Teaching to Narrow the Divinity-Medicine Gap

As Harvard Divinity School Professor Sarah Coakley points out, "the Divinity School is physically surrounded by Harvard's biology labs," and yet "there is a huge gap in [course] offerings for science and religion at Harvard." Coakley finds this situation especially discouraging given that there are a not-insignificant number of HDS students with background and interest in science and medicine.

But Coakley, an ordained priest in the Church of England with impressive accomplishments in a wide range of pastoral as well as academic settings in Britain and the United States, is not the type to gripe about a problem without doing something to remedy it. She is trying to fill the "science and religion" gap at Harvard through her own scholarship and research initiatives, as well as through interdisciplinary course offerings. Most prominent among the latter is the immensely popular "Medicine and Religion," a course cross-listed at the Medical and Divinity Schools that she has twice co-taught with Arthur Kleinman, who has appointments at HMS and in the Anthropology Department of the Faculty of Arts and Sciences.

The impetus for creating the course came in 1999-2000, when Coakley was doing her own Clinical Pastoral Education (CPE) training at St. Elizabeth's Hospital in Brighton. "During the whole year, only one doctor talked to me," she said, "and I discovered that most trainee doctors have no idea how chaplains are trained."

Having already been engaged in academic work that bridged the worlds of medicine and religion, including co-chairing a vibrant Mind/Brain/Behavior Interfaculty Initiative group at Harvard, "Pain and Its Transformations," which started in 1998, Coakley felt she had to do something to counter the great divide that too often exists between ministers and doctors in hospitals and other health-care settings. What better point at which to intervene, she decided, than at the point medical and religious professionals are receiving their training.

So Coakley enlisted Kleinman, her co-chair from "Pain and Its Transformations," and the two developed a course that would bring together students from the Medical and Divinity Schools to think through the different ways that religion and medicine relate. The two professors came up with broad topics of discussion for the class: pain and suffering; death, dying, and grief; ritual and healing; spirituality and its cultural manifestations; ethnic perspectives; and moral questions that bridge medicine and religion. Coakley and Kleinman taught the class for the first time in fall 2001, after which they received a Templeton Foundation course grant, allowing them to tweak it for its second go-around, in fall 2003.

"Interaction between the medical and divinity students was pedagogically built in from the beginning, in that we made sure there was at least one medical student and one divinity student working together on presentations each week," Coakley said. "Creating an intense conversation between the two sets of students became even more explicit this time. With the Templeton money, we were able to double the number of hours that our teaching assistant, Paul Jones, had with the students in small groups. So instead of having just a preparatory meeting with the medical and divinity student teams who were going to present each week, he also saw them after they had presented or written a paper, to help them to digest what they had learned together."

Coakley and Kleinman acknowledged that structuring a course to meet the needs of these particular groups of students proved to be even more difficult than they had imagined. "It's not just the usual problems of an interdisciplinary course, it's the problems of two sets of students whose lives and pressures are very different," Coakley explained.

"The medical students have to be at the hospital at 8 in the morning with their scrubs on, their coursework includes the intensity of ingesting facts, and they have exams every week," she added. "They tend to be young, very idealistic, and immensely competent academically and clinically. The divinity school students, on the other hand, are used to [discussion-oriented] classes requiring extensive reading and writing long papers. Many of them are older students who have come with wisdom and a wealth of experience from many realms, including some who have been nurses, midwives, chaplains, and physicians. The first time I taught the class, we had an extraordinary proportion of Divinity School students who had experienced life-threatening illnesses themselves."

The differences extend beyond training and experience to intellectual proclivities, Kleinman quickly discovered. "There is a diversity of perspectives among the Divinity School and Medical School students," he said. "You see this particularly when we read William James. In the two years I've taught the class, medical students tend to see James as the strongest statement of what religion is. This suggests that, for them, the self is the final common pathway to religion. Whereas for Divinity School students, there are a whole bunch of other perspectives that are significant, not just theological ones, but ones that relate to the anthropology of religion, and postmodern and postcolonial interpretations of religion.

"There's a very basic tension there in the pedagogy. The class would be different if we were teaching anthropologists or Divinity School students alone than it is when medical students are an integral part of the course."

In fact, Kleinman said, his own background as both a physician and an anthropologist made him feel "equally divided in this setting." He explained: "Usually, I feel unified, but in this class I sometimes felt the need to emphasize clinical, medical things, and other times felt just as strong a need to emphasize anthropological things." In that way, he said, the class was a lesson in how "being a teacher can often shake up your own views about as much as it contributes to the education of others."

Yet, as teaching assistant Paul Dafydd Jones pointed out: "Because the tensions and differences [between the students] were so stark, they could find points of connection, most obviously around death and dying and pain. If there's anything both doctors and ministers face in their training and in their vocations, it's the big questions of people around death and dying, and 'why is this happening to me?' There's a very human, face-to-face quality for both the professions."

Jones said that in the sessions he ran with students, the interaction between the disciplines became very concrete. "It's one thing to deal with abstract ideas on the level of the esoteric," he said, "but when students got to talk about their CPE experience, or their rotation, that made the material very direct."

