Shadowing, confirmation, and humor

After last semester's shadowing experience (with Dr. A, a good doctor but PP board member) I decided I need to follow a pro-life OB/GYN in the future. With this goal in mind, I searched the AAPLOG physician directory. I called several offices and ended up with three days of shadowing Dr. C, whom I had never met before. I've blogged about him before, but only isolating our differences. We have a lot in common and I learned a lot.

The first day, I observed a hysterectomy, shadowed during his office hours, and watched him perform a circumcision. Day two was more office visits, plus rounding and learning how to suture; day three was office, plus learning how to gown and glove. I enjoyed it! His office was warm and charmingly decorated, his staff seemed happy to be doing their work with him, he talked at leisure with his patients, he spent very little time charting, and he was a kind teacher.

Whenever he found something pathological, he let me look (or feel!). I saw two cases of uterine prolapse, possible early vulvar and rectal cancer, a cervix s/p cone biopsy, and cervical blanching during colposcopy. We also mentioned Li-Fraumeni syndrome and cutaneous larva migrans, which had previously only been words and pictures on a page. I felt engaged and charged! I can get used to that.

My complete newness to physical diagnosis caused some amusing episodes, like when he told me to feel a patient's thyroid:

	Dialogue: outer • inner	Actions: purported • actual
Doctor	(to patient) Mind if she feels your neck?
Patient	No, not at all!
Me	Thank you. Right. So... The thyroid gland is supposed to be here somewhere...does she have one? I guess it'd be here... (to patient) Please swallow.	Thyroid exam. Mimes a thyroid exam. Feels...a neck?
Doctor	I don't know about this kid... Left or right?
Me	What is he talking about? Does she only have half a thyroid gland? I obviously didn't pick that up... Well... I have a 50/50 chance... Left.
Doctor	You are fooling nobody. Good. It's like a little pea, moving under your fingers. (to patient) Swallow.	Puts my hand back on the patients neck, beneath his. Presses (hard).
Me	Good grief. Oh, cool.	Feels the thing for the first time.

Tweezers, but you can bill more
if you call them "pickups" (jk).
After a few minutes of touching
the needle in my bare left hand, I
said  aloud to Dr. C, "this can't be
right,"  and he got me these.

Needle driver/holder. This thing is well-
designed. The short effector side of the
lever (left) magnifies the force you
place at the affector side (with scissor
handle and locking mechanism).

Yeah...I have a long way to go before I should be trusted with patients. I missed a melanoma-esque mole and a palpable uterus on an abdominal exam, and I missed fibrocystic changes on a breast exam. I got to hear two mitral valve prolapses (lub-click-dub; listen to one here), but I could only hear the louder one.

I'm clumsy with suturing and gloving. (It's all about muscle memory.) Dr. C gave me two pair of old pickups, a small needle driver, some expired ties, and opened suture so that I can practice. He also gave me three pair of unpackaged ("contaminated") sterile gloves and an opened gown. How generous of him! Someday, all these things will be second nature to me. I can get used to that.

I did get good at finding fundal heights and fetal positions. I made mistakes, but by and large (even in a primagravid uterus!) I could make out where the baby's head, buttocks, and back were located.

This doesn't matter during most of pregnancy (only at 30 weeks and on). However, you look slick if you find the baby's back, guesstimate where his heart is, and place the fetal doppler RIGHT on the spot. The result: immediate, deafening, staticky heartbeat to the delight of the mother and the attending. I can get used to that.

Catholic Medical Association: Student Section

So, I realized the purpose of this blog is to record my experience as a Catholic medical student. So here's something to report:

This week our Catholic medical students group brought in a priest and an ER doc to answer questions. I forgot to count how many people came, but I estimate we had almost 20. That's about four times the usual attendance, so I'm pretty excited! There were still a few Catholics in my class who didn't come, though, so there might be room to improve.

I want our group to be a chapter of the Catholic Medical Association - Student Section and am working toward this. Surprisingly, I feel some pressure from our advisors about Catholic identity. The same advisors who said we couldn't host a pro-life Catholic speaker (excuse was being a publicly-funded university system) say that the dues the CMA charges might be too steep for the benefits we gain.

