Emily Viverette: This is the FaithHealth Learning Forum Podcast, a podcast series designed to offer insights into the Division of FaithHealthNC, a dynamic partnership between Faith Communities, Wake Forest Baptist Medical Center, Emily Viveretteand other health care providers focused on improving health. I’m Emily Viverette, Director of FaithHealth Chaplaincy and Education. This particular series focuses on mining the wisdom of key leaders within the division of FaithHealth Ministries. Today I’m talking with Reverend Keith Stirewalt. Keith, is the Program Manager for Clinical Medicine in the Department of FaithHealth Chaplaincy and Education. Keith’s role is tailored in many ways to his unique background and skillset as an ordained minister and physician’s assistant. Keith, thanks for talking with us today.

Keith Stirewalt: Thank you.

Viverette: There aren’t many chaplain PAs in the world that I’m aware of, so I wonder if you could first share a little bit of your background and how you ended up in this particular position.

Stirewalt: Well, I actually started off working in aspects of medicine way back in 1978 when I was an undergraduate working in the hospital. I was interested in medicine and I had a physician tell me, “If you think you want to go into medicine, maybe it would be beneficial for you to work in the hospital and see what medicine really is.” In addition to doing things like working in the laboratory, drawing blood and working in medical records, I also went through EMT training back at 1978 and did first responder work at primarily extricating people from vehicles using the Jaws of Life. That sparked an interest in medicine that continued for obviously decades.

Viverette: Wow. And that’s something I didn’t know, as a former EMT. You started your interest in medicine, but you ended up in divinity school and chaplaincy. How did all that happen?

Stirewalt: With trying to think of a visual of my vocational life and realize that a labyrinth probably describes it pretty well. Either that or for those of you who know the cartoon Family Circus, when Billy would go to get something he would frequently get lost and it would take him forever to get where he needed to go. But my work in the hospital, I actually ran into physicians who would say, “Those business administrators, they really just don’t know what it’s like to have to practice medicine.” And the business people at the hospital would say, “Well, those physicians, they really just don’t get what it’s like to have to run a hospital.”

My original intent out of that was to come to Winston-Salem and to attend the Physician Assistant Program here at what was then the Bowman Gray School of Medicine, and then get an MBA. And so started off my life in a general practice for a year and moved into the urgent care field, and then started getting an MBA at night, going at night for three years. And in the meantime, developed a specialty in occupational medicines, particularly in toxicology testing in the workplace.

Did that for a while and eventually became the Operations Director in addition to the Laboratory Director for four offices and remembered an earlier call to the ministry that I had experienced back at the age of 13. And I remember telling my mother that I felt a call and decided that I wanted to be a minister. And again, this is back in 1973 and she said, “No, you’re not going to become a minister. They are poor and have no social standing.” And she probably was right on both counts, but that earlier call was always there.

In addition, Margaret, my wife who has her Masters in Christian Education, some of our conversations I realized that I was kind of sitting in the pew but didn’t quite understand what was going on. And those things combined and the fact that I just felt like I was at the end of my trajectory in medicine at the time helped me to realize that I wanted to go back and study at divinity school. And so I studied some at Moravian Theological Seminary, but eventually went to Wake Forest School of Divinity and graduated after three years.

The intent was that I was going to go back to work for the hospital system I worked for doing occupational and administrative medicine, and maybe doing some part-time ministering for little or no cost to a local congregation. But as they say, life has a way of making different plans for you, and I discovered chaplaincy. And I did a year of academic chaplain internship and then I ended up doing two years of chaplain residency here at Wake Forest Baptist Medical Center.

Viverette: We always worry about those folks who stick around, “I am doing two years of residency.”

Stirewalt: Well, after the second year, as they say, “You don’t have to go home but you can’t stay here.” I ended up leaving and actually ended up working in a church for three years and it was good. But to be frank with you, I missed my sick people. Sick people, that’s where my ministry lies, that’s where really my vocational soul lies. And I would drive by Baptist Hospital many days and think, “I wonder what’s going on there.” And especially when I would be sitting in church committee meetings till late at night, I would think, “Please tell me that this wasn’t God’s plan for me.” And eventually a position came open at Wake Forest again and I was able to come back.

