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.

Suffering and Joy in Catholic Medicine (CMA Conference)

I went to the CMA conference last October and spent most of the time with my poster and networking with people. I was late to almost every talk! There was lots to take away, but there were also things missing.

From Ashley Fernades' talk before the first panel began, I took away that not all hard days are bad days. The idea that suffering and joy are not mutually exclusive is still hard for me to integrate with my life. When I am exhausted, I have no energy to be happy. My reason accepts that happiness and joy are not the same, but when there is no reason for satisfaction besides God it is rather hard for me, a sinner, to be joyful. Dr. Fernandes made it a point to say, on day one of the conference, that joy is a choice made each day.

Bishop Conley drilled this further. Joy seems like hard work, he said, but it is possible with Christ. He can work a total transformation in us. Our entire lives must be missionary joy, it's an unshirkable responsibility. This doesn't have to be overwhelming, the Bishop said. This is cor ad cor missionary work--one heart to one heart at a time.

Michael Aquilina spoke on the emergence of the hospital, which paralleled the rise of Christianity. Mr. Aquilina observed that there were resources for hospitals in the ancient world, but the hospital only came about once a religion that valued solidarity, charity, human dignity, and the redemptive value of suffering became legal. He asked a rather chilling question: will the hospital survive in a post-Christian world? I think it's already gone in most ways. The hospital now is a cog in healthcare and research systems, embedded with lots of bureaucracy for the purpose of payment and prestige. Of course, as long as there is illness and as long as there are charitable caregivers, there will be that spirit of merciful care of the sick. But the hospitals of St. Basil, St. Pio, and even St. Theresa of Calcutta are not the ones that western doctors work in now.

Then came the practical advice of John Travaline, a physician and deacon who spoke about practicing like a real Catholic. He stressed the importance of seeing opportunities to restore human dignity to those with diminished personhood, to look for chances to be present to others (e.g. don't double book, imagine the workplace as a holy place, make your office accessible). He stressed that wounds are a sign of God's presence, chances to participate in Christ's restoration of man.

Src: www.catholicmedkc.org

Finally, Dr. Greg Burke reviewed a sample examination of conscience for physicians. Several things were relevant to this theme of missionary suffering and joy. Am I ashamed of my Catholic identity? Am I plagued by guilt without sin (blamed or self-blaming for a case when you acted according to your conscience)? He reminded his audience that it is humanly impossible to know everything. "Don't beat yourself up for being human," Dr. Burke said. Strive to become more and more a saint instead, consult appropriately, avoid scurrilous conversation, and don't worry about the messiness of how it plays out.

All these men encouraged attendees: find in medicine a chance to become Christlike. It was a great message.

This post wouldn't be complete if it ended without my personal reflections on going to the conference. Perhaps this is because I'm used to the breakneck pace of residency, but I found the conference a little slow and a little repetitive. For the first time I was frustrated with the CMA for ignoring a few elephants in the room. Why wasn't anyone talking about NPT and evidence-based gynecology? Why wasn't anyone talking about virtue-based pediatrics? The conference was refreshing because it was more anecdotal and had a looser schedule (very effective for burnout prevention), but I was still hungry for more at the end. Going through the talks again was helpful, but I wish there was more original research and open discussion at these conferences.

Control and Being a little Legislator

I have realized that I can't control anything, and I'm trying to live with that.

This is as much a psychological milestone as it is a spiritual one. Human beings can't influence most of what happens to them: we can't change the weather, we can't change history, and we can't change the people around us or their choices. Christians embrace this like they embrace the inevitability of suffering: they see that God has made it a way to go to Him.

It's refreshing to admit I can't control a lot. As a doctor, I can't control who will page or call me and whether it means I get out of bed on call. I can't control who will walk into my clinic or how long they'll need to talk about it. I can't control who will come into triage or the ED and whether they'll need a complicated workup or a surgery that day. At the most extreme: I can't control how placentas and cancers grow and I can't stop babies and women from dying. There's a vulnerability that can be exhausting (another patient? I already need to see twelve. Another ultrasound? Another phone call?). It's hard to maintain generosity and avoid being lazy. Also increasingly since residency is the inability to control my body: I can't just stay up as long as I want--my body turns off after 36 hours on and I miss meetings that I schedule after that.

