The Gift of Burnout: Initiation into Becoming a Healer

This is the title of a poster presentation that my good friend, Gary Orr, and I presented at the Australasian Doctors’ Health Conference in Perth, Australia, November 22nd, 2019. This conference takes place every two years, rotating through the Australian states and New Zealand. Here is a screen shot of the whole poster, it is a bit difficult to read in this format, so I’ll break down the elements and type them in below the poster…

THE GIFT OF BURNOUT: INITIATION INTO BECOMING A HEALER

David R. Kopacz, MD, ABPN, ABIHM, ABoIM, Puget Sound VA, University of Washington

Gary Orr, MB BS MSC DIC MRCPsych (UK) Dip Interior Design (Au)

HYPOTHESIS

Burnout could be a predictable rite of passage that occurs several times throughout the education and practice of being a doctor. It is part of the initiation into becoming a healer.

We should not aim to prevent burnout, but rather to expect it and plan for how to create healing inner and outer environments to support doctors through the burnout phase of initiation into becoming a healer. Currently there is a failure of moral leadership in health care institutions, resulting in moral injury (1,2) and burnout with rates upward of 50% of physicians.

This poster provides a new view of burnout, re-examining it as a process of transformational learning and initiation into the archetype of the wounded healer. We will examine the process of finding strength and compassion in our wounds and discuss how we can develop a system of mentorship that guides and supports those going through the initiatory wounding of burnout. Gary will show how the path of a healer sometimes leads out of clinical care and into larger challenges of reinventing one’s self and the effects of design on health.

Introduction:

The World Health Organization has recently defined burnout as an “occupational phenomenon.” (3)

• feelings of energy depletion or exhaustion;

• increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job;

• and reduced professional efficacy

Symptoms of burnout have been reported in over 50% of physicians (4,5). Much of the literature on burnout, implicitly or explicitly, focuses on deficits, deficiencies, or negligence of self-care of the clinician. Individual suffering is marginalized and responsibility for addressing burnout is placed upon the individual. Yet there is a growing realization that burnout is a consequence of a mismatch between the professional values and ideals of physicians and institutional demands that require physicians to compromise their values and ideals – some have begun to call this moral injury. An initiation perspective depends on the availability of elders to communalise and contextualise suffering and yet our institutions marginalize the human and silences the elders.

Burnout as Initiation

We can view burnout as a necessary step for us to grow as healers rather than a pathology to be avoided. The problem then shifts from the individual experiencing burnout to the professional community whose job it is to guide and support the burnt out clinician to become comfortable in suffering rather than to eliminate or minimize discomfort and suffering. Initiation is a form of transformational learning, which does not seek to restore a previous state, but rather the transformation of the individual, leading to a new and expanded identity.

Rather than blame the victim or search for deficits — shift to narratives of transformation and healing.

  • Intentional Suffering – approaching suffering rather than avoiding (6)
  • Initiation (6,7)
  • Hero’s Journey – Joseph Campbell (6)
  • Wounded Healer
  • Soul Loss
  • Feelings of being fragmented, apathy, lack of joy in life; the inability to make decisions; the inability to feel love for others or receive love from another, often resulting in the sense of being emotionally flat-lined. despair, suicidal ideation, addictions, and depression (8)
  • Transformational Learning & Education – Jack Mezirow,(9) Richard Katz (10)

Burnout as moral injury

Outer Environments of Burnout / Healing:

  • Contributing Factors
  • Poor physical environments
  • High levels of clinical demand
  • High staff turnover
  • High staff sickness and absence
  • High levels of violence
  • Poor personal control over day to day scheduling of calender
  • Poor clinical leadership and evidence of bullying, undermining of the professionalism of the practitioner
  • Discrimination which was dismissed by leadership

While we can view burnout as a necessary step in the growth as healers, the problem then shifts from the individual experiencing burnout to the elders of institutions and professional communities whose job it is to guide and support the wounded clinician through the initiation process. We know how to use suffering for growth, Indigenous communities have been doing this for millennia, the question is: Can our institutions and professional organizations create the ritual space for elders and sufferers to do the work of transformation, or will there continue to be failure of moral leadership?

If there is a failure of moral leadership, moral injury will be the result – where physicians are put in institutional situations in which there is cognitive dissonance between professional values and institutional priorities. If we look at recommendations on treatment for moral injury, we see the importance of community, interpersonal connection, reconnecting to meaning and purpose and reconnecting to positive aspects of identity. (11)

Lived Experience of Burn Out and Personal Reflections

Personal Reflections on Moral Injury

Finding oneself constrained in a system that is not able to reflect on its failings can lead to stagnation of the system. Then, when the incoming senior comprehends the moral failings of the system’s leadership, and then calls the leadership to account, but the leadership fails to stand to account. The incoming

senior individual becomes scapegoated, victimized, marginalised, and ostracised. If there is a lack of Elders within the service and subsequent of the Silencing of the Elders, many of whom had a personal over-identification with the service. This failure of moral leadership leads to a lack of elders within the system, and those that are there, are silenced. There are then consequences for the institution

Science – Evidence-based Reductionism

All too often, an evidence-based reductionism can lead to dehumanisation of the process of intellectually comprehending the psychodynamic underpinings of such human behaviour. This can lead to the process of devaluing an individual’s unique experience and expertise, and the individual becomes scapegoated, victimized, marginlised, and ostracised.

Institutional vs. Individual Values

Burn-out takes place when the individual is not able to reconcile the conflict between their own value system and that of the institution.

Economic vs. Individual Values

The trend of chasing multiple KPI’s as proxy measures of care, removes the process of individual’s being treated as individuals, resulting in increased stress in the work place. For example: the KPI of time to transfer from ED, can lead to rushed decision making in order to meet the KPI, rather than allowing a sensible treatment approach to take place, and safer discharge planning processes to be put in place. Increased time to be able to clearly create an effective discharge plan, can lead to an improved out for patient and staff – can there can be cost savings for the service.

Design

Healthcare environments outside of well resourced centres are often characterized by poor standards of the physical environment. Working in a poorly maintained environment has an impact on both staff and patients. There are multiple Issues of OH&S; impacting staff and patients contibuting to increase violence and aggression in the healthcare space, leading to high staff turn over and increased risk of burn out. People are less likely to respect a poorly maintained environment.

Review Procedures

These can be a helpful mechanism of independent external review and recommendations, but the impact can be limited depending on invested interests and potential issues of Elders having been silenced by higher failings of moral leadership. Grass Roots activism and lived experience groups can be a helpful alternative source of raising issues within a service.

Leave your job

Leave medicine – this was the choice that Gary made

Institutions need to Change:

Institutions need to expect burnout, and create workforce and job planning that takes account of such.

There is an opportunity for institutions to create working practices that encourage doctors to create portfolios that include variety in both clinical, leadership, academic and teaching opportunities. Create healing & supportive circles/communities of elders to support working through burnout.

There is a requirement to shift from prevention to developmental career guidance, and institutions need to take moral responsibility for contributing to burnout.

It is possible that institutions and professional organizations are incapable of morality and compassion, because those are human traits—the responsibility of the institution is to organize humans and create space and support for humans to provide moral guidance and the human wisdom of elders.

Discussion:

The fact that we cannot heal the wounded healers is an indictment of our current health care institutions and professional organizations and calls for a refounding and reorganization of the way we do medicine.

We recognize that a crisis of the individual healer is a crisis of the system.

We have allowed institutional economics and protocolised flow charts to replace human caring and moral leadership.

Our institutions have lost focus on the care in health care—no longer caring for their staff or creating

institutional spaces for the care of the patient.

Questions and Reflections:

Is this conference (ADHC) capable of caring for the souls of those who are caring for the souls of others?

Is the ADHC an organization that inspires hope, helps us find meaning & purpose, and cares for those who burnout?

Is a doctor merely a human form engaging in an AI process?

Do we have caring elders in medicine capable of guiding the younger generations through burnout and through initiation into becoming a healer?

Does Health Care still care about Caring?

What is the Economic toll of Burnout – for the individual; for institutions?

Are $’s more important than people?

Does the desire to care predispose one to burnout?

Are concepts about machines & economics good models for caring for the soul?

Are health care workers expendable equipment?