Viverette: Obviously, we’re really glad you did. I’m curious, can you say just a word about what is it about chaplaincy that seems to really be one of your passions?

Stirewalt: Well, let me start with one of my misconceptions. And that was being a person who’s been involved in clinical medicine for, as well as a physician assistant, and then going to divinity school. I was certain I was going to be God’s gift to chaplaincy and I don’t think that’s true. It took me a while to figure that out. But there is a resonance there. There’s part of the human condition, the tender space of being in medical need.

The disadvantage, the power disadvantage and the need to feel God’s presence in a place of lowness often that intrigues me. I think while it’s very easy for us to help people realize God’s presence when things are going well, being in the hospital, being in a place of brick and steel, of doctors and nurses and others is a place of disadvantage and a place where I felt I could bring that reminder of God’s presence even in the sad places. The intriguing portion of this is that the questions of medicine, realizing that we don’t have all the answers and the theological questions that we encounter, especially towards serious illness and the end of life. Both of those things in those spaces are places where we want answers, our souls beg for answers. Our intellect begs for answers and yet to me the true intersection and the intriguing part is it’s really about being comfortable with the questions, rather than having those firm answers.

Viverette: That is a shift in thinking probably from the way a lot of folks in medicine are trained to find the answer and fix it and address it.

Stirewalt: And patients don’t usually appreciate when you say, “Well, it could be any of these five things and you choose which one works best for you.”

Viverette: Fast forward a little bit. You came into chaplaincy, you have this background in medicine your background as a PA, background with an MBA. Suddenly, now through the work of FaithHealth, you’ve been able to weave together chaplaincy and your clinical medicine experience in a new way. Talk a little bit about what your role is today and how does that make sense being in a Division of FaithHealth?

Stirewalt: I’m blessed to have what I think is the neatest job at all of Wake Forest Baptist Health and actually I’ve told many people this. Here, let me just give an example of some of the different roles I have. Of course, I serve as the clinical liaison for the Division of FaithHealth, meaning that my role in this sense is to help with varying cases where medical knowledge might be beneficial to our folks as they do their work. Also, to reach out though to clinical folks occasionally and say, “Here’s someone we have and here’s what their need is, so to be able to bridge that.

I also am a physician assistant attached to palliative care and my specialty area again is kind of a narrative medicine during serious illness and end of life. I’m also the chair of the Policy Subcommittee about bioethics for the hospital system and get to work into that area. And I teach at the medical school a day a week in what’s called the MAPS Class, which is the Medicine and Patients in Society, which roles in all kinds of things that involve ethics and social determinants of health. Many of the things that FaithHealth works with each day.

And I also teach some at the PA school. And out of all the things that I get to teach and help facilitate, my favorite thing, which would probably be no surprise is to teach clinical people about the intersection of spirituality and clinical medicine. Because my thesis is that all of us have what I call a theology of health. And that is that theology of health and that spirituality that undergirds us helps us in our way of understanding our state of health, whether we’re healthy or whether we have ailments that continue on. And that’s part of the lens that we use.

And historically as faith and health were linked, there were some misuses of that. What FaithHealth has tried to do and what my ministry and my medicine try to do is to reintegrate those two things in a positive way. I seek to help clinicians understand that their patients are spiritual beings. And that’s an important part, again, of how they perceive and receive their state of health, and that ignoring that is misunderstanding the patient.

Viverette: You do wear so many hats and it is fascinating. It sounds like you’re someone who likes to keep busy doing lots of different things. I mean, just looking over the history of what your professional life has looked like, you’ve had lots of opportunities to do very different things and now you’re finding ways to weave all that together. What I think is one of your gifts is your knowledge of the system. Our medical system is so complicated in general. No matter where you go in the United States, it’s complicated to figure out healthcare. Could you speak a little bit to how you help FaithHealth in navigating, kind of challenging the complexity of this system sometimes? Can you think of an example without…

Stirewalt: Without betraying any conferences?