The doctor-patient coin has two sides. I can't control how my doctor interprets the evidence on re-scoping versus empiric titration. I can't control what she'll find on that colonoscopy, either. I can't control what the meds will do, I can't control whether I develop extraintestinal manifestations, and I can't control whether or when I'll lose my colon or get cancer. (I also can't control the past, which includes a lot of knowledge about UC that I sort of wish I didn't have.)

And there are a scattered other few things. I can't control whether my siblings will stay Catholic, whether my married friends will stay married, whether my archdiocese will close my parish, whether the state will stop payment from CMS to my hospital....

There are some things that I can control a little more, but always weasel out of my grasp. I can't always seem to control the cleanliness of my apartment. Sometimes it looks like six frat boys live there and I can hear my German-standard cleanliness mother (who had us wipe the microwave and oven doors as part of the list of things to do with the dishes) tsking in my mind. Mom, I think I've wiped the oven once and vacuumed three times since moving here.

Then there are the things I wish were in my control and might be in my control, but I don't think my will is disciplined enough. These are all the parts of the life of virtue that I think I could do better on, even though my life now in residency tempts me to excuse all kinds of stuff. I have to learn to live like a saint even while working my current schedule. What if I died in residency? What will be my excuse that I didn't possess my own heart in each moment, form my conscience, and use every opportunity to love God and calmly grow in virtue?

But my old approach to virtue doesn't work now. (Lots of people said this about med school, that they're undergrad method of studying didn't work in med school. I didn't have to make that transition from TAC, but perhaps it'd have been better if I did, because I'd have recognized this need for something new sooner.) I can't legislate little changes any more. 

In med school, I wanted to be able to floss every day, so I made a little law for myself, invented a method for predisposing myself, created positive self pressure (a dental appointment), and unconsciously created negative pressure (shame). And it worked. The same thing worked for a lot of pious practices and projects. Now I can't get myself to floss, even though I applied all the same interventions. The same problem exists for a lot of my pious practices and projects. I don't know why this is, but I have a strong hunch: the core battle of my life, chronic exhaustion, makes it hard to pressure myself to do things. There's not enough energy for sustained enforcement upon myself. 

But the other day I had a realization. Considering the relationship between myself and God, I am never the legislator. God makes the laws and He stands under the reality in which I exert my free will with His help. This helped me realize what doctors of the Church and saints have long known: all that is needed for holiness is to follow one's conscience in each moment. When each opportunity to floss presents itself, I accept His grace and take care of my body. And because God's will is less totalitarian than man's, I might even decide (shocker) that flossing is not indicated in certain situations. (Do you floss after 30 hours at work? I fall into bed.)

How to Raise your Children so They Want a Catholic College

Thomas Aquinas, reading.

A real liberal education is very different from most college educations, and one in a Catholic setting is even more formative. I credit TAC with saving my soul in many ways. 
Recently someone asked me how my parents managed to get me to want that.

I think there are many paths to places like TAC, Wyoming Catholic, UD, Christendom, UST, Benedictine, and Steubenville. Some of my classmates (especially professors' kids) went to liberal arts grade and high schools. They heard philosophical discussions at home and heard about these colleges from a young age. Some of them got a "leg up" from this approach, but I could tell that others were a little tired of it.
 Other classmates were nontraditional, coming to liberal arts after a more typical college education, or being sent there by a religious order to discern whether they were called to marriage. 


I and most others had a middle road. My parents were confident that their faith was the truth. They discussed objective truths and common sense at dinner in ways I found normal, not schoolish. My parents were strongly involved in the pro-life movement. Even though I was involved in secular sports and hobbies, my parents helped form my opinions when groups went awry (like the Girl Scouts) or when movies were inappropriate.

Most importantly for me, my parents helped me read. We had so many books! We had fiction and nonfiction for every kid's taste. My parents read to us and we read to them. I devoured secular science fiction, fantasy, historical fiction (everything but romance). There were also bibles, encyclicals, and books on the saints on the shelves, but I went to truth via fiction. It was a short step from the Chronicles of Narnia and The Man who was Thursday to Mere Christianity and Orthodