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Thursday, February 26, 2015

“Foot Care”

Once I was visiting the oldest member of my church.  “How are you?” I asked.
“I’m doing OK,” she said, “but I just get so frustrated that I can’t do the things I used to.”

“Dora,” I replied, “you’re 105 years old!” The fact that she was able to wake up in the morning, recognize me and carry on a lively conversation was nothing short of remarkable at her age.

Atul Gawande
Atul Gawande’s book Being Mortal is a reflection on what it means that we are creatures who, over time, age and eventually die. Human existence means learning to live within the limits of our mortality.

Gawande writes from the perspective of a surgeon. Modern medicine, he says, operates out of a paradigm centred on diagnosing and curing disease, and fixing what is broken. But what about when people can’t be fixed? What about when the problem is not a specific pathology but simply the limitations of being mortal which become more pronounced with age?

The tendency of the medical system is to a) continue to try to fix what’s wrong, often inflicting needless suffering on the patient, or b) simply give up. Care of the elderly eats up huge resources, but often with little positive results.
Gawande says the question needs to change from “How can we fix what’s wrong with this patient?” to “What is the best and fullest life possible for this person, given his or her limitations?”
I think there’s an analogy here for many of our churches. (Recognizing that any analogy can only be pushed so far. There are similarities between an individual and a community, but there are also differences.)
A lot of churches, like a lot of church members, are struggling with diminishing capabilities. They are not what they once were. They can’t do what they once did. Partly that’s the result of changes in our culture, which has pushed religious institutions out of the centre and onto the (almost invisible) margins.
The leadership in many United Churches are people whose concept of a vital and healthy congregation was formed in the 1950s and 1960s.
Even though they know things have changed, their attitudes and actions are still driven by powerful memories which shape their image of a healthy church.  Compared to that memory, the present reality of the church can only seem like a failure, a shadow of what once was.

The problem is that a lot of energy goes into ultimately futile strategies to try to “fix” what is wrong – to get the young families back, to change the music, to start this or that program. All of this can distract us from engaging deeply with the basic question: “Given the reality of where we are, what does a full, abundant life in Christ look like?”
The fact is that most United Churches will have a high percentage of older people. To change that significantly would really mean that the present church would need to cease to exist and something entirely different take its place.  So, the question is, “How can we be faithful and fruitful as who we are?”
Atul Gawande writes of shadowing a geriatrician as he treats his elderly patients. Ironically, in an aging society, gerontology is a dying specialty, with low in status and relatively low in pay. Few medical students are interested in specializing in the care of the elderly.
But geriatricians can make an enormous difference to people’s lives, often through paying attention to very simple things. Gawande watched as the doctor examined a woman in her 80s who had no specific medical condition. Her main problem was that she was old.
Gawande noted how much attention he paid to his patient’s feet.
That’s because one of the main threats to the well being of the elderly is falls, and one of the top three causes of falls is improperly cared for feet.  Simple, modest, low tech.  But crucially important.

I wonder:  What would the church equivalent of “foot care” be? What are the simple things we could be doing to prevent “falls” in our churches – those preventable crises that can fracture an already fragile congregation, incapacitating it and perhaps hastening its death?
We may not be able to “fix” everything in the sense of recreating the kind of robust strength of people’s memories. But what steps can we take to stabilize congregations so that they can continue living well.
Another key ingredient in the care of the elderly, Gawande discovered, is a reason for living. Boredom and depression are two of the great robbers of vitality. Helping people discover a reason to get up in the morning is enormously important to their well being.
It’s what, in the church, we call a mission. Many congregations are abandoning any sense of real mission because they believe they are too small, too old, too tired to do anything useful. But that’s because their mental image of being in mission implies strenuous physical activity or traveling to a different part of the world. Jesus calls every Christian to a mission and I don’t think Jesus intended to abandon us when we get to a certain age.
The real problem is that if nostalgia, loss and low congregational self esteem dominate, we become unable to discern the possibilities of the here and now.
I am not suggesting that all we should do is palliative care, “keep the patient comfortable” until the end. That is one of the differences between an individual and a community. A community is not limited by the life span of any one individual. Communities can regenerate and be reborn.
But, Atul Gawande advocates shifting the focus of medical care from simply fixing and curing to helping people determine what is most important and taking simple measures to minimize threats, enhance possibilities and instil a reason for living. Studies have shown that when these things happen, even the frailest of the elderly can experience a profound transformation in the quality and meaning of their lives.
As Christians, we believe in a God who raises the dead. We believe that real transformation is not our achievement, but a gift of divine grace. Our role is often to remove the barriers that prevent us from experiencing that transformation.
Perhaps if we became more focused on helping congregations determine what a rich, full life in Christ means, given the limitations of their situations, we might find that change happens in exciting ways we never expected.  

Monday, February 16, 2015

Unexpected Discoveries

I haven’t posted lately because I’ve been doing a lot of reading.
 And thinking. Thinking about how often we learn important lessons almost by accident. It’s not what we go looking for, but what we stumble across that makes the difference.
Almost thirty years ago I took the summer off to study music and practice the piano 
What does this have to do with
intensively. It was a kind of sabbatical before we had sabbaticals. I learned a lot about music. But through the process of practicing, preparing and performing music, I learned more about preaching than I ever did in any homiletics class.
The historian J. H. Hexter wrote a wonderful essay about the process of discovery. He said that every historian has a field of research that he or she pursues intentionally; but real breakthroughs often come, not from that research, but from other sources – a book on an seemingly unrelated subject, or a random personal experience.
Hexter described this phenomenon using the metaphor of the medieval village, which was surrounded by an area of cultivated land called “the Sown.” That’s where the people systematically ploughed, planted, fertilized and reaped. But beyond the Sown was an area of uncultivated land called “the Waste” where anyone’s animals were free to graze.
The Sown, he said, is like the chosen field of research – or, if you’re not a scholar, the thing you deliberately set out to learn. But our discoveries often come from the “grazing” we do – the books and articles we read, the movies we watch, the conversations we have with strangers and friends.
I’ve been grazing lately. Several months ago, I read an article in The Atlantic magazine about whether our expensive health care system is doing what it’s supposed to do – make us healthier. The author of this article referred to eight or ten new books about the challenges facing our health care systems.  
One of them was entitled Being Mortal by the Boston surgeon Atul Gawande.
Atul Gawande
Lo and behold, it was available in the local library. I had to put a hold on it because it was checked out (always a good sign.) When I finally got to read it, parallels to my experience in the church leapt off practically every page.
Atul Gawande writes about the topic he knows as a highly skilled surgeon. But he really writes what it means to be human in an increasingly complex technologically driven world.  And it’s about whether our institutions achieve the purpose for which they ostensibly exist – to enhance human well being. And, if they don’t, what we can do about it.
After Being Mortal, I read his other three books.
Complications is about the incredible complexity of modern medicine. But it’s really about the humanity of the physician. No matter how much skill and training one has, mistakes and failures are inevitable, because the doctors from whom we expect superhuman ability are fallible human beings, just like their patients.
Better is about how to improve doctors’ performance. But it’s really about the importance of character. Doctors have all the training, skill and expertise they require. What’s needed are diligence, the wisdom to do the right thing, and ingenuity. Sometimes I wonder if, in ministry, we are intentional enough about trying to improve our performance, and how we would measure that improvement.
The Checklist Manifesto is about how a simple tool can make an enormous difference.  Gawande argues that medicine’s shortcomings will not be improved by more information. The problem is that there is so much information, it’s beyond the capacity of the human brain to cope with. Gawande helped to develop a simple surgical checklist that has drastically reduced complications and deaths from surgery worldwide.  I wonder what simple tools we could devise in ministry to be more effective at what we already know how to do?
Being Mortal: Medicine and What Matters Most is about the health care system’s inability to deal with the frail elderly and the terminally ill. Modern medicine is about curing disease and fixing what’s broken. But what do you do with someone who cannot be cured or “fixed.” Modern medicine, Gawande argues, is in a state of denial about the basic fact of human existence: we are mortal creatures who eventually break down and die. What does it mean to help people experience the fullest life possible, right up to the very end?
These questions cut to the heart of what we are facing as churches. Like so many of our individual members, many congregations are getting old, breaking down, coming to the end of their life cycle. My work as Presbytery Support Minister has shown me how we tend to discount those congregations because they can’t be “fixed” – and how we fail to nurture the life that is still in them to the full. What "matters most" in the situations in which our churches find themselves?  
But the implications of what Gawande is saying go beyond the issues of terminal illness or frail old age. He’s talking about living a full, rich and meaningful life even as we honestly face of the limitations of our mortality. "What matters most?" is a basic question at every stage of our lives.
Surely the Christian community should have something profound to say about this. We claim to have some insights into what matters most . Isn’t mortality one of the great themes of the Bible? Isn’t seeing mortality as a promise to be lived into, not a problem to be fixed, central to the Christian vision? Could renewal in our churches be less about institutional expansion and more about empowering people to engage with these questions in their own lives, especially as our society ages?
Sometimes I think the thing we need to do is read less about what to do about the church’s problems, and ponder more deeply what it means to be human in God’s world. And if we can help people on that journey, we’ll never need to worry about being “relevant.”
In future posts, I’m going to delve further into Atul Gawande’s books. I’d recommend them to anyone. They’re easily accessible and highly interesting and readable.
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