I think, particularly for serious, terminal illness, supporting people is not optional.

Switching gears a bit, tell us about the skill-building and resilience work you’ve done.

I think if you don’t proactively care for the rest of your life then your work life takes over. Although it’s pronounced in medicine, it’s in all fields. The pace and stress of our contemporary culture can be contrary to well-being in general.

When I first came to UCSF, I saw a culture of silence around stress, anxiety, and burnout. I started reading about burnout and the numbers of people who qualified to be burnt out at any given time, which may be at least 50% and trending upward. It just seemed to me that in any other profession if half the workforce was impaired, somebody would be doing something. I’ve really become passionate about this in the last couple of years.

So I developed a burnout prevention and resilience skills training class for providers. We work on mindfulness, social connection and support, positive psychology emotions like gratitude, appreciation, self-compassion, and humor, and delve into the sources of meaning in our work.

Based on your work, what would you say are the key stressors in medicine, generally?

Well there’s research on the electronic medical record and the increasing focus on metrics and “value-driven medicine,” which can lead to reduced connection with patients. I hope that what I’m doing makes some difference, but fundamentally, I believe there needs to be a real commitment on the part of the health system, to understand and make the changes that need to happen.

What is the fundamental problem? How do you define that?

Well I don’t think anybody knows. I think that’s what we’re saying. How can it be that so many people aren’t happy in such privileged work? It’s not clinical. It’s the system. It’s yet another flow sheet that you have to fill out; the actual amount of time spent with patients is low. No wonder we get burned out. We’re just doing orders all the time and answering phone calls.

It’s the loss of interconnectedness.

Yes, it’s the loss of connection. That goes back to even why chaplains may not be recognized as adding value. You can’t put a metric on connection. You can’t say, “I made 5 connections.”

Anything else you would like to share?

I don’t know how you feel about it, but I feel so grateful to have the opportunity to be in people’s lives in the intimate way we get to be and I, especially, get to be in a way sometimes even more than doctors. You get to be there, and you may even want to talk about the things that we were mentioning, but they’re asking you about their creatinine and their platelets and their urinary incontinence, so that’s what you’re having to talk about. I don’t have to do that, so I feel like I get the best seat in the house that way.

I think the seriously ill have so much to share and often are wise, particularly the young ones, from having dealt with illness. I’m really interested in that idea of wisdom and how you develop wisdom. Traditionally wisdom is associated with being an elder and having lived a long time and having a lot of experience. I think our work gives us that opportunity. We don’t have to necessarily live through everything to develop that kind of wisdom, but just to be with people who are living through these things.

So here I am, almost 70. I’m working harder than I’ve ever worked in my life. My partner is retired. She’s like, “Come on, let’s play.” She rides bikes, takes the dog out, cooks, reads. But I just can’t stop. I think it’s because I feel like, what else would I want to be doing with my time? I think that’s an amazing thing to be given that gift that I learn from my patients all the time and learn about what’s important. Obviously people are different, but it all boils down to relationships in the end.

That’s the promise of medicine, and I think that’s the great sadness of what’s going on with the epidemic of burnout. People lose connection to that.

There is some element to being present in these hard and difficult times that can bring perspective to life; and to know the sadness, in some ways

…is to know the joy.

Thank you, Denah, for sharing your thoughts with us.

We recently spoke with Denah Joseph, a clinical chaplain who works with the Palliative Care team to provide spiritual services to patients with serious illness. In addition, Denah leads efforts to address burnout among healthcare providers.

Denah, tell us about yourself.

My first career was actually in clinical psychology, but I’ve been a Palliative Care chaplain for 15 years. I also teach skill-building for providers around burnout and resilience.

What brought you to Palliative Care?

I’ve lost three sisters and a partner to breast cancer, and my dad died when I was quite young, so I’ve had a lot of exposure to loss. The other big thread in my life has been my spiritual practice. My father was an Orthodox Jew, but exceptionally ecumenical for his time. His first wife was Irish Catholic, and my father used to go to church, sit, kneel, and say the rosary, and light candles for his Catholic friends. Three hundred nuns from the local diocese all came to my dad’s funeral. It was really remarkable.

I’ve been a practicing Buddhist since I was 19. When I went back to school to become a chaplain I wanted to bring more of my spiritual interest into counseling work, so chaplaincy seemed like a really interesting way to do that.

Tell us more about what a chaplain actually does.

