Spiritual Challenges in a Physical (Medical) Practice
Dr. Payne is Associate Professor in the Department of Family Medicine at the Medical College of Georgia in Augusta.
Normal, normal, normal. So went the tests that I had ordered on my patients. Just having finished my internship, I was ready to stamp out disease and heal the sick. But . . . there was nothing tangible to treat. Over and over the situation was the same: patients with bodily complaints but without disordered biochemistries that I could detect. There were exceptions, such as lacerations, sprains, broken bones, strept throat, high blood pressure, and an occasional anemia. Mostly, however, my patients fell into the former category. I wasn't trained to handle normal or negative tests, only those that revealed disease. Reassurance that "everything was all right" seemed inadequate. Indeed, it was! The patients still hurt or felt tired or "nervous." They did not want to feel the way that they did and I couldn't help them.
Obviously, psychiatrists could help them. They knew how to handle these patients. I had not had much training in psychiatry, but I did know that they had labels for such patients and methods to treat them. Sincerely, I wanted to help patients, but I couldn't. The only answer, then, was to specialize in psychiatry. Since most physicians were specializing, I had expected eventually to specialize in something. Now that I had had a closer look at the most common problems with patients, I knew what they needed.
Also, I was a new Christian. To get some grounding in the Bible, we were in a weekly Bible study. When I mentioned to our leader that I was going into psychiatry, he handed me a book to read. He had not read it, but he thought that it might help with my decision. The book was Competent to Counsel by Dr. Jay Adams. The book disturbed me. It cut through almost everything that I had been taught about psychiatric problems. I was so disturbed that I called Dr. Adams on the phone, made an appointment, and flew to Philadelphia to talk with him. Because of the book and that conversation, I chose to enter Family Medicine instead.
By this time I knew that whatever a person's problem, they first needed Jesus Christ as their Lord and Savior. As I saw patients again with non-biochemical problems, I was confronted either to refer them or counsel them myself. There were no Christians in psychiatry or psychology who were locally available, so with considerable anxiety I began to counsel them myself. God granted amazing success immediately. These counselees and others began to make referrals to me. Sometimes, I saw them in my home in the evenings. Eventually, my church Session approved me to counsel formally as a ministry of the church. Thus, fourteen years I have spent on research, study, writing, and practice on the subject. Most examples in my book were counselees over this time.1
It is a well-accepted and documented fact among physicians in primary caret that a large number, if not the majority, of the patients that they see do not have problems with their body. These problems may be called "non-organic", "functional," or "psychosomatic." Usually, the physician examines the patient and is unable to detect any bodily disease either by his physical exam or by "tests." Obviously, however, the patient is "diseased." That is, he considers himself to be ill.
The physician then has a more difficult problem than if the patient had a physical illness for which there was a clear treatment. A brief attempt to explain to his patient the nature of the problem may be heard as, "There is nothing wrong with me" (the patient knows that something is wrong or he wouldn't be in the physician's office) or "It's all in your head" (the patient knows that it is his body that is bothering him because he hurts or otherwise is uncomfortable). Some patients will understand, but many will not.
The situation gets worse. Faced with an office full of patients, the physician cannot really take time to explain fully to the patient. It really does take time, especially when the patient is hearing such an explanation for the first time. And he usually is!
Even though physicians are aware of the exact nature of the problem, they rarely communicate adequately to the patient. As mentioned, time is one problem. I believe, however, that the physician is often insecure within himself to make an accurate explanation to the patient. He has experienced other patients' reactions to such an explanation. Further, what does he have to offer? He can give a medication, but how can he solve those situations in the patient's life that are triggering his bodily complaints? Often, he opts to give medication. Studies have shown that the overuse (translate "abuse") of tranquilizers and other psychotrophic drugs is stark evidence of this scenario.
Further compounding the situation is the media projection that when you really need an answer, "Consult your physician." The implication is that he will solve the problem, whatever it is. Also, our society is bombarded with the latest "cures." Physicians know how these reports are distorted. The journal article that reports the "cure" honestly presents its limitations, side effects and relative infrequency with which it truly cures or makes patients better. This accuracy, however, is mostly lost in the media presentation where the glorious triumphs of modern medicine are hailed. The example of "arthritis" medications comes to mind. How often we hear of some new breakthrough, but the physicians can still only moderate the symptoms. He can do very little about the progression of the various arthritic diseases.
