Friday, January 25, 2008
From Julius Varwig to Julie Dupree: Professionalizing Hospital Chaplains
BY NANCY BERLINGER

The television writers’ strike threatens to interrupt the introduction of an intriguing new character on the long-running television drama ER: a chaplain. So far, Julie Dupree – young, attractive, tattooed, casually chic amid the ubiquitous scrubs, “pretty hot for a chaplain,” according to one doc – has been seen praying with a young pregnant woman undergoing a risky procedure, holding the hands of a dying teenager and his mother, presiding over a cringe-worthy session of music therapy and over a moving “blessing of the hands” ceremony, laughing as a recently widowed patient tells jokes (“grief is something I’m good with”) and reassuring firefighters that their buddy, just out of surgery, would be fine. She described herself to a curious medical resident as “a spiritual person with a spiritual life who lives in the real world” but adds, “I’m not a nun.” (Indeed: in a later episode, these two colleagues wake up together, and not in a spiritual way.)

Spotting a chaplain on a primetime hospital drama is rare. There was Father Mulcahy on M*A*S*H, of course, but he was a military chaplain who ended his tour nearly 25 years ago. On television as in the real world, chaplains are the invisible professionals in health care. The writers of ER deserve credit – in season 14, but better late than never – for introducing viewers to another dimension of critical-care medicine: Real chaplains do work in the ER and the ICU, and are closely associated with end-of-life care.

Julie Dupree seems to be a certified chaplain – she mentions her training – which means someone at this fictional, perennially strapped public hospital scraped up her $35,000 salary. Hospitals are not required to hire certified chaplains, who have completed theological coursework – typically, a master of divinity or an equivalent graduate degree – plus 1600 hours of supervised clinical training through a clinical pastoral education (CPE) program. While several Joint Commission standards require hospitals to demonstrate that they are addressing patients’ and families’ spiritual needs at end of life and are making spiritual care available to patients in general, chaplaincy is an unreimbursed service. It is therefore a perpetually vulnerable service. Some hospitals still rely on a patchwork of local clergy and laypersons to attempt to meet the varied spiritual needs of patients. While cheaper than investing in staff, this practice does not ensure that patients or families in crisis will be carried for by clinically experienced professionals. At many other hospitals, the “one-person department” is the norm: The chaplaincy director may be paged to the bedside of a dying patient, to care for a family in the ER, or to help resolve a conflict in the ICU, while simultaneously training nurses and other staff to conduct “spiritual assessment” questionnaires to identify patients’ specific needs, and coordinating volunteers capable of filling basic requests, such as distributing electric candles on Shabbat. (Needless to say, the chaplaincy director, as a manager, also serves on a slew of committees.)

The fragile economics of chaplaincy are compounded by semantics. It is notoriously difficult, even for chaplains, to describe what chaplains do. Being “a spiritual person with a spiritual life who lives in the real world” is not going to work for the bean counters at budget time. So what does a chaplain like Julie Dupree do to earn her keep? In the early ER episodes, she tended to start conversations by asking, “would you like to say a prayer?” This elicited groans from real chaplains. It’s a stereotype, and it’s a bit like having a surgeon start by asking, “so, would you like to have an elective procedure?” It’s just not how it’s done in the real world of the hospital.

The words “hospital” and “hospitality” are rooted in the word “host,” reflecting medieval monasteries’ role as providers of last resort and of a safe place to die. This model survived vestigially for centuries: Anthony Trollope’s 1855 novel The Warden describes “Hiram’s Hospital,” a residence for the elderly poor, administered by a kindly clergyman and funded by a medieval bequest. At the time Trollope was writing, medicine was sorting itself out as a profession, distinguishing itself – through degrees, clinical training, and credentials – from the trade of the apothecary and the craft of the humble general practitioner. This process of professionalization also included William Osler’s creation and championing of the medical residency program in the late 19th century. As hospitals became more systematic, science-based institutions, the role of clergy as health care providers – except at the deathbed – became an artifact, outside of hospitals run by religious orders.

The word “chaplain” denotes ministry outside of a congregation, and in particular, within an institution where individuals have been displaced from their own congregations and communities, hence the presence of chaplains in the military, in prisons, and at colleges. The first step in the professionalizing of chaplaincy within health care institutions in the United States is often credited to Julius Varwig (1876-1937), a German-born Evangelical pastor. Before emigrating in his late teens, Varwig worked at the famed Bethel community for the disabled and began his theological training under its founder, Friedrich von Bodelschwingh. (These names may be familiar to religious ethicists and medical historians alike. In 1933, Dietrich Bonhoeffer visited the Bethel community and met the founder’s son – also named Friedrich – who collaborated on the early resistance document known as the “Bethel Confession” and later joined Bonhoeffer in opposing Nazi euthanasia policies aimed at residents of institutions like Bethel.)

Varwig completed his theological training at Eden Seminary near St. Louis, and for nearly 30 years worked as pastor in Midwestern congregations. In 1926, he proposed to his church that he begin a “hospital mission” in St. Louis’s public institutions for the sick and poor. He was granted permission – but refused funding. Then as now, hospital chaplaincy was unreimbursed – Varwig scrabbled to cover his salary and other costs through stipends and side jobs. The church mission board’s letter introducing Varwig to hospital officials recommended him “to minister unto such of their sick and infirm who are without church affiliation and who may desire spiritual or other advice . . . with the sole intent of rendering a much needed service to suffering humanity.” (That last part of the recommendation may be a reassurance that Varwig, while most definitely a Protestant pastor, was not seeking to proselytize.) Varwig continued to work in hospitals, and to build the idea of “hospital mission,” for the rest of his life. His obituary in a church publication describes him as a “true pioneer, pathfinder, and organizer.”

Around the same time as Julius Varwig was creating a new, badly paid job for himself in St. Louis, clergy and medical educators in Massachusetts were beginning Osler-style innovations in theological education, bringing future ministers into hospitals for supervised training in caring for the sick. While the first professional chaplain and the first CPE program in the United States can therefore both be dated to the 1920s, the professionalization of chaplaincy is not nearly complete. Julie Dupree’s position may be nearly as precarious as Julius Varwig’s in terms of funding and status. And while Varwig’s ministry was ecumenical by 1920s standards, Julie Dupree and her real-world counterparts – there are approximately 10,000 certified chaplains in the U.S. and Canada – are professionally responsible for demonstrating a much broader and deeper awareness of the varieties of religious – and nonreligious – experience they may encounter among patients, families, and hospital staff. They must understand the 21st century hospital in all of its clinical, technological, and organizational complexity. They must play on teams that did not exist in Varwig’s day, or even 30 years ago: The chaplain typically serves on the ethics committee, the IRB, and the palliative care team, among other assignments.

And they have to try to define that word – “spiritual” – that was self-explanatory for Varwig and his mission board, and that gives us so much trouble today, and that can be especially confusing in contemporary health care. Who’s responsible for helping patients, families, and professional caregivers cope with the blows illness and trauma may inflict on an individual’s sense of identity, meaning, and purpose, and on social and self-transcendent relationships?

When faced with a “spiritual” crisis, should we page Psych? Social work? Integrative medicine? The wellness program? Or the chaplain? Stay tuned.

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