Coakley agrees that there are points of contact between religion and medicine. Although the two professions may by necessity entail very different lifestyles, she noted, "In a number of areas, medicine and religion are drawing very close at the moment, not just in placebo research and the increasing interest in complementary medicines, but in the acknowledgment of the significance of trust in patient-doctor relationship and the importance of spiritual practices in healing."

All of the instructors agreed that one of the most interesting discussions occurred the week the class addressed issues around Clinical Pastoral Education, the hospital-based program that trains ministers for chaplaincy. "The CPE week was in some ways the climax of the class," Coakley said. "We were lucky in that the medical student who presented was someone who had already taken the risk of doing CPE, so she had inside knowledge of it, and acted as a kind of prophetic catalyst."

Interestingly, two of the students who presented together in this class had done CPE together at Massachusetts General Hospital the previous summer. Both said the training was invaluable for them, but for different reasons. Divinity School student Jordana Gerson, in the second year of the Master of Theological Studies degree program, found the "on-call" time to be the most powerful part of the experience. Gerson, who is Jewish, and plans to go to rabbinical school, told the class that she learned a great deal from the interfaith, diverse team at MGH about how to do chaplaincy in an interfaith setting. She said she also ended up reflecting on "the difference between curing and healing" and on the role of the hospital chaplain, coming to see the vital importance of the chaplain as someone who "treats the whole person."

The medical student, Carolyn Casey, found that her CPE experience really "balances out my medical education." She explained: "We probably talked too much about feelings for 10 weeks, but I have talked far too little about feelings [the rest of the time in medical school]. By August [the end of the CPE training], I took up less psychological space."

"The single biggest gift I took from CPE was learning how to give comfort [to patients]," she continued. "In the future, when a patient asks, 'What's going to happen to me?' or 'Is God angry with me?', I'm not going to bolt!" And practically, Casey said, "as a physician, I will not just know that there are chaplains; I will have a relationship with the chaplaincy office and I will screen people for whether they want to talk to a chaplain."

Members of the class were so impressed by the students' accounts of CPE, Coakley said, that a number of medical students came up and asked the instructors if they could do the program. "The question is how we're going to fund it, but we have a lead on foundations who might be willing to help pay for this, so we might be sparking a new trend," Coakley said. "Arthur [Kleinman] and I are enthusiastic about trying to create the opportunity for more medical students to do CPE."

"I hope the trend will not go just one way," Coakley continued. "It would be wonderful if more medical students knew what chaplains do in their training, but it would also be wonderful if the CPE structure itself was more rigorous psychoanalytically. Right now, programs really vary according to where you do them. The vast majority of students at HDS have positive experiences, because our field-education director, Dudley Rose, has hands-on knowledge of the best local programs, but students not at those top-notch programs can have bruising experiences."

Kleinman has had his own questions about the two "social medicine" requirements for medical students, particularly with their placement at the beginning of medical students' training. He and Coakley both believe med students might benefit more from taking at least one of those courses toward the end of their training, after they have had more direct experience with patients. Coakley notes that after they have started to experience the very real stresses of caring for patients, medical students find that they need their own personal and spiritual practices, to help avoid burnout. Moreover, having even more course offerings of this kind might help to sort out the irreconcilable tension Kleinman identified in this class between having the thrust be "a substantive examination of the intersection between religion and medicine from academic perspectives" and "providing an opportunity for a space of self-reflection about students' own experiences of illness, care giving, and the like and their own personal spiritual quests."

It is on this level of trying to effect possible institutional changes that Coakley sees some of the most important outcomes of the class. "My hope is that down the road, this experiment could transmute into something that has an institutional effect on the curriculum in both places, and perhaps in CPE programs," she said.

Whatever happens, the class has provided valuable insight for the instructors and the students into the challenges and rewards of undertaking interdisciplinary and cross-school initiatives. Said Kleinman: "I've only become more certain that teaching about religion in its engagement with suffering and caring is extremely important and that this crucial topic should be widely taught, but [at the same time] I've become less certain about how best to do this."

"There are a bunch of massively complicated issues surrounding this topic in a tremendously pluralistic society," said Jones, "so there needs to be a lot more hard thinking about what is the best role a minister should play vis-à-vis medicine, and what is the best role a medical practitioner should play vis-à-vis religion. If people in both fields can talk to each other and notice each other, that's at least a starting point."

Meanwhile, Coakley continues her own academic and research work around these issues. An edited volume from the culminating conference of the "Pain and Its Transformations" group will be out in 2005. The book concludes, according to Coakley, with "a big suggestive question mark about how apparently unconnected fields of endeavor [such as neuroscience and religion] could be incredibly important for the future investigation of pain management." To that end, Coakley has recently worked on grant proposals together with some of the most cutting-edge pain researchers in the country to develop a set of experiments investigating the modification of pain on the basis of charismatic prayers and Christian contemplative prayer. Through the pain group and these other endeavors, Coakley said, "I have experienced probably the most interesting conversations I've had at Harvard." One of her favorites involved having to explain different Christian theories of grace to the neuroscientists with whom she has been collaborating.

"We are only in the early melting-pot stage, but these kinds of conversations ought to be going on among scholars and students," Coakley said. "Harvard is particularly well set up for just this kind of collaboration."

Perhaps most important, through the religion and medicine course, she concluded, "we are creating a camaraderie between students who will be some of the leading clerics and the leading doctors in this country."