Now, what is the patient to think? He expects his physician to have all these answers along with all the latest cures. When the physician tells him there is little or nothing that he can do medically, then the patient's logical conclusion (from the evidence presented to him) is that this physician is deficient. Sometimes, they tell you so!
We all fall short of this image. And, although we did not create it, we have done little to persuade people otherwise, even as I have just described our failure to explain face-to-face with the patient. Further, I believe that many physicians have come to believe this falsified image.
The pressure is great in these situations. The following thoughts may go through the physician's head .3 Dissatisfied patients do not come back and one's practice may not grow or it may even dwindle. In many cases there may be an organic explanation, but modern medicine is not yet sophisticated to detect it. Most physicians practice this way so why be different? The patient is most likely to get better regardless of what I give him.4 And so on. Admittedly, I am influenced by these thoughts, so I am not just "throwing stones." Such situations are difficult.
Finally, the physician presents a bill from $25.00-500.00, depending on how "thorough" his workup has been. Now, we have a patient that is really upset. Not only has this physician failed the "image" of medicine, he must pay dearly for his experience!
Another choice that the physician has is to "follow the crowd," prescribing medications when they are not really indicated and explaining little of the cause of the patient's problems. It is also the most expedient, both in time and money for the physician. In addition, the patient gets what he came for: a physical solution to his "physical" problem.
At this point someone may argue that the physician has done his duty as a physician simply to rule out organic disease and to give a pharmacologic remedy that approximates a physiological solution to the patient's problem. I don't agree. The physician has not treated the whole (Biblical) man.
The Unity of Man
All disease and illness is a result of the sinful condition of the human race. Adam and Eve were created to live forever. Thus, from the "beginning" sin and disease have had a close identity. We see this relationship in some of the words used for health and healing and sin and disease. Ozos is the Greek verb stem for salvation, but it is used in contexts that clearly mean physical healing (Mt. 8:25, 9:21; Luke17:19, 18:42). Hugies from which "hygiene" is derived, may designate spiritual health (Luke 5:31, 15:27). Asthenes may be used to designate a physical problem (John 5:5; II Cor. 12:5; Gal. 4:13) or spiritual weakness (I Cor. 8:7, Mt. 26:41).5
The central question is, "What is health?" If physicians are to maintain, enhance or restore people's health, then they must have a clear concept of what health is. Since man is composed of both body and soul,6 health must include both these components. Health of body is fairly clear, especially to a physician who has spent years studying it, but what is health of the soul?
Christians often present salvation superficially, simply as being saved or not saved. Actually, salvation has eight or more parts, depending upon the manner of classification. 7 An example of this complexity is seen in just two verses (Rom. 8:2930). For my purposes here, only two parts need be presented: regeneration and obedience. Some Christians refer to "regeneration" as being "born-again." I cannot take the time to discuss the differences here, but simply point out that at a point in time a person is saved, that is, he becomes a child of God (John 1:12) where he was formerly an enemy of God (Rom. 5:10).
"Sanctification" could have been used instead of obedience, but the latter denotes the specific task of the believer. Obedience to Jesus Christ and love of Him are one and the same an. 14:15, 21). Both obedience and disobedience have consequences (Gal. 6:7-9). Being a Christian does not obviate the consequences of God's commandments. If we disobey, we will not experience the blessing of obedience, but will experience the consequences of our sin(s).
Thus, health of soul consists of regeneration and obedience. Health of the whole person is not possible without these characteristics. The physician, then, at least ought to diagnose these spiritual dimensions of disease whether he chooses to treat them or not. My position is that physicians have an obligation to make spiritual counseling available to patients. Simply, physicians are to diagnose and treat disease. If the cause of that disease is spiritual, is it any less the physician's responsibility to direct the patient to where he can be healed, if the physician does not provide the healing himself?
Let's look at this problem from the standpoint of morality. A man presents to his physician with chest pain. A complete (whatever that is) exam reveals no evidence of organic disease. Personal questioning, however, brings out an extramarital affair. Should the physician be "nonjudgmental," as we are taught repeatedly in medical school, and not mention that the most serious danger to his health at the moment was his need for salvation and obedience to the Seventh Commandment? Are we as Christian physicians to offer "wholistic" (Biblical) health as well as bodily health?