What?

• First of all: grace is priceless. The graces of community (with other Catholic medical professionals) and the merits of others' prayer and sacrifice are beyond purchase. Invisible, but invaluable.
• More earthly now: the Linacre Quarterly is the bomb. It's like the NCBC publications, except medical enough to be fun. Plus, there's other members-only content on the CMA website.
• Also earthly: CMA membership = CMA conference scholarships. And CMA conferences are incredible. Are you going to A Witness to Hope: Medicine and the New Evangelization in 2013?
• And last: what's $45? Sure, membership in lots of other medical associations is free for students, but truly...what's $45? Four days of groceries, tops. So fast for the Fridays in Lent and you've bought yourself a CMA membership.

Anyway, the upshot is: the Catholic group here is giving me mixed feedback. This has been your report on my experience as a Catholic med student.

Icons and iPads, Heretics and Humility

The other day, as I was studying with the icon in front of me (at left), a friend asked what it was.

Normally, I don't show it off. I'm usually in a study carrell or in a room by myself. That day, I was with a group but the icon was behind somebody's backpack and was only visible after that person packed up and left. (It's covered in bright red felt on the back, so once it's exposed it's hard to hide.)

My friend, a Protestant, simply said, "what's that?"

I turned it around, telling her it was an icon. She'd thought it was an iPad or some other gadget. I smiled and shook my head.

"No," I replied. And because I knew this friend was an earnest Christian I went on, "but it's sort of better. You're looking right at the Truth Himself."

I told her I carry it around so that I can look at Christ during study, a reminder of Someone I love and a little escape to reality about His constant presence. She asked if there were particular prayers I say when I look at it, and I shrugged "no," it's just to gaze at. She asked why it looks the way it does.

I told her about Mary's and Christ's outward gaze being like a conversation with the viewer, because an icon is a window to heaven. I explained Mary's three stars (she is the next-most-perfect thing to the Trinity) and the red and blue garments (Mary is human and clothed with divinity; Christ is God, clothed with humanity). I said the inclination of Mary's head indicates her role in pointing us to Christ. I showed her how the shape of Christ's hand identifies Himself (ICXC).

(If the conversation had continued about icons, I could've told her about the gold background signifying heaven, the two-dimensional features meaning that the figures are (in a way) not of our world and not in our time. I could've mentioned that icons are usually painted on wood, to use natural and durable substances for such an exalted purpose. But, there was a much more incredible conversation to be had!)

Speaking about Christ's hands I mentioned talking about the Greek Orthodox Church and the word "schism" dropped out of my mouth. She wanted to know the difference between a schism and a heresy. I told her that I'm not precisely sure, but a schismatic church can maintain valid sacraments, "and heretics usually deny something big, like the divinity of Christ."

"So," she said, "this might be an unfair question, but what was the Protestant Reformation?"

I looked at her and then at the carpet. "That would be a heresy," I said, and immediately mentally flagellated myself for such stupid phrasing and delivery of such an important thing. But somehow, she was very understanding! She's a very mature person, so she understood I was speaking about the historical event and not her, personally or even Protestantism today.

I looked it up later to make sure I'd said the right thing. Protestants are our brothers by Baptism. The merits of the Church gain salvation for all those saved. Protestants seem to meet the definition of material heretic, like many spirit-of-Vatican-II Catholics. But check out what then-Cardinal Joseph Ratzinger wrote in The Meaning of Christian Brotherhood:

