Some patients need absolution, not medicine

My heart is blighted like grass, and withered, for I forget to eat my bread.
–A patient’s prayer, Psalm 102

I diagnose and treat medical problems. I love doing it. Sometimes I make a big difference in someone’s life. More often, I just reassure them that they’re going to be ok. Or I give them advice about what they need to do to live healthier. But what I do has limits, and people frequently bring me problems that are well beyond my ken.

A business man comes to me for chest pain. He feels guilty because he has been misleading his business partner in a negotiation.

A wife has vague urinary symptoms after her affair of several years ends.

A middle aged man comes to me for insomnia. His endless work responsibilities have caused him to miss important events with his kids.

Of course, they each believe they may have a medical problem, so I examine them and order the appropriate tests. I rule out coronary disease, and infections, and hormonal problems. I call them with the good news. The tests are all normal. But they are not relieved. Their symptoms persist or even worsen.

I think I must be missing something. I send the business man to a cardiologist, the wife to a urologist, the father to a sleep specialist. More diagnostic tests are ordered. They are all normal. Good news, right? No. They are not reassured. Their symptoms continue and with every unrevealing test result they seem to give their symptoms more attention.

All primary care doctors see lots of these cases. These patients are seeking care in the wrong marketplace. They don’t have a medical problem. Their conscience is bothering them. They’re not sick; they’re guilty. They do not require medicine. They seek absolution.

But I have no prescription for that, no advice for attaining forgiveness, for undoing wrong deeds. Perhaps I should send them to a psychologist. I ask some questions looking for symptoms of depression or anxiety disorder. I come up empty. They’re mentally healthy, yet they are miserable.

What’s the medical specialty that helps people who’ve done wrong? What’s the service industry that undoes guilt? I’m no expert, but as far as I can tell, the only methodical approaches to this are in organized religions. My colleagues and friends who are psychologists and psychiatrists may object. But it seems to me that mental health professionals can only clarify the patient’s goals and feelings, clarify if the ethical damage can be undone, and work through the feelings. That’s a lot, but it doesn’t strike me as what these patients are craving. They want to atone. Organized religions have a formula for that.

I’m not here to tell you to go to church. And I’m certainly not going to delve into theology or suggest that any religion’s recipe for forgiveness is true in a fundamental or exclusive sense. I’m just suggesting that if you know you’ve done something wrong, and you feel terribly about it, maybe you don’t need a doctor. Maybe you need a minister, a priest, or a rabbi.

Like I said, I love what I do. I can fix some medical problems, and I can help prevent others. I can help you live more days and make those days healthier. But there is more to life than that. Sometimes there is also wrongdoing, and guilt, and redemption. For that, I have no training. Forgive me.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • Leon Directo

    Many physicians and nurses have found it beneficial to make a referral to trained healthcare chaplains when the dimension of care stretches past the bio-medical. Not surprisingly, a number of studies correlate meeting spiritual-emotional needs of patients increases their satisfaction with doctors, nurses, and interdisciplary team — above an expectation that excellent medical care is provided, the patient expects that care is given to the ‘whole person’.
    The National Comprehensive Cancer Network (NCCN) Guidelines for Distress Management offers algorithims that include a pathway for the onc team to refer to chaplaincy services / assessment for guilt (DIS-22) among other presenting distress triggers. National Quality Forum and National Consensus Project delineate Domain 5 as Spiritual-Existential Aspects of Care as a clinical best practice: “Assess and address spiritual concerns” — not limited by faith tradition or disease process or lack thereof.

    • Albert Fuchs

      Thank you, Leon. That is wise and practical advice.

  • George Handzo

    Thanks for highlighting this important and insightful piece. I agree with the sources you point up. In direct answer to Dr. Fuchs’ question,”What’s the medical specialty that helps people who’ve done wrong?”, I would say that specialty is the clinically trained, board certified professional health care chaplain. We are the spiritual care specialists on the health care team. Yes, organized religion can be helpful for many. However, lots of surveys now show that fewer and fewer people are part of organized religious communities in the US. The professional chaplain is trained to work with people of any faith and to engage the organized religious community when appropriate. Leon correctly points out that the NCCN Distress Management Guidelines offer an algorithm for the assessment of spiritual issues and referral. The work of Puchalski and Ferrell (Making Health Care Whole) offers an even more detailed model for integrating spiritual care.

    • Albert Fuchs

      Many thanks. You and Leon are illuminating a gap in my knowledge, which I appreciate. I’m familiar with healthcare chaplains in the hospital setting. Are they also available in the outpatient setting? If so, how do I find one? (Perhaps by Google-mapping “healthcare chaplain” in my neighborhood.)

      • Leon Directo

        Dr. Fuchs,
        I contacted Cedars Spiritual Care Services since that seemed closest to your location. Currently their chaplains are available for inpatient and ER. Outpatient cancer service line does have spiritual care support. Ideally an outpatient palliative care agency would have professional spiritual resources but none came to mind outside of hospice. What may work for your patients who are not currently affiliated is sharing a list of faith communities (hospital chaplaincy departments may share a list) and having your staff in-serviced by a local healthcare chaplain so they have a context to sensitively make such a referral. They suggested for further information you might contact Sr. Rabbi and Manager Jason Weiner, BCC at 310.423.5550. I sent a LinkedIn invitation your way and you may certainly contact me directly.

        • Albert Fuchs

          Thanks again. I’m very grateful for the pointers. (I was aware of the hospice chaplains and make use of them frequently.)

          • George Handzo

            I’m presenting the monthly Ethics Noon Conference at Cedars next March 20th. The working title is “Medicine
            and Spiritual Care: A Shared Commitment to Listening on the Way to
            Healing.” Would love to have both you and Leon come.

  • Alexis Hinds

    Dr. Fuchs,

    Speaking in my role as a psychiatrist I would offer that in fact these patients may benefit from some kind of counseling, be it a psychiatrist or a psychologist (or a chaplain). These symptoms sound very much like manifestations of anxiety.

    • Albert Fuchs

      Maybe. I explicitly considered the mental health angle in my post. Is all guilt a manifestation of anxiety? I guess my post argues that it isn’t, though I freely admit to having no expertise in the matter.

  • drjoekosterich

    Brilliant piece. Not all “symptoms” are caused by medical disease. Yet in these politically correct days moral judgements are an anathema. People feel guilty at times about what they do. This can be overcome but not via medical “treatment”.

    • Albert Fuchs

      Thanks for the praise!

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