Should we prescribe birth control pills without parental permission? Should we prescribe birth control of any type to an unmarried woman? Should we treat a sexually transmitted disease in an officer of a local church without informing them of his problem? Should we confront the homosexual with his sin against God, as well as the severe diseases that he is exposing himself to? Should we tell the "workaholic" executive that he needs to rest one day in seven? These are questions with which we must grapple. The Bible speaks to them, so we must learn to speak with our patients about them. What can we do about it practically?
First, we must realize what we are up against. The "image" of medicine has been described above and patients come with that attitude. Further, most are fixed in their minds that their problems are medical and expect a solution on that basis.8 Even further, we must realize that unless they are born-again (regenerated) or unless the Spirit of God is calling them, they do not want spiritual solutions (Mk. 7:18-23; Rom. 1:18-32). My experience and that of other Christian physicians confirms this resistance in patients toward spiritual solutions.
Jay Adams' has coined the term, "pre-counseling" or "problem-oriented evangelism"9 for counselees (patients) who are unbelievers. They are unable to understand Biblical corrections (I Cor. 2:6-16), much less able to carry them out without the power of the Holy Spirit (John 15:5b; Phil. 4:13). For example, how can you give hope to the depressed1O housewife who is tired of the drudgery of housework, her children and the husband who neglects her? What she needs is forgiveness of her sins (always a contributing factor to a person's problems), purpose and significance in her role as a mother and wife and a practical approach to solve her daily problems. She may need an antidepressant medication, but most likely needs Biblical counsel.
Second, the patient can be given hand-out materials that explains the relationship of their body to their spirit." Unfortunately, such materials have not yet been written. '2 Even with these handouts, they will likely need personal explanation and counsel.
Third, Christian physicians may have to seek out a counselor to whom they can refer patients. In my early days of residency I faced this problem. Since I knew no one locally who would take a Biblical approach, I decided to see what God might do through me. He was gracious in the response of several patients and later a regular counseling ministry. I would not, however, advise every physician to pursue that path. Certain factors ought to be considered.
1. Is there someone locally (within an hour's drive) that is trained in Biblical counseling? Since my early experience, many training programs in Biblical counseling have been established and many counselors trained. 'I The Biblical ideal is that counseling be done under the authority of a local church.14 Thus, a trained pastor might replace another who is leaving, be brought in to start a church or, if one's church is large, an additional staff person could be hired to function primarily as a counselor. Also, a group of churches may hire someone to start a counseling ministry separate from a particular church, but under the authority of one or more.
2. The physician may choose to counsel himself. First, the physician is already well-trained to practice medicine. That is what he does best. Training in counseling requires much reading and study for the theological background within which practical application must be made. Then, practical training in counseling incurs more time and study and being away from one's practice. After all this effort, the testimony of others as well as his own experience, must confirm that you have the spiritual gifts for counseling. Lastly, the role of counselor is primarily that of the pastor."
If no one else is available or you believe that you have the Biblical qualifications, the knowledge, the training and will do it under the oversight of a church, then go to it! I suggest setting aside 1-2 half-days per week where you are neither on call nor have other patient responsibilities. You will have to adjust your whole seven day week so that you meet your other duties of husband, father, church member and personal spiritual growth. '6 One physician gave up private practice to devote more time to counseling because he perceived that that was God's call for him. His step was a very large one, considering the length of training that is required to be a physician and the time and financial investment in practice thereafter.
Every physician should evangelize and do simple counseling with some patients who will not go for counseling, but with whom he may be able to witness to the gospel of Jesus Christ, especially if he is able to give counsel and comfort that encourages their openness to the gospel. At the same time a physician should not spend a lot of time with recalcitrant patients. He should not allow his compassion to exceed his wisdom. He must remember that the Holy Spirit must convince and convict people of their need for Christ and obedience to Him. We should spend our time with those who are responsive. Christ instructed the disciples to turn away from certain people (Mt. 10:11-15). That does not mean that we give up on them or stop treating them as patients, but that we spend time with those who are receptive and pray that God will work in those who have failed to respond.
What About the Psychologist and Psychiatrist?