How does an institution take moral responsibility for the wounds and suffering of its workers?

How does an institution undertake reflection?

How does an institution undergo refounding?

Can we create healing circles of elders to guide physicians from wounded to wounded healer?

Remedies & Remediations

  • Recognizing burnout as the disorienting first step of transformation
  • Finding Your Soul (soul retrieval)
  • Re-envisioning Your Calling (reconnecting to your healing vision)
  • Finding Your Self (the counter-curriculum of re-humanization) (12)
  • Finding Your Tribe (mentors and guiding elders)
  • Finding Your Bliss (what brings you joy?)
  • Starting a Revolution (compassion revolution resources) (12)
  • Becoming a Medical Activist

REFERENCES:

1. ZDoggMD, “It’s Not Burnout, It’s Moral Injury,” https://zdoggmd.com/moral-injury/

2. Talbot, SG & W Dean, “Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT, 7/26/18.

3. World Health Organization, https://www.who.int/mental_health/evidence/burn-out/en/.

4. Dzau, VJ, DG Kirch, and TJ. Nasca, M.D. “To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis,” New Engl J Med, 378(4), January 25, 2018.

5. Shanafelt, TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600-13.

6. Kopacz, David and Joseph Rael. Walking the Medicine Wheel: Healing Trauma & PTSD. Tulsa: Pointer Oak & Millichap Books, 2016.

7. Moore, Robert L. The Archetype of Initiation: Sacred Space, Ritual Process, and Personal Transformation. Xlibris, 2001.

8. Shared Wisdom website, Hank Wesselman and Jill Kuykendall, http://www.sharedwisdom.com/page/soul-loss

9. Mezirow, Jack. “Transformational Learning Theory,” in Jack Mezirow, Edward Taylor, and Associates (eds.), Transformative Learning in Practice. San Francisco: Jossey-Bass, 2009.

10. Katz, Richard. “Education as Transformation: Becoming a Healer Among the !Kung and the Fijians.” Harvard Educational Review, Vol. 51, No. 1, February 1981.

11. Griffin, B, N Purcell, K Burkman & S Maguen. “Can trauma cause a moral injury?” ISTSS Stresspoints, (01/01/2019) https://www.istss.org/education-research/traumatic-stresspoints/2019-januarycan-trauma-cause-moral-injury_aspx

12. Kopacz, David. Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. Washington DC: Ayni Books, 2014.

This presentation was submitted as a workshop using the suffering of burnout as a process of initiation into becoming a healer however, it was accepted as a poster significantly limiting experiential and healing components. This highlights the challenge of working positively with burnout – institutional limitations interfere with the proper functioning of human beings

Circle Medicine Series on CLOSLER

Thanks CLOSLER for publishing a series of 5 short articles on Circle Medicine!

Out of One, Many – David Kopacz, 2018

I have been working on this concept of Circle Medicine since I had the realization that a number of different holistic models I was working with all included circles: the Hero’s Journey, the Medicine Wheel, the Circle of Re-humanizing Medicine, the Circle of Health, and Circle Medicine: the circle of circles.

In our forthcoming book, Becoming Medicine: Pathways of Initiation into A Living Spirituality, we have a table comparing Circle Medicine with Linear Medicine. Linear medicine is the predominant, biomedical approach in contemporary medical practice, however it misses crucial aspects of human being that are only found in holistic, circular models of medicine.

Linear Medicine Circular Medicine
Pathological Process Natural Process
Treatment          Transformation
Elimination of symptoms Acceptance of symptoms
Restoring old state    Achieving new state
Disease-based Health-based
Biomedical Model Holistic Model
Evidence-Based Medicine Human-Based Medicine
Hierarchical        Collaborative
Can Foster Dependency     Empowering

Here are links to each of the short articles:

CIRCLE MEDICINE: A HOLISTIC APPROACH TO HEALTH FOR CLINICIANS AND PATIENTS

THE HEALING CIRCLE AS A HOLISTIC FRAMEWORK

THE CIRCLE OF RE-HUMANIZING MEDICINE

THE CIRCLE OF WHOLE HEALTH

CIRCLE MEDICINE

Rainbow Medicine Wheel, David Kopacz, 2017

The Circle of Re-humanizing Medicine – new guest post at CLOSLER

Thanks again to the folks at CLOSLER for the next in a series of guest post on various forms of Circle Medicine & Circle Healing. This week’s post is titled, “The Circle of Re-humanizing Medicine.”