As a field, healthcare chaplaincy is relatively new. The old model was if a person was religious, somebody would arrange for a rabbi or an imam or a priest to come into the hospital and take care of the pastoral needs of that patient. In the last 10 to 15 years, the consensus guidelines for quality patient care now include addressing the spiritual dimension of patients’ lives. Instead of relying on volunteers from the community with no quality assurance, it’s required that any hospital over 200 beds have spiritual care available. In order to be a board-certified chaplain, you need to be endorsed by a faith community, and have an advanced degree in either Pastoral Counseling or Theology.

Everybody has spiritual needs even if they don’t use that word “spiritual.” We define it in terms of meaning, relationships, impact on one’s life, hope, fears, reconciliation issues, legacy issues, etc. Approximately 80% of patients want their physicians to understand a little bit about their spiritual/existential/emotional world, and only 20% of doctors ask—so there’s a really big gap. This can be a 5-minute conversation about who are you, what’s important to you, what’s the biggest struggle with your illness that is not medically oriented.

Can you share a patient encounter where you learned something?

Recently I cared for a patient whose wish was to survive to see his only son graduate from college. His wife and son both were like, “You’ve got to hang in there, Dad. You’ve got to hang in there.” He had very advanced pancreatic cancer, and the chances of him making it to graduation were exceedingly small, but nobody was dealing with this.

During the hospitalization, I went to the patient and his wife and I said, “We’re all hoping that you’re going to make it until the graduation but in the event you don’t, would you like to write a letter to your son?” In the Jewish tradition, it is called an ethical will. It’s the idea of legacy work. Just like you would make a will for your material possessions, an ethical will expresses what you value, what you hope for and dream for your beloved. He wanted to do it. His wife said, “Absolutely not, that’s like believing you’re not going to make it.” He was a very gentle guy. He would generally completely defer to his wife, but this time he said, “No, I want to do this.”

So I met with the patient and asked questions like, “What are the things you would hope to be remembered for? What are you most proud of that you want your son to know? What would you want your son to know if he became a father?”

I had him just talk, while I took notes. Later on, I wrote it up on official stationery and gave it to the patient.

What was his reaction when you gave the letter to him?

He started to cry. He said it was perfect. I usually read it to them so they can make edits if they want to. It sort of brings the grief forward when you imagine talking to a beloved that you’re leaving behind.

A few days later the patient died in the hospital surrounded by family members.

His wife, who had advocated so strongly against the letter, hugged me. She said, “That letter is the most important thing that happened here in the hospital.” I was shocked she said that, I had no idea he even shared it with her.

If people have the opportunity to share what’s important to them, particularly generationally, it could address a very deep need to be remembered.

Reflecting on it, I actually see myself as a healer and all my work is in healing, whether it’s working with physicians or working with patients or working with students or working with people in my private practice. It’s a theme that runs through everything. It’s not a word we hear often enough in medicine.

Why not?

The culture of medicine has lost its roots, in that sense. I hear a lot of people say, “There’s nothing we can do medically, so we’re just supporting them through this.” Supporting people through the experience is often seen as less valuable, but I think, particularly for serious, terminal illness, supporting people is not optional.

Switching gears a bit, tell us about the skill-building and resilience work you’ve done.

I think if you don’t proactively care for the rest of your life then your work life takes over. Although it’s pronounced in medicine, it’s in all fields. The pace and stress of our contemporary culture can be contrary to well-being in general.

When I first came to UCSF, I saw a culture of silence around stress, anxiety, and burnout. I started reading about burnout and the numbers of people who qualified to be burnt out at any given time, which may be at least 50% and trending upward. It just seemed to me that in any other profession if half the workforce was impaired, somebody would be doing something. I’ve really become passionate about this in the last couple of years.

So I developed a burnout prevention and resilience skills training class for providers. We work on mindfulness, social connection and support, positive psychology emotions like gratitude, appreciation, self-compassion, and humor, and delve into the sources of meaning in our work.

Based on your work, what would you say are the key stressors in medicine, generally?

Well there’s research on the electronic medical record and the increasing focus on metrics and “value-driven medicine,” which can lead to reduced connection with patients. I hope that what I’m doing makes some difference, but fundamentally, I believe there needs to be a real commitment on the part of the health system, to understand and make the changes that need to happen.

What is the fundamental problem? How do you define that?

Well I don’t think anybody knows. I think that’s what we’re saying. How can it be that so many people aren’t happy in such privileged work? It’s not clinical. It’s the system. It’s yet another flow sheet that you have to fill out; the actual amount of time spent with patients is low. No wonder we get burned out. We’re just doing orders all the time and answering phone calls.

It’s the loss of interconnectedness.

Yes, it’s the loss of connection. That goes back to even why chaplains may not be recognized as adding value. You can’t put a metric on connection. You can’t say, “I made 5 connections.”

Anything else you would like to share?

I don’t know how you feel about it, but I feel so grateful to have the opportunity to be in people’s lives in the intimate way we get to be and I, especially, get to be in a way sometimes even more than doctors. You get to be there, and you may even want to talk about the things that we were mentioning, but they’re asking you about their creatinine and their platelets and their urinary incontinence, so that’s what you’re having to talk about. I don’t have to do that, so I feel like I get the best seat in the house that way.

I think the seriously ill have so much to share and often are wise, particularly the young ones, from having dealt with illness. I’m really interested in that idea of wisdom and how you develop wisdom. Traditionally wisdom is associated with being an elder and having lived a long time and having a lot of experience. I think our work gives us that opportunity. We don’t have to necessarily live through everything to develop that kind of wisdom, but just to be with people who are living through these things.

So here I am, almost 70. I’m working harder than I’ve ever worked in my life. My partner is retired. She’s like, “Come on, let’s play.” She rides bikes, takes the dog out, cooks, reads. But I just can’t stop. I think it’s because I feel like, what else would I want to be doing with my time? I think that’s an amazing thing to be given that gift that I learn from my patients all the time and learn about what’s important. Obviously people are different, but it all boils down to relationships in the end.

That’s the promise of medicine, and I think that’s the great sadness of what’s going on with the epidemic of burnout. People lose connection to that.

There is some element to being present in these hard and difficult times that can bring perspective to life; and to know the sadness, in some ways

…is to know the joy.

Thank you, Denah, for sharing your thoughts with us.

We recently spoke with Denah Joseph, a clinical chaplain who works with the Palliative Care team to provide spiritual services to patients with serious illness. In addition, Denah leads efforts to address burnout among healthcare providers.

Denah, tell us about yourself.

My first career was actually in clinical psychology, but I’ve been a Palliative Care chaplain for 15 years. I also teach skill-building for providers around burnout and resilience.

What brought you to Palliative Care?

I’ve lost three sisters and a partner to breast cancer, and my dad died when I was quite young, so I’ve had a lot of exposure to loss. The other big thread in my life has been my spiritual practice. My father was an Orthodox Jew, but exceptionally ecumenical for his time. His first wife was Irish Catholic, and my father used to go to church, sit, kneel, and say the rosary, and light candles for his Catholic friends. Three hundred nuns from the local diocese all came to my dad’s funeral. It was really remarkable.

I’ve been a practicing Buddhist since I was 19. When I went back to school to become a chaplain I wanted to bring more of my spiritual interest into counseling work, so chaplaincy seemed like a really interesting way to do that.

Tell us more about what a chaplain actually does.

As a field, healthcare chaplaincy is relatively new. The old model was if a person was religious, somebody would arrange for a rabbi or an imam or a priest to come into the hospital and take care of the pastoral needs of that patient. In the last 10 to 15 years, the consensus guidelines for quality patient care now include addressing the spiritual dimension of patients’ lives. Instead of relying on volunteers from the community with no quality assurance, it’s required that any hospital over 200 beds have spiritual care available. In order to be a board-certified chaplain, you need to be endorsed by a faith community, and have an advanced degree in either Pastoral Counseling or Theology.

Everybody has spiritual needs even if they don’t use that word “spiritual.” We define it in terms of meaning, relationships, impact on one’s life, hope, fears, reconciliation issues, legacy issues, etc. Approximately 80% of patients want their physicians to understand a little bit about their spiritual/existential/emotional world, and only 20% of doctors ask—so there’s a really big gap. This can be a 5-minute conversation about who are you, what’s important to you, what’s the biggest struggle with your illness that is not medically oriented.

Can you share a patient encounter where you learned something?

Recently I cared for a patient whose wish was to survive to see his only son graduate from college. His wife and son both were like, “You’ve got to hang in there, Dad. You’ve got to hang in there.” He had very advanced pancreatic cancer, and the chances of him making it to graduation were exceedingly small, but nobody was dealing with this.

During the hospitalization, I went to the patient and his wife and I said, “We’re all hoping that you’re going to make it until the graduation but in the event you don’t, would you like to write a letter to your son?” In the Jewish tradition, it is called an ethical will. It’s the idea of legacy work. Just like you would make a will for your material possessions, an ethical will expresses what you value, what you hope for and dream for your beloved. He wanted to do it. His wife said, “Absolutely not, that’s like believing you’re not going to make it.” He was a very gentle guy. He would generally completely defer to his wife, but this time he said, “No, I want to do this.”

So I met with the patient and asked questions like, “What are the things you would hope to be remembered for? What are you most proud of that you want your son to know? What would you want your son to know if he became a father?”