...there is no appropriate category in Catholic thought for the phenomenon of Protestantism today (one could say the same of the relationship to the separated churches of the East). It is obvious that the old category of ‘heresy’ is no longer of any value. Heresy, for Scripture and the early Church, includes the idea of a personal decision against the unity of the Church, and heresy’s characteristic is pertinacia, the obstinacy of him who persists in his own private way. This, however, cannot be regarded as an appropriate description of the spiritual situation of the Protestant Christian. In the course of a now centuries-old history, Protestantism has made an important contribution to the realization of Christian faith, fulfilling a positive function in the development of the Christian message and, above all, often giving rise to a sincere and profound faith in the individual non-Catholic Christian, whose separation from the Catholic affirmation has nothing to do with the pertinacia characteristic of heresy. Perhaps we may here invert a saying of St. Augustine’s: that an old schism becomes a heresy. The very passage of time alters the character of a division, so that an old division is something essentially different from a new one. Something that was once rightly condemned as heresy cannot later simply become true, but it can gradually develop its own positive ecclesial nature, with which the individual is presented as his church and in which he lives as a believer, not as a heretic. This organization of one group, however, ultimately has an effect on the whole. The conclusion is inescapable, then: Protestantism today is something different from heresy in the traditional sense, a phenomenon whose true theological place has not yet been determined. (pp. 87-88, emphasis mine)

Lessons learned:

1. Don't mentally label people as heretics; it's not black and white. 
2. I am so humbled by people's good character. This mature and gracious friend is not closed off in her quiet love-chase for Truth. (So pray for her!!)
3. Icons are better than iPads (but you already knew that).

Challenge Accepted

I plan to be a pro-life, NFP-only OB/GYN and hope to use naprotechnology. I'm very excited about this, but our culture doesn't feel the same way. For example, the overwhelming majority of opinions on an SDN thread about Catholic OB/GYNs are discouraging:

An OB/GYN who doesn't prescribe contraceptives. That's funny.

...sterilization and contraception is part of the career...

 ...I'm pretty sure the law requires a doctor to refer a pt to someone who offers those services. So, even if you wont do ABs [abortions], you have to refer the pt to someone who does....

...you may have difficulty getting enough continuity patients as many patients in a resident OB/GYN clinic are seeking contraception. At my institution, you have to log continuity patients.

...you have the viewpoint of a student with no real experience.

Our Lady of la Salette, a remarkable apparition
because our Lady appeared seated and crying
with her head in her hands before
standing to speak to the visionaries.
This statue is how I feel when I read these quotes!

...you should not join a field in which the scope of practice is such that they will be placed in a position where they are unwilling to provide care (I'm talking about contraception) or refer for care (abortion) frequently. I just can not get over how selfish this is. How many other specialties could you do where yours and your patient's interest not be constantly opposed. Unless you are planning to do some fellowship like gynecologic oncology or reproductive endocrinology, being an OBGYN who will not prescribe contraception or refer for abortion is unconscionable. You will end up blocking your patient's access to the care they desire. Go into some other specialty!

I am a Catholic OB/GYN resident but I don't have a problem with contraception or sterilization. If you do, then OB/GYN will be a difficult residency for you because that is what you are going to be an expert in. I also happen to think Humanae Vitae was a misguided encyclical. I think that at some point in the future the Church's prohibition on contraception will change.

"Intro to Disease" schedule

Typing these posts feels so weird! However, I put them up because I want to keep a memory of what it was like to be a medical student; in addition, as a pre-med I always wondered "what do med students do all day?" My typical existence goes like this:

6:30a - wake up, exercise (my version of exercise = a walk + some leg lifts)
7:15a - meditation on the day's readings
7:40a - Morning Prayer
8:00a - eat, dress, pack lunch

Studying with my diptych and my binder of spinal cord slides.
(That's sacral or lumbar cord; you can tell because of the
enlarged ventral horns.)