Here is the Takeaway summary:

We need human-based medicine in conjunction with evidence-based medicine. If we only identify as scientists and not as healers, we risk dehumanizing our patients and ourselves.

They also included the Circle of Caring for Self & Others that my sister, Karen Kopacz, designed for use with the workbook of that same name that I have been developing with Laura Merritt. It is based on my 2014 book, Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine.

Caring for Self & Other Circle

Next week is the last in my series of guest posts at CLOSLER, please check it out. It is on the VA Circle of Health, another holistic model of Circle Medicine.

CIRCLE MEDICINE: A HOLISTIC APPROACH TO HEALTH FOR CLINICIANS AND PATIENTS

New Zealand Landscape, 2, David Kopacz, 2011, featured in the article

It can be helpful to see the circle path of the hero’s journey as the healer’s journey, the path that we take through our lifelong medical education. For the true healer, this is not a journey we make just once, but periodically we embark on exploring new depths of the suffering of the world, reaching deep into ourselves to find new resources for healing to bring into our work and world.

Thanks to the team at CLOSLER from Johns Hopkins for publishing the first of a series of my posts on Circle Medicine! Here is a link to the full article.

Burnout as part of the healer’s journey: I have been thinking of burnout in this way. Maybe burnout is a necessary step for us to grow as healers. There are intrinsic elements in our work that change us, working with illness and death. When we get “infected” by our work, we incubate until we can find a cure and healing path. There are also extrinsic elements of burnout, such as institutional pathologies and frameworks. In modern times, healing has been regulated and institutionalized, and institutional economic and organizational demands are sometimes at odds with the demands of healing. We must continually work to reconcile the essence of our work as healers with the daily reality of the institution.”

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Bánh Xe Y Học: Hành Trình Walking the Medicine Wheel: Healing Trauma & PTSD – published in Vietnam!

Walking the Medicine Wheel: Healing Trauma & PTSD, which Joseph Rael (Beautiful Painted Arrow) and I wrote in 2016 has been translated into Vietnamese – Bánh Xe Y Học: Hành Trình. This is important for healing the wounds of war and helping former enemies become brothers & sisters.

150 Years of University of Illinois

I was contacted by The News-Gazette from Champaign-Urbana and they are asking for reflections on University of Illinois for the 150th birthday of the University. I wrote a fairly long piece as I started to reflect on my time there.

Here is the link to the The News-Gazette UIUC 150 years & beyond website and here is the link to my page. 

Looking Back to University of Illinois Urbana Champaign

06

David Kopacz, Allen Hall, 1986, photo by Mary Pat Traxler

The person who had the greatest effect on me at UIUC was Professor Peter N. Gregory in the Religious Studies department. The first class I took from him was Zen. As a freshman I thought it was amazing that I could come to university and study something for credit which I was also able to apply in my own life. Not only was the material fascinating, but Professor Gregory was a fabulous story-teller who made the material come alive in his lectures.

gregory

My sophomore year I took another class he taught, East Asian Religions. There I read the Tao Te Ching, The Analects of Confucius, and my favorite, the Burton Watson translation of The Basic Writings of Chuang Tzu. I have carried Chuang Tzu with me on many camping trips, travels, and free and easy wanderings throughout my life. This class also opened me up to the American Transcendentalists as Professor Gregory spoke of some of the similarities with the Taoist philosophers in the fundamental goodness of nature and human nature and the hazards of being overly civilized.

 

My junior year, I took the Introduction to World Religions class, which Professor Gregory coordinated. This further opened my world to many different religious traditions and this has given me a structure for my spiritual development throughout my life.

black elk speaks

One of the books we read for the class was Black Elk Speaks, by John G. Niehardt. I read this book several times, even making a pilgrimage to Black Elk Peak (then Harney Peak) in South Dakota, later in my life. I remember we also read the Bhagavad Gita translated by Juan Mascaró. As I was also interested in anthropology and was majoring in psychology, I was trying to understand what made life meaningful for human beings and how they described the sacred. I had a strong pull to working with Native American/American Indian cultures. By that time I knew I was going to apply to medical school and likely be a psychiatrist and I thought that I would join the Indian Health Service to be of service and to learn about indigenous ways of healing. This did not come to pass as I got caught up in life. However it did seem to set a template for later events that I will describe shortly.

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My senior year, a friend of mine, Glenn Girlando, arranged an independent study class with Professor Gregory on Carl Jung. There were three of us in the Psychology department who wanted to study Jung and the only person Glenn could find who could teach Jung turned out to be Professor Gregory. He had worked in a Jungian research lab earlier in his life. This turned out to be very formative to me. Jung has been one of my intellectual and spiritual teachers throughout my life. I have been reading Jung, off and on, since I was about 17 and his theories have been practically useful in my life. Jung’s work was not just on treating mental illness, but on how to create mental health. His focus on lifelong personal and spiritual development and his concept of individuation provided a conceptual framework that I have found inspirational and practical. The independent study class also gave us more personal time with Professor Gregory. I even remember discussing with him some doubts I was having about my career choice of whether I should go into medicine or philosophy/religious studies.

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After college, I went up to University of Illinois Chicago for four years of medical school, then four more years for psychiatric residency. I was still thinking about the Indian Health Service, but my wife, Mary Pat Traxler, whom I met at UIUC (we both lived in Allen Hall), accepted an internship in Omaha, Nebraska and we moved out there. I worked for the VA and University of Nebraska. After two years we returned back to Champaign-Urbana, I worked for Christie Clinic for three years. When I left that job I had a two-year non-compete clause so I could not work within 30 miles of Christie Clinic. We did not want to move, so I commuted down to Paris and Mattoon, working in rural community mental health. After my two years were up and I could return to work in Champaign, I started a holistic psychiatry private practice on University Avenue near West Side Park. We were very settled and happy there and I lived near my college friends Rick Valentin and Rose Marshack and we even got the band back together, so to speak, when Rick, Mike Barry, and Doug McCarver and I did a few shows with our band Vibraking. Eventually, though, as happens sometimes in Champaign-Urbana, people come and go, and many of our friends moved away. We were very comfortable living there, but I still felt the urge to live in another culture and Mary Pat and I moved to Auckland, New Zealand for three years and I worked as a psychiatrist with the district health board there. When we returned back to the USA, we moved to Seattle, where we have been living for the past six years. I started working again for the VA and have an assistant professor position at University of Washington. I published my first book I 2014, Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. I have been working on the implementation of Whole Health at the VA with the national VA Office of Patient Centered Care & Cultural Transformation. One interesting thing happened in the Pacific Northwest, and it is the reason that I am telling so much of the story of my life after having left Champaign-Urbana. Through a series of events, starting with picking up a book at Powell’s Books in Portland, Oregon, I came to meet Joseph Rael (Beautiful Painted Arrow). Joseph grew up on the Southern Ute reservation as well as at Picuris Pueblo in the Southwest. He is the author of a number of books on Native American/American Indian healing and he has become a mentor to me, bringing things full circle from reading Black Elk Speaks in Professor Gregory’s class when I was at university. Joseph and I have published one book together called Walking the Medicine Wheel: Healing Trauma & PTSD and we are nearing publication on our second book, Becoming Medicine: Pathways of Initiation into a Living Spirituality. The influence of University of Illinois Urbana Champaign and Professor Peter Gregory has continued throughout my life and seems to culminate in this idea of A Living Spirituality—the study of a practical application of finding the sacred meaning in life as a form of life-long work.

 

David R. Kopacz, MD

UIUC class of 1989

UIC Medical School class of 1993

 

 

 

“Cultivating Caring,” my new article on CLOSLER

 

View St. Brides Bay (Bae Sain Ffraid)

Saint Brides Bay (Bae Sain Ffraid), Pembrokeshire, Wales, David Kopacz, (2018)

A short article I wrote just went up at CLOSLER, entitled “Cultivating Caring.” CLOSLER, out of Johns Hopkins, is named after Dr. William Osler, is a Miller Coulson Academy of Clinical Excellence Initiative promoting importance of the doctor-patient relationship.