Viverette: Yes.

Stirewalt: I will say yesterday I was in an interdisciplinary team meeting and of course it involved doctors and nurses, and care coordinators and people from hospice and a patient came into… We started discussing a patient and there was a very deep theological component to the patient and the patient’s family to their receipt of the team. How they received us and how they received the information. And I was able to provide again, a spiritual lens to help them sharpen that spiritual lens to understand why us providing straight logic and saying it again and again wasn’t necessarily helpful to the situation. And that we needed to understand again, the spiritual lens of the patient and in this case, his father, to understand the better way to communicate with them and to partner with him in his health.

Viverette: That’s great, thank you. I’m also thinking about how we have some new policies around our medical center that I’m sure lots of other health systems too use navigating kind of financial challenges. And how you have been working closely with another partner in helping people navigate some of these issues. Can you say just a word about that?

Stirewalt: We were able to secure a patient financial counselor who is now, actually physically their office resides with us and they’re bilingual, which is helpful as well. Let’s start back where we requested that we have one that’s integrated into FaithHealth, but also out of our request we requested someone who was bilingual. Because many of our patients who speak only Spanish are at a disadvantage. Now that we have some additional paperwork for people to fill out in order to be financially vetted as they come into the system, we need someone who can help them.

Yesterday or actually two days ago is a good example where we had a patient who hadn’t filled out all the paperwork but really needed to be seen and seen soon by one of our specialties, actually surgery. And I was able to advocate for this patient and to help lean in and impress upon our folks just how important it was for us to get this person in and they will be seen tomorrow.

Viverette: As someone with a background in medicine and in ministry, what do you wish medical professionals understood about spiritual care?

Stirewalt: Oh, as I run into more and more people who are second generation, unchurched or unsynagogued, there’s a bigger bow wave to help them understand that spirituality is important. That again, it is an integral part of who our patients are and who our patients’ families are. To help them understand that there are positive aspects of religion. And unfortunately, in clinical medicine, especially in bioethics, we tend to run into religion or spirituality in a sense that it seems to be blocking the healthcare that we want or the understanding that we want. And yet there’s some very positive aspects and in fact, predominantly positive aspects to being in a community of faith that I want them to understand. It’s not just trying to understand that I am a Baptist minister who goes to a Moravian church, and therefore I think blank. But to help me explore, well, what does that mean? For medical people, not to hear miracle language in terms of a stop sign, but to learn that it’s an invitation to a question. And the question is, what does a miracle look like to you today? And to realize also that these, the answer to that question often shifts as time goes by.

We in the clinical view tend to go from A to B fairly quickly. We know that a patient is headed to a B regardless of what we do, but to remember that in the elasticity of the patient and the family is a bit different and it takes them a while to come to grips with what’s occurring, especially in very, very sad circumstances. The gift of that time, the gift of understanding their person in front of them as a spiritual being. And that being a positive thing, that’s what I wish clinicians would have a better view of.

Viverette: Great. So I’m going to flip the question. What do you wish chaplains and ministers understood better about doctors or healthcare workers, or medical professionals?

Stirewalt: First off, the struggle that they go through. I every day end up talking to someone who’s clinical, who’s going through the tough work of taking care of patients who we know are not going to survive. And yet the family, going back to what I was talking about before, the elasticity, the family’s not there yet. The patient may not even be able to make a decision, they may not be conscious. They may be close to death, but the family’s not there yet and there is a weight of taking care of people, of continuing to do things that we know are not going to help the patient get better.

Also, I would like them to realize that things like palliative care and hospice are not a statement, there’s nothing more that we can do. There is always something more that we can do, but it’s a refocus of care. It’s honoring that person’s end of life as we do their life. It is providing symptom control, it’s taking care of pain, it’s taking care of anxiety, it’s inviting them into a theological space where they can freely express their anxiety. And that in addition to that great weight that clinicians carry, there is the weight that we struggle as well, we would love to make everyone better. We’d love for everyone to put down their mat and walk out of the hospital and yet that’s not the reality that we live in.

