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Join us for an episode featuring Patricia A. Gabow, a nephrologist, as she discusses her book, The Catholic Church and Its Hospitals: A Marriage Made in Heaven? Patrician delves into the origins and evolution of the Catholic health care system in the United States, exploring how Ethical and Religious Directives influence patient care, particularly in reproductive and end-of-life services. She examines the transparency of these institutions, the historical role of Catholic nuns, and the balance between religious beliefs and patient rights in today’s pluralistic society.

Patricia A. Gabow is a nephrologist.

She discusses her book, The Catholic Church and Its Hospitals: A Marriage Made in Heaven?

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Patricia Gabow. She’s a nephrologist, and we’re going to talk about her book The Catholic Church and Its Hospitals: A Marriage Made in Heaven? with a question mark at the end. Patricia, welcome to the show.

Patricia Gabow: Well, thank you, Kevin, for having me, and thank you for all the wonderful podcasts you do to help us all stay informed. It’s a lovely service that you provide, so thank you.

Kevin Pho: Well, let’s start by briefly sharing your story and journey.

Patricia Gabow: Well, it’s a little bit surprising that I became a physician, in many ways. I grew up in an Italian immigrant family in rural Pennsylvania, not exactly a place where you’d expect a girl to go to medical school. In addition, everybody in my family was a school teacher, starting with my grandfather, my mother, her two brothers, and my stepfather. And somehow from eighth grade on I knew I wanted to be a doctor. Who knows where that came from?

But I went to Penn, University of Pennsylvania School of Medicine, and at that time there were six girls in a class of 125. So an interesting time. Penn at that time certainly was very academic, but from the point of view of care delivery it really had two levels of service. There were big open wards, where patients were just separated by curtains, for the poor patients, and suites for the rich patients in another building.

And that experience made me convinced that I wanted to be at an academic institution, but I also wanted to be at a safety net that focused on care for the most vulnerable in society. And so Denver Health was perfect. And I always tell my mentees, try to find an institution that aligns with your values. If you do that, you’ll be able to spend your whole career there. And that’s what I did.

I started out as an entry-level doc, started the kidney service, then became chief of medicine, then became CMO, and then for the last 20 years I was the CEO of this integrated delivery system that had community health centers and alcohol detox and school-based clinics and the 911 system, and of course the hospital. So that’s a short version of my journey.

Kevin Pho: Your book is titled The Catholic Church and Its Hospitals: A Marriage Made in Heaven? ending with a question mark at the end. So before talking about that book, what led you to write it in the first place?

Patricia Gabow: Well, I’ve had a long interest in Catholic health care, because I’m a physician, because I led a system that was a safety net, and I’ve been involved in national health policy for decades, and I’m a practicing Catholic. So all of those reasons gave me an interest in Catholic health care.

And then, as I started to think about this book, and I started talking to my friends and colleagues, some of whom are very knowledgeable about health care, I was surprised that they knew virtually nothing about the many dimensions of Catholic health care. So I thought, well, if very knowledgeable people don’t know about it, there’s probably a lot of people who don’t know about it, and somebody should write a book about this. And I thought I could do it.

So literally I picked up a pen and started to write it, really trying to do a book that covered the whole spectrum, from the theologic basis through the early beginnings to where it is now.

Kevin Pho: All right. So to give some context before I ask you questions about the book, explain briefly the origins and the evolution of the Catholic health care system in the United States.

Patricia Gabow: Well, it really started with the nuns who came over as missionaries. We tend not to think of America as being a place for missionaries, but these nuns came from largely Europe, and they were women who, interestingly enough, although they were in a structured hierarchy in which men ruled, they actually had more power than most women in society, and especially out in the West where there was virtually no hierarchy.

So these women really believed in service to the poor, and so they started the Catholic health care system around the country, literally in some cases building hospitals that were to serve the most vulnerable in the population. And they were selfless. During the many epidemics that hit America in the early years, smallpox, et cetera, they were the ones who would go out and care for the patients.

And out of their vows of poverty, out of their vows of service, out of their commitment to really follow Jesus’s example, to heal the sick, especially the most vulnerable, the Catholic health care system grew across the United States. But they were the founding mothers.

Kevin Pho: And if you were to make an educated guess, what is the estimate of the number of health care institutions in the United States that are Catholic based?

Patricia Gabow: Well, I actually don’t have to guess. There are many, and let me just give you some statistics about the vastness of how those small hospitals that the nuns started, what they’ve become over time.

So right now, four of the 10 largest health care systems by operating revenue are Catholic in the United States. And 46 states have at least one Catholic hospital, and in 20 states more than 20 percent of the beds are in Catholic hospitals. And in some states like Colorado, that number is really surprising. I live in Colorado, and 38 percent of the beds and 42 percent of the deliveries are in Catholic hospitals.

If you look at Ascension, they alone have 149 hospitals. And it’s not just hospitals anymore, they have clinics, they have urgent care centers, freestanding emergency rooms, pharmacies, insurance companies. So they’ve become very large corporations. And they have 4.5 million admissions and 500,000 deliveries in Catholic hospitals. That’s about 14 percent of all admissions in the United States and about 13 percent of deliveries.

And sort of one of the more surprising statistics about reach is, CommonSpirit, which is the largest Catholic system by revenue, says one in four Americans have access to care in their system. I mean, this is a big part of American health care.

Kevin Pho: So tell us the key points that you want readers to come away with after reading your book.

