Servant and Doctor

As every July intern (and July upper-level) knows, becoming a physician requires a certain authority, almost a certain hubris. While any leadership role requires poise and prudence, the physician is uniquely in charge. Physicians delegate tasks and they're called "orders." Orders are to be followed, or else the physician is to be called and the orders are to be discussed. Healthcare is team-based and multidisciplinary, but there is still a captain of the ship, and his or her orders are the final word.

It is difficult to maintain an attitude of Christian charity and servanthood while executing this role at work. Worse, I get into habits that make it difficult to be an ordinary person in other settings and to be a receptive soul at prayer. I have noticed that I have to intentionally "switch gears" when I am an ordinary parishioner in the Young Adult group, a cantor at Mass, one of the newest and youngest virgins in the Archdiocese or at the convocation. Even more, I have to be humble when I've been in the wrong in a conflict or when I've been a bad friend and have not kept in touch. I would like to integrate the clinical hubris with the virtue of humility (and common sense) but it seems difficult. Perhaps it will become easier when I'm no longer a trainee, when those in my workplace haven't seen me as an intern who knew nothing. Perhaps it will be easier the more comfortable I am with my scope of practice; perhaps I will have to aggrandize less authority and will simply carry it.

But it seems like a long shot to rely on something spontaneously happening to make it easier. I think I'll have to continue to struggle with changing gears for now, and hope that it becomes easier to drive the stick-shift of my soul through all its settings.

Disagreeing Theologians are Doing it Right

All that fruitful disagreement is how we got
universities! This is the University
of Paris, circa the middle ages. Credit: Ex Urbe.

This is a short post to point out three key points about engaging in Catholic ethics as a faithful daughter (or son) of the Church. I am writing this in anticipation of several posts that will cover controversial territory in obstetrics. (Spoiler alert: it's not intrauterine pregnancy.)

Key points:

1. The Church does not have doctrine about every procedure and situation. And that is okay. It's actually better to legislate carefully rather than redact hastily-promulgated stuff that wasn't well thought out.
2. Faithful Catholics who have worked to form their consciences can discuss issues on which the Church has not spoken. It is even okay if they disagree!
3. New scientific data can complicate the issue and that's okay, too! We shouldn't rest until we're confident about what we know.
4. This patience, freedom, disagreement is extremely productive in the search for the truth, and often leads to the Church laying out doctrine.
5. Theologians who are truly faithful will concede when they're wrong and adopt what's true, even if they don't understand it. Sometimes, they won't know they're wrong until an official promulgation or until more science comes out, but that's okay.

That's all. I've mentioned Point #5 before when talking about St. Hildegard of Bingen and St. Thomas Aquinas.

At left is a painting of St. Thomas presenting all his works to the Church (the female figure) who wears the papal tiara and sits in the light of the Holy Spirit. Yes, the man was wrong about when life begins, but he was a faithful son of the Church and the model for all theologians.

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Postscript on blog data for 2015: number of posts last year was not bad, considering it contained my first six months of intern year. Sure, it didn't touch the absurd 136 posts I created in 2012, when I was just out of college and living fancy free as a medical student. (Twenty-one posts during one single month...what on earth did I have to say almost every day? And that happened twice that year!) I think my most valuable posts so far have been in 2015, as I've wrestled with ethical issues.

Guessing and Pride

Vocabulary: Pimp (v.): to ask questions, often in front of other trainees or professionals, to assess a student's or resident's preparedness, medical knowledge, or professionalism

Third year medical students get used to getting pimped. We're advised (by survival guide books, by older students and residents, by faculty) to guess if we don't know an answer. This advice is logical. A third year knew even the smallest biochemical details of the pharmacology he's being asked about a mere six months ago, but after STEP 1 and two or three other rotations, he's refocused so many times that he can't exactly recall the correct answer. A third year sort of knows what to study for clerkships, and definitely never knows what to study for particular attendings. In general, a third year has just enough knowledge to know what's being asked, what the answer choices mean, and what he's missing to know the correct answer. (It's a very frustrating experience.)

We're advised to guess because we have enough knowledge to say something vaguely correct. I followed this advice, and had good and bad results.

I should have played the lottery during my pediatrics rotation. That's how lucky my guesses were. One outpatient physician with particularly pronounced ADHD forgot that he told me the most common cause of URI was "viral." When he asked me the question and I informed him that it was "viral," he was very pleased. I answered a few more softballs correctly, then he hit me with a hard one. "Why no fluoroquinolones for this patient?" he asked.

Fluoroquinolones! My M1 box of memories contained something about teeth...or was it cartilage? Tendons? Shoot! I had to pick between them. Because I remembered "cartilage" and "tendons," I eliminated "teeth," and then flipped a mental coin. "Cartilage malformations," I said. The whole internal answer-picking had taken only a fraction of a second.

"Correct!" the attending said. I got a fabulous evaluation.

Inpatient looked like it was going to be a different story. Our attending was demanding and taught in a more classical fashion: we presented patients in front of everyone on rounds, wrote detailed notes, and did long mock case workups. While I was in front of the room at the board (pen in hand) pretending to work up a child with renal failure, he told me a stool culture came back positive for Shigella.

"So," he said. "You wanna give him antibiotics?"

His CBC was terrible, he was febrile, he already had an IV in, and I very much wanted to give antibiotics. I remembered that Salmonella and Shigella had funny reactions to antibiotics...something about the child would feel better but there would still be bacteria in the stool...for even longer? But that was only for one of the two species (darn the person who named these two things so similarly!!)... Do I hazard a guess, or do I just give the antibiotic? I gambled.

"We could," I said, "but doesn't it prolong clearance in the stool...?" I trailed off gingerly, just in case I was wrong.

The attending raised his eyebrows.

"It does," he said, surprised. Apparently I'd skirted the trap he usually set for students. He then told a few case histories of patient's he'd treated. "So," he concluded, "if it's just going to be fluids, what do you want to use?"

"D5 half-normal," I replied. That wasn't a guess; that's what everyone in the unit was on. He gave me a mischievous look and pressed further.

"There is one case in which you would consider using quarter. Do you know who?"

Time for another guess. Babies are all water balloons at birth, so my brain spat out:

"The neonate?"

The attending clapped and grinned. "That's hot!" he said (which must have meant something different when he was a teenager). "Strong work." And I got another fabulous evaluation based on guessing.

But this has terrible effects, especially when we're asked to guess in front of other people. Those of us with the vice of pride (which is many doctors and student-doctors, and (so I'm told) a few other humans) do terribly in this environment. We have one of several reactions. It's a little complicated, so I made a flowchart.

I was typing this post while my attending was at a meeting; he came back and we had a mini lecture/pimping session on hydrocephalus. And I guessed some more. It will never end.