Viverette: Communication is such an important part of this and when we kind of line up on opposite sides of the fence without these conversations, it’s really hard for everybody.

Stirewalt: I think sometimes acceptance that death is going to occur sounds like an anti-theological statement, when it’s not. It is part of who we are and I’m convinced that God is no less present in places where folks are dying than when we’re outside feeling the sun on our backs.

Viverette: And that’s what makes you a chaplain.

Stirewalt: Yes.

Viverette: What is it that really nourishes your passion these days?

Stirewalt: I really enjoy those spaces now where the clinical part of me and the ministerial part of me get to intersect. I realize that the training I received at chaplaincy has been so formative. My joke is, the reason I stayed for two years is because it took me two years to get it. I’m kind of slow. But chaplaincy certainly helped me to see and embrace some of my limitations, but I find new limitations of course each day. But I find that there are ways that I can use either part of me to help as the team takes care of people. And even happens out in the wild. I was able to spend time with a neighbor whose husband passed away early in the morning a few weeks ago, and to be present with her in the space that she needed.

Viverette: The flip side of this, what do you find most challenging about your work?

Stirewalt: Well, I’ll speak from both sides for this. From the clinical side, there is too often an impression of religion as an impediment to the medical care that we want to provide. And again, I think they need to work in concert. From the patient side and the family side, it is again the failure for us to realize sometimes that things like palliative care, like taking care of symptoms, things like hospice actually can yield far better end of life experiences than “aggressive therapy.” And I use that term aggressive very carefully because we tend to use aggressive and fighting, and fighting terminal illness. And I’ve had patients who will privately say to me away from their families, away from their clergy, “I don’t like when people say we’re going to fight with you.” Number one, people don’t always stay with you. But the second thing is that means if I end up terminally ill, that I have lost a battle. And that implies I didn’t try hard enough. And so I see beautiful people, people of faith whose lives end, who are afraid that they disappointed others. Because if they just prayed harder, or if they just prayed right, or if they just stuck it in there and worked harder, they would’ve lived. There’s enough that we take to the grave with us without adding that as well.

Viverette: Well, the job that you do is not an easy one in some ways and I can see that it really, a lot of it nurtures what you love. But I’ve been asking this question a lot too. How do you take care of yourself in the faces of all the kind of stresses of working in a large system?

Stirewalt: Well, first off, I’m blessed in ways that many of our clinicians are not. And that is I have a sackful of chaplains just down the hall, I have people that I can reflect with. I’m in the type of work where I can’t go home and talk with my wife about anything specific, obviously for reasons of privacy but can talk in generalities. But also take care of myself by occasionally picking up the ukulele that’s in my office and playing and singing where hopefully no one can hear. Or by listening to music, or taking a break and reading.

I’m also aware… one of the things that I’ve taught in the past is spirituality for clinicians. I’ve learned through observation that for some people taking 20 minutes or 30 minutes to take care of themselves spiritually is either not practical, or in my case, just I tend to lose focus. I’ve learned to do smaller… take things to take care of myself. One of my colleagues here taught me that anytime you use a hand sanitizer, that’s a good place to kind of resubmit yourself. And I use tactical breathing and sometimes just take a break and just be.

Viverette: Nice. Well, your office is next door and I haven’t heard you sing yet.

Stirewalt: I’ve been successful on that.

Viverette: You’ve been successful.

Stirewalt: God has been kind in that you’ve not heard me sing.

Viverette: Well, what haven’t I asked you about your work and what were you hoping to share?

Stirewalt: I think I’m circling back to one of your questions about one of the things that it’s always a work in progress with me. There’s a joke that no matter what I speak about, and I have spent a lot of my time speaking and teaching as well, that it always ends up revolving around death eventually. And that is that I see serious illness and death and reflection as a sacred space. And I think that I would like to see in our places of faith more open conversations about the sacredness of this time. The fact that again, this is not the absence of God, in fact, this is a time where we need to be most aware of God’s presence.