8:30a - commute (less lousy now that I'm listening to the audiobook of How the Catholic Church Built Western Civilization. If you haven't read it and think you think you already know what it says, you're wrong and you need to read it! I'm sure you're as Catholic as can be, but you've been schooled by our culture and it's colonized your thinking. Read this!
9:00a - class (remember when I was going to try not going to class? Yeah...I go almost all the time still. Old habits (high school, TAC) die really hard. However, that experiment did succeed in removing most of the personally-imposed stigma of watch lectures later.)
12:00p - Midday Prayer, then lunch
1:00p - more class! Sometimes, neuroscience lab (way better than anatomy lab; interesting, and no lack of wonder for the organ. The brain is a conspicuous exception to our culture's failure to reverence the body.)
4:45p - head to the church, after studying
5:10p - Evening Prayer in community, with the religious sisters and other students before Mass. This has been a blessing! It's nice to learn new hymns, sing in chorus, have my patience stretched by others, and recite loudly and slowly (which I usually can't do in the apartment or at school).
5:00p - Mass (!)
6:30p - arrive home
7:15p - study
9:00p - "holy hour," not in the real sense of Adoration, but spent reading Introduction to the Devout Life or some other book.
10:00p - Night Prayer, then sleep

Riches in the mentally disabled

Tired of hearing about recessions and the economy? Lets talk about a different kind of riches.

There is a mentally disabled man who works in the lab at one of the hospitals in my hometown. It is his job to circulate through the hospital, visiting each floor and checking for lab samples that need pickup. He stops at every nurse's station to check their lab outbox, and takes any specimens back to the lab with him.

I met him when I finished my phlebotomy certification as a sophomore in college. He never forgot his job, but would stop and talk to me occasionally. His two topics of interest were the train schedules and my hair. Like many mentally disabled adults I know, he would talk for an uncomfortable length—not a truly agonizing length, but just over normal...just enough for me to try to break off the conversation because I had to go draw a patient's blood or had to follow my preceptor around.

This week (almost three years later) I shadowed in the same hospital and I saw this man in the hallways. I recognized him instantly: his dark blue uniform, the red plastic case he carried (always in the same hand) for the specimens, his glasses slipping on his nose, his rumpled hair, his slight slump, his determined gait. He high-fived the MA, and said nothing to the OB/GYN (he sees them often, probably several times a week).

Then, he came to me, and without an instant of hesitation, he hugged me and said "It's good to see you! It's been a long time!" The hug was an uncomfortable length—not a truly agonizing length, but so long that I tried to stop the hug three times before we actually came apart.

But think about it: what an incredible moment! He recognized me! I was an extern phlebotomist for three weeks and he must've seen thousands of people in the intervening thirty-two months. I felt so special. After being the newcomer and learner to an office for a week, I drank in how he established me.

People with mental defects, special needs, etc are so valuable. How can we abort them or undervalue them? This man enriched my life today and I would be a little more impoverished without him. We can't afford to lose these lives.

Crumbling dreams in a world of turbulence

Medical school is fascinating right now. We're in our first systems block (several weeks of intensely studying one organ system): neuroscience. I'm learning about adrenergics and T1/T2 weighted MRIs! By itself, "neuro" would be interesting and manageable.

But I'm not just going to medical school. I'm a Catholic, a leader, a dreamer. I care about the Church and the fate of souls and of my country. I feel the suffering of mothers and children and families affected by our culture.

There is too much going on. It's not all bad: there are evil measures going on, but these provoke a lot of good thought and pruning for the springtime of the Church. Even so, I feel like a boat about to capsize.

• The HHS mandate. This video of Gloria Purvis is excellent. She gets politically incorrect, but she stays with the truth.
• Persecution is now. Vatican.va taken down by pro-choice hackers, and The New York Times ran an ad "in odium fidei."

Nationally and globally, turbulence is increasing exponentially. I see my dreams of a Catholic women's clinic, maternity home, and/or hospital crumbling. I want to love others by my prayers, my hands and my study! Why am I being prevented from love?

God + come to our assistance. Lord, make haste to help us!

Listening

Last week I woke up and it hurt to walk. Whenever I swung my right leg forward, I got a jolt of pain that took my breath away. I hobbled through my morning routine and made an appointment at the health center.