Patricia Gabow: Well, I think it relates to some of the things that surprised me. And therefore, I guess if it surprised me, it probably surprises a lot of people. And in fact, as I’ve talked about the book, I can affirm that that’s the case.

So the vastness of the system, which we just talked about. The other is the ethical and religious directives for Catholic health care services, the ERDs. Now, I knew about them, but I didn’t really realize that there were 77 of them, and I didn’t realize their breadth. And I think it’s important that people understand the ERDs and understand their reach.

Of the 77, the first component of the ERDs is, these hospitals are supposed to distinguish themselves in care of the poor, the vulnerable, the migrant, the refugee. The other things they impact, health care delivery particularly in reproductive care and end-of-life care. And it’s important to understand that anyone who’s employed by a Catholic system must obey these ERDs, even if obeying them means that you’re not doing what the patient is requesting. So that’s important.

And patients don’t know this. There was a study that 70 percent of people think there would be absolutely no difference in their care if they went to a Catholic hospital or a secular hospital. 40 percent thought they’d get an abortion for a life-threatening pregnancy, and 27 percent thought they would get an abortion for a serious fetal indication. And of course women can’t get any of those at a Catholic system. And so I think people need to know that.

The other thing is, they’re not transparent. You know, I would have thought, being a Catholic, that these Catholic institutions would want to put up in bright lights that they were Catholic, but you can’t find that on many landing pages, and 75 percent don’t say they follow the ERDs.

So I think those are things that people should know, and that I try to point out about Catholic health care. Given how vast it is and how important it is in the care delivery, it’s important to know these things, I think.

Kevin Pho: Now, doing the research for your book, and you mentioned that Catholic institutions can’t go against their ERDs, when talking to some of those physicians, if they can’t perform or can’t have a certain service at a hospital, do you find that they may refer out to a secular system? What are some of the options that physicians have if some of the ERDs go against what they need to do from a medical decision-making standpoint?

Patricia Gabow: Well, that’s a very interesting question, because part of the ERDs are that you can’t refer, that that’s viewed as being complicit in an immoral act.

Now, I think, while I didn’t interview physicians for this book, let me be clear about that, others have, and physicians do often try to create workarounds for them, but they often find themselves in a moral dilemma around this.

And I think it brings up a bigger point, which maybe we could go into now or we could go into later, and that is, I think right now in America physicians are facing a serious issue about the conflict between their professed oath as a physician and their own conscience, and their employment contracts, and the laws that are being enacted in some states. And I think we really have to examine this intersection between our professed oath, our own conscience, our employment contracts, and legal requirements.

Kevin Pho: From your experience, and you mentioned that you are a hospital CEO, how can you imagine some physicians navigating those tensions and interests?

Patricia Gabow: You know, it wasn’t an issue at the institution I was at, and that’s why, as I said at the beginning, I think it’s really important, if you can, and of course not everybody has this option, to pick an institution that aligns with your own values. Because otherwise you’re facing moral dilemmas intermittently or regularly, depending on the institution.

I do think that as a profession we have to examine it. And I think that if you look at the AMA code of ethics, they do say that physicians have a right to exercise their own conscience, but they do put some guardrails around it, that you should reveal to the patient upfront where there are areas that you can’t do because of your own beliefs, and you should refer.

So this is a tension then that’s created, and I don’t have a magic wand for solving it, but I think, as with all dilemmas, we have to talk about them, and the profession really needs to engage in this discussion with the broader society about, what do you do when these competing values intersect?

Kevin Pho: So tell us the response you received since the book was published. What were some of the responses you received, perhaps from the Catholic institutions?

Patricia Gabow: Well, I would say there hasn’t been any kind of organized response. I have done lectures and book discussions, and the most common response has been, I had no idea about the ERDs, I had no idea that doctors in a Catholic institution had to follow the ERDs, I didn’t know how vast or how rich the Catholic institutions were.

And I had one CEO of a major health care system, no longer CEO, of one of the big health care systems, who thought that they actually did a lot of good, and maybe I should have raised up more how much good they do. And they do do good, and I think that’s a true fact. But there are areas that I feel are issues that should be addressed.

And my book ends with, I never believed that you should point out problems and then be silent about solutions. So the last chapter of the book is 30 recommendations. And some of them are for the bishops, because the bishops do have responsibility for overseeing Catholic health care. They don’t run them, they don’t financially support them, they don’t benefit from them financially, but from a Catholic perspective they oversee them.

I think that the bishops should be zealous for the first part of the ERDs, which is care for the poor. And while the Catholic systems are not worse than any other system in caring for the poor, they’re not better. And they should be better, from their history. I think the bishops should demand transparency about the care.

Kevin Pho: We’re talking to Patricia Gabow. She’s a nephrologist, and we’re talking about her book The Catholic Church and Its Hospitals: A Marriage Made in Heaven? that’s ended by the question mark. Patricia, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Patricia Gabow: People should know whether their facility is a Catholic facility or not, and they should understand what that means for their care. And of course it doesn’t affect all kinds of care. I mean, if you’re going in for neurosurgery it’s unlikely to be an issue. It’s primarily, you should know this for reproductive care, end-of-life care.

And for physicians, I think it really is, how do we as a profession explore this intersection between our oaths and our employment contracts and the laws that are being enacted across the country? And that’s terrain that has yet to be well defined, I think.

Kevin Pho: Patricia, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Patricia Gabow: Thank you for all you do.