The role of the psychologist is easy to determine. He has none. Stay with me. What is it that psychologists do? They "talk" with people and in a (very large) variety of ways try to change their thinking and behavior. That is, they do not give medications as psychiatrists do. Anything that they do, a trained Christian (pastor, physician, layman, etc.) can do.
The more important dimension in counseling is the Biblical one. As we have seen, the health of patients who have physical complaints for spiritual problems, is dependent upon their regeneration and obedience. The proper Biblical counsel can "heal" that patient regardless of who gives it. The psychologist has no special place here. In fact, he has less reason to counsel in this situation than the trained Christian because he will be more influenced by his psychological training than by his Biblical understanding (in most cases).'
The role of the psychiatrist is more difficult. I have discussed it at length in my book.18 Briefly, however, there are two categories of patients whose physical and spiritual causes are difficult to discern. First, there are patients who are psychotic. That is, for various reasons they are not "in touch" with reality and can no longer function in their daily responsibilities. Special care is needed for several days for such people. (I believe that the challenge of this situation is one that Biblical counselors have not yet adequately addressed.)
Second, some behavioral and/or perceptual problems are likely to have a real physical basis, i.e. be "organic."19 This area is one that needs research by those trained in Biblical counseling and in the use of psychotropic medications. It may be the most difficult area of medicine to discern.
These two categories, however, do not necessarily justify the specialty of psychiatry. Physicians can be trained to manage these patients as they manage others with proper medications and treatment. Even if the physician does not counsel the patient himself, he can manage the patient's medications as someone else gives Biblical counsel.
The physician who is a Christian should not ignore the spiritual conditions of his patients. Further, he should attempt to give adequate explanations to their nonphysical problems and provide (either himself or by referral) Biblical counseling. The psychologist who does not qualify as a Biblical counselor has no role in the "treatment" of this patient. The psychiatrist may have a role, but considerable dialogue and study is needed to define whether this specialty is really needed or whether physicians can be trained to provide whatever "medical" role is needed.
1. Payne, Frankin E. Biblical/Medical Ethics, Milford, Michigan: Mott Media, 1985.
2. Physicians whom patients see initially for a problem. Family physicians, pediatricians, general internists and obstetrician/gynecologists are usually listed in this category.
3. At least such thoughts may be present early in one's practice. Constantly repeated situations usually numbs one's sensitivities to uncomfortable situations.
4. An estimated 80-90 percent of problems that present to a primary care physician's office are "self-limited." That is, they will get better or get well without any treatment. Or, any treatment by the physician may decrease the symptoms, but will do nothing to effect the "cure" of the problem.
5. I have covered the meanings of these words relative to health in my book, Payne, Biblical/Medical, pp. 102-106.
6. This is not the place to enter into the dichotomy /trichotomy debate. While I am strongly convinced of dichotomy, the trichotomists can think of "soul" as representing "soul and spirit" or the nonphysical part of man.
7. Murray, John. Redemption Accomplished and Applied, Phillipsburg, Pennsylvania: Presbyterian and Reformed Publishing Company, 1963.
8. Often, the fixation continues to prevent change during the counseling process.
9. Adams, Jay E. More Than Redemption, Phillipsburg, New Jersey: Presbyterian and Reformed Publishing Company, 1979, pp. 309-326.
10. 1 use this word here only because many physicians refer to her as "depressed." This diagnosis is extremely overused. As described here, this woman does not need pills, she needs a change in her attitude and behavior.
11. See Note 4 above.
12. Jay Adams and others have written a vast literature for specifically counseling problems, but not for getting from the soma (body) to the pneuma (spirit).
13. Write the Christian Counseling and Educational Foundation for information. Their address is 1790 East Willow Grove Avenue, Laverock, PA 19118.
14. Adams, Jay E. Competent to Counsel, Phillipsburg, NJ: Presbyterian and Reformed Publishing Company, 1970, pp. 42-43.
16. Payne, Biblical/Medical, pp. 221-235.
17. Kilpatrick, William Kirk. Psychological Seduction, Nashville, TN: Thomas Nelson Publishers, 1983.
18. Payne, Biblical/Medical, pp. 155-180.
19. The number of these organic problems, as well as those who need "special care" in the paragraph above, are far fewer than most psychiatrists (including those who are Christians) estimate. The response to many of these to Biblical counseling is truly amazing without hospitalization or medications.
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