I had him just talk, while I took notes. Later on, I wrote it up on official stationery and gave it to the patient.

What was his reaction when you gave the letter to him?

He started to cry. He said it was perfect. I usually read it to them so they can make edits if they want to. It sort of brings the grief forward when you imagine talking to a beloved that you’re leaving behind.

A few days later the patient died in the hospital surrounded by family members.

His wife, who had advocated so strongly against the letter, hugged me. She said, “That letter is the most important thing that happened here in the hospital.” I was shocked she said that, I had no idea he even shared it with her.

If people have the opportunity to share what’s important to them, particularly generationally, it could address a very deep need to be remembered.

Reflecting on it, I actually see myself as a healer and all my work is in healing, whether it’s working with physicians or working with patients or working with students or working with people in my private practice. It’s a theme that runs through everything. It’s not a word we hear often enough in medicine.

Why not?

The culture of medicine has lost its roots, in that sense. I hear a lot of people say, “There’s nothing we can do medically, so we’re just supporting them through this.” Supporting people through the experience is often seen as less valuable, but I think, particularly for serious, terminal illness, supporting people is not optional.

Switching gears a bit, tell us about the skill-building and resilience work you’ve done.

I think if you don’t proactively care for the rest of your life then your work life takes over. Although it’s pronounced in medicine, it’s in all fields. The pace and stress of our contemporary culture can be contrary to well-being in general.

When I first came to UCSF, I saw a culture of silence around stress, anxiety, and burnout. I started reading about burnout and the numbers of people who qualified to be burnt out at any given time, which may be at least 50% and trending upward. It just seemed to me that in any other profession if half the workforce was impaired, somebody would be doing something. I’ve really become passionate about this in the last couple of years.

So I developed a burnout prevention and resilience skills training class for providers. We work on mindfulness, social connection and support, positive psychology emotions like gratitude, appreciation, self-compassion, and humor, and delve into the sources of meaning in our work.

Based on your work, what would you say are the key stressors in medicine, generally?

Well there’s research on the electronic medical record and the increasing focus on metrics and “value-driven medicine,” which can lead to reduced connection with patients. I hope that what I’m doing makes some difference, but fundamentally, I believe there needs to be a real commitment on the part of the health system, to understand and make the changes that need to happen.

What is the fundamental problem? How do you define that?

Well I don’t think anybody knows. I think that’s what we’re saying. How can it be that so many people aren’t happy in such privileged work? It’s not clinical. It’s the system. It’s yet another flow sheet that you have to fill out; the actual amount of time spent with patients is low. No wonder we get burned out. We’re just doing orders all the time and answering phone calls.

It’s the loss of interconnectedness.

Yes, it’s the loss of connection. That goes back to even why chaplains may not be recognized as adding value. You can’t put a metric on connection. You can’t say, “I made 5 connections.”

Anything else you would like to share?

I don’t know how you feel about it, but I feel so grateful to have the opportunity to be in people’s lives in the intimate way we get to be and I, especially, get to be in a way sometimes even more than doctors. You get to be there, and you may even want to talk about the things that we were mentioning, but they’re asking you about their creatinine and their platelets and their urinary incontinence, so that’s what you’re having to talk about. I don’t have to do that, so I feel like I get the best seat in the house that way.

I think the seriously ill have so much to share and often are wise, particularly the young ones, from having dealt with illness. I’m really interested in that idea of wisdom and how you develop wisdom. Traditionally wisdom is associated with being an elder and having lived a long time and having a lot of experience. I think our work gives us that opportunity. We don’t have to necessarily live through everything to develop that kind of wisdom, but just to be with people who are living through these things.

So here I am, almost 70. I’m working harder than I’ve ever worked in my life. My partner is retired. She’s like, “Come on, let’s play.” She rides bikes, takes the dog out, cooks, reads. But I just can’t stop. I think it’s because I feel like, what else would I want to be doing with my time? I think that’s an amazing thing to be given that gift that I learn from my patients all the time and learn about what’s important. Obviously people are different, but it all boils down to relationships in the end.

That’s the promise of medicine, and I think that’s the great sadness of what’s going on with the epidemic of burnout. People lose connection to that.

There is some element to being present in these hard and difficult times that can bring perspective to life; and to know the sadness, in some ways

…is to know the joy.

Thank you, Denah, for sharing your thoughts with us.

The only real voyage of discovery consists not in seeking new landscapes but in having new eyes.