But also to realize that things like living wills and healthcare powers of attorney are both love and justice. And if I can take a moment to talk about that. The living will is a way for us to say to our medical team, “If I ever get to the point where you can’t help me get better, concentrate on making me feel better, which is again, take care of my pain and anxiety.”

When I did chaplaincy work and was able to talk with people at the end of life who were still able to talk, I thought I was going to hear their deepest, darkest secrets. The consistent themes I heard though were, “I don’t want to be in pain, I’m anxious. Not only do I not want to experience these things, I’m afraid about my family experiencing these things.” This document again can help us to focus on that. The healthcare power of attorney helps us to pick the person who will speak for us when we can’t speak for ourselves. We’re picking someone to make our medical decisions when we’re incapable of doing so and communicating them to the medical team.

And why do I say they’re love and justice? Well, they’re justice from this aspect. My values will be carried forward by these documents or by this person or persons I choose to make my medical decisions, and their job will be to make the decision that Keith would want would he be able to speak for himself? The justice aspect is, I have someone representing me to the medical team. The love aspect’s a little different. One of the questions we ask on these documents is, “What if we say, “Listen, if my healthcare agent, in my case by a wife, kind of changes her mind and says, ‘I know Keith didn’t want this, but I’d like him to have this done,’” the document says, who should we listen to? Should we listen to the living will or should we listen to your healthcare agent?

Unfortunately, I’ve been able to hear as a clinician and as a chaplain and a minister, many things said at the end of life or toward the end of life I wish I hadn’t heard. And that was, “Don’t you wish you had waited three more days?” Or, “What if they invented something new?” Or, “What if this was a test by God and you failed because you let Keith die?”

I told my wife, “I can’t take these things away from you. People can say whatever, but I can do this in the choices that I’ve made, in the honest conversations I’ve had about my end of life wishes, I have given you the answer. This was so important that he made the decisions for me. And this is the last, I love you, that I gave to Margaret, and to my children and I gave it to them ahead of time. Again, there’s the justice aspect of, who will speak for me? But the love’s eye aspect is, I’ve had honest conversations to where they know they’re going to make decisions. And no matter what they decide, if they’d make those in love, that’s fine with me.

Viverette: I can’t believe we almost got through an entire conversation without talking about advanced directives. That’s also been a large part of Keith’s work with us. He does a lot of education with our chaplain residents and across the system and a lot of the policy writing around advanced directives. And he’s also worked at a state level, right?

Stirewalt: Yes. I’m blessed to be part of a task force right now on serious illness and end of life where we’ll make some recommendations to the North Carolina Institute of Medicine, who will then make recommendations, hopefully to other folks including our legislators to try to improve some of the laws that we have. Again, we can honor the wishes of our patients at the end of life. I would be happiest if we lived in a world where the clinical people and patients and their clergy felt like they could be honest with each other and receive honest answers.

I want to empower our patients to ask for the truth. Because one of the truths is that clinical people are hesitant to give sometimes very hard news to patients. It’s not easy to say, “We’re not going to be able to fix this issue, but I’m going to stay with you, I’m going to take care of you.” We need to be empowered to say that to patients, but we also need for patients to be empowered to ask for that truth, to say, “What are my options? What are the good things and bad things that can happen with what you’re recommending? What if we do something different? And, what if we just watch and wait?”

Viverette: If people want more information about advanced directives, where should they go?

Stirewalt: We’re part of a community coalition that we helped start, it’s called Got Plans 123. And so it’s G-O-T-P-L-A-N-S-1-2-3.org, and it is a community resource. We have paired with other healthcare organizations and with local hospices to create a space for people to be able to get the information necessary. And it also directs people on how to get these documents done for free.

Viverette: Great. Well, Keith, thanks so much for being a part of the conversation today and for sharing so much of your wisdom and your background with us. I look forward to hearing the ukulele soon, next door.

Stirewalt: Thank you.