The article focuses on how caring and compassion are resources that we need to attend to and cultivate, particularly in the healing professions. You can link to the article here.

Photo of Dacotah Building published in MNopedia Article

In 2013 I visited my sister in St. Paul, Minnesota and we made a bit of a literary tour, stopping at bookstores and also W. A. Frost where a young F. Scott Fitzgerald frequented when he was growing up in the neighborhood. W. A. Frost is in the historic Dacotah Building, built in 1889. I took a few photos and posted them in my blog, “A Literary Tour of St. Paul, Minnesota,” and MNopedia liked one of them and used it for their article on the Dacotah Building.

You can follow the link to the MNopedia article.

Here is my photo that was published with the article:

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Here are a couple other photos of the building:

Link to my original blog post from 25, May, 2013, “A Literary Tour of St. Paul Minnesota.”

“Coming Home to Peace” excerpt from Walking the Medicine Wheel published in Parabola Magazine, Fall 2018

Parabola Magazine has just published an abridged version of the “Coming Home to Peace” chapter from the book that Joseph Rael and I wrote, Walking the Medicine Wheel: Healing Trauma & PTSD.

journey-home-cover-large

I am so excited and honored that our work is being featured in this great magazine. I first read Parabola when I was in college. It is the journal of The Society for the Study of Myth and Tradition and always has great features on topics around “the search for meaning,” with past contributors including Joseph Campbell, Mircea Eliade, and Jacob Needleman. This current issue revolves around “The Journey Home,” and it is fitting to have our piece on the struggle of veterans to find their way home after military service. This issue features Parker Palmer, whose Center for Courage and Renewal has recognized my last two books as selections of their most courageous books of 2014 and 2016. I have also written guest blogs for their organization: “Recovering Hope, Poetry, and Connection in Health Care” and “Finding the Held-back Place of Goodness in the Broken Hearts of Veterans.” It is great to see Joseph’s and my work sharing space in Parabola with an excerpt from Parker Palmer’s new book, The Brink of Everything: Grace, Gravity & Getting Old. Another author I have great respect for is featured in this issue, Kabir Helminski, with an excerpt from his book, Holistic Islam: Sufism, Transformation & the Challenge of Our Time. Peter Kingsley, author of Reality and A Story Waiting to Pierce You, has also been interviewed by Parabola in the past.

How exciting and rewarding it is to have Walking the Medicine Wheel: Healing Trauma & PTSD – this work of the heart that Joseph Rael (Beautiful Painted Arrow) and I have done together – honored in this way, being published in a magazine that has inspired me since my days in college.

front-cover-final

I am also happy that we are able to promote the work of so many others in this Parabola essay. Ed Tick, John Wesley Fischer, Jonathan Shay, Bryan Doerries, Claude Anshin Thomas, Judith Herman, and Robert Jay Lifton are all cited and credited for their work. I am also happy that Buchanan Rehabilitation Centre, where I worked in New Zealand, is mentioned in the piece, as that is a place very dear to my heart.

Here is a quote from the article:

“We can assist returning veterans through creating an initiation and rehabilitation framework. In essence, we as a society, need to have some framework for accepting, understanding, and transforming veterans’ pain. Transformation means that we take something that exists in one state and transform it into another state. For instance, wee take something that is manifesting its energy in a ‘negative’ way and transform it so that it manifests in a positive way,” (Parabola, 88).

I wish we had a little more of Joseph’s words in this piece, but this was a section putting our work in the context of the work of others. Joseph says that we need to help veterans find the “held-back place of goodness” in their hearts. If you want to hear Joseph in his own words, you can watch one of the videos on the website for Walking the Medicine Wheel.

The Parabola editors choose one of our paintings from the book for the article. The painting below is my rendition of Joseph’s medicine wheel that I added some universal spiritual symbols to in the center.

Cosmic Medicine Wheel.jpg2

Cosmic Medicine Wheel, David R. Kopacz, © 2016

This issue of Parabola is not out on the newsstand yet, but you can see the cover and some of the current issue on their website and it should be on the newsstand soon!