—Marcel Proust

Hospitals can be complex, challenging, and dehumanizing for both patients and practitioners. In a national survey, up to half of hospitalists were affected by burnout and scored highly on emotional exhaustion and depersonalization scales.¹

Yet hospitals are also ripe with meaningful stories. In addition to patients’ narratives, the stories of multidisciplinary team members who make quality patient care possible reveal that we are bound together in more ways than we realize. Now, we have the opportunity to tell these stories.

This issue of Journal of Hospital Medicine introduces a new series: In the Hospital. Through selected interviews we explore the day-to-day lives of members of our hospital team. Highlighting the “team” in healthcare has been a longstanding focus of JHM, but we also hope that this series will demonstrate how each individual we meet with is not only a critical part of how patients receive care but is also an important member of our community.

We invite readers to appreciate the common threads that bind these pieces together. These stories will introduce us to individuals who have discrete and often disparate job descriptions, but all of them care about patients and want the best for them. Some are frustrated with the health care system and the constraints it places on our efficiency. Many of them worry about how to balance the demands of work with the need to be available for their families and friends. Many are trying their best to maintain their humanism, build resilience, and sustain themselves in ways that meet their personal goals for excellence, empathy, and fulfillment.

This series begins with the story of a palliative-care clinical chaplain whose life experience and perspective brings to light issues of resilience, meaning, and purpose. Future stories in this series will include a variety of providers across a spectrum of practice environments. We look forward to engaging you in this journey and welcome feedback and contributions.

Disclosures

The authors have nothing to disclose.

The only real voyage of discovery consists not in seeking new landscapes but in having new eyes.

—Marcel Proust

Hospitals can be complex, challenging, and dehumanizing for both patients and practitioners. In a national survey, up to half of hospitalists were affected by burnout and scored highly on emotional exhaustion and depersonalization scales.¹

Yet hospitals are also ripe with meaningful stories. In addition to patients’ narratives, the stories of multidisciplinary team members who make quality patient care possible reveal that we are bound together in more ways than we realize. Now, we have the opportunity to tell these stories.

This issue of Journal of Hospital Medicine introduces a new series: In the Hospital. Through selected interviews we explore the day-to-day lives of members of our hospital team. Highlighting the “team” in healthcare has been a longstanding focus of JHM, but we also hope that this series will demonstrate how each individual we meet with is not only a critical part of how patients receive care but is also an important member of our community.

We invite readers to appreciate the common threads that bind these pieces together. These stories will introduce us to individuals who have discrete and often disparate job descriptions, but all of them care about patients and want the best for them. Some are frustrated with the health care system and the constraints it places on our efficiency. Many of them worry about how to balance the demands of work with the need to be available for their families and friends. Many are trying their best to maintain their humanism, build resilience, and sustain themselves in ways that meet their personal goals for excellence, empathy, and fulfillment.

This series begins with the story of a palliative-care clinical chaplain whose life experience and perspective brings to light issues of resilience, meaning, and purpose. Future stories in this series will include a variety of providers across a spectrum of practice environments. We look forward to engaging you in this journey and welcome feedback and contributions.

Disclosures

The authors have nothing to disclose.

The only real voyage of discovery consists not in seeking new landscapes but in having new eyes.

—Marcel Proust

Hospitals can be complex, challenging, and dehumanizing for both patients and practitioners. In a national survey, up to half of hospitalists were affected by burnout and scored highly on emotional exhaustion and depersonalization scales.¹

Yet hospitals are also ripe with meaningful stories. In addition to patients’ narratives, the stories of multidisciplinary team members who make quality patient care possible reveal that we are bound together in more ways than we realize. Now, we have the opportunity to tell these stories.

This issue of Journal of Hospital Medicine introduces a new series: In the Hospital. Through selected interviews we explore the day-to-day lives of members of our hospital team. Highlighting the “team” in healthcare has been a longstanding focus of JHM, but we also hope that this series will demonstrate how each individual we meet with is not only a critical part of how patients receive care but is also an important member of our community.

We invite readers to appreciate the common threads that bind these pieces together. These stories will introduce us to individuals who have discrete and often disparate job descriptions, but all of them care about patients and want the best for them. Some are frustrated with the health care system and the constraints it places on our efficiency. Many of them worry about how to balance the demands of work with the need to be available for their families and friends. Many are trying their best to maintain their humanism, build resilience, and sustain themselves in ways that meet their personal goals for excellence, empathy, and fulfillment.

This series begins with the story of a palliative-care clinical chaplain whose life experience and perspective brings to light issues of resilience, meaning, and purpose. Future stories in this series will include a variety of providers across a spectrum of practice environments. We look forward to engaging you in this journey and welcome feedback and contributions.

Disclosures

The authors have nothing to disclose.