It's interesting to reflect on the episode, because I realize my brain has already begun the transformation into a doctor's brain. My thoughts weren't: dang, I'm missing class...what could this be...I have to drive and pay a copay.... Instead they were:

Subjective:

•  ** y/o female presenting with R hip pain
• Attributes of pain:
• Onset: this morning; had some slight pain yesterday in the same area, but was not concerned
• Duration: lasts less than a second as she moves her leg
• Timing: during flexion of R leg
• Location: "in the joint"
• Quality: dull "but powerful"
• Severity: 8-9 early this morning, 5-7 now
• Modifiers: better when standing; constant soreness when sitting
• Pain does not radiate
• Stretched yesterday
• Has experienced similar, minor episodes w/in past year 

Objective:

• Pelvis is posteriorly tilted during gait; patient doesn't know when pain is worst during motion
• Minor scoliosis

Assessment:

• Ddx: muscle strain, hemorrhage, erosion, malignancy
  (I don't know if all those are even possible...but since I don't have much education all I can use is my imagination!!)

So...I went to the doctor. She was extremely rushed and it seemed like she concluded that it was a muscle problem really early on in the exam. She asked for ONE of the attributes of pain (location) and what I did to myself to cause it. Granted: her patients are mostly young college students and probably mostly suffer accidents, not disease. And while she may have ruled out other possibilities, I felt like "muscle strain" was a foregone conclusion before she came in.

Without looking at me, she went through an H&P as she sat in front of the EHR on her computer. It was more like an interrogation. (Like when you donate blood and they read off the questions at a mile a minute! "Between 1980 through 1996, did you spend time in the United Kingdom that adds up to six months or more? Have you ever had yellow jaundice, liver disease, viral hepatitis, or a positive test for hepatitis?") After a few questions, I just started to shake my head continuously as she kept rattling off questions. I was sort of upset at this point. It hurt to walk here, I wanted to say. I had to park far away because it is so hard to park on campus. I walked here, and no one asked me anything about my pain except where it was.

But then, I had to answer, "oh, yes," to a question. And she said rather loudly with obvious exasperation, "ah ****, that changes everything! Since when [have you had that]?"

That was the last straw. I burst out in tears. She began to worry and passed me a tissue and wanted me to tell her that it wasn't her fault that I was crying. I explained that I had an exam coming up and that the stress often gets to me (which probably contributed).

But I was seriously hurt! So, the thesis of today's rant: doctors, listen to patients. Listen.

A doctor's clinical acuity increases with listening. Someday, I want to become my patients' ally in a fight against their sickness. To treat a person I must (1) know them and have their trust, and (2) grasp their disease two hands: their experience, and my medical knowledge. To become this united with the patient, I must listen desperately.

But is this possible? In my experience last week there was a chasm between the doctor and the patient: the doctor’s mind quickly identified my condition, ruling in or ruling out items on an expertly narrow differential, but I, the patient, was new to the symptoms, frightened, in need of a little attention.

This level of devotion to the diagnosis may be impossible for a doctor bound by the current system of 10- or 15-minute visits. Nevertheless, this level of investment in each patient encounter stands to enhance diagnosis, compliance, and the success of treatment. I consider such investment a mandatory part of my future.

And the hip? It's better already; I guess she was right.

My breviary, a symbol of the Faith

Hurray, another cop-out post filled with a humanities assignment! We were each asked to choose an object we would keep in our future office which would stand as a symbol of our spiritual life.

I chose the Divine Office, which all priests, all consecrated people, and some laypeople (like me) pray each day.

My breviary (on top of an old medical text) with our Lady.

The Office reflects the spiritual life very well. It is both regular (prayed according to rules) and personalized (because the psalms the Church chooses often seem hand-picked for my circumstances). Its times and seasons reflect the winding road of human life: it is partly sung and partly recited; it has seasons of fasting and seasons of feasting; it has times for standing and times for sitting. Also like the spiritual life, it is both communal and private—the Office is said by the Church as a whole and in each soul who prays it.

But this particular copy has separate significance and symbolism. In many ways, it symbolizes my Faith. It used to belong to my mother, and she gave it to me, just as my parents gave me the Faith. It has weight, reminding me that my Faith is a charge laid on me, but a light burden and even pleasant and comforting. It is red, a color of complete love; this reflects the love of a beloved wife, or the love of a martyr. This is the love which I have for Christ and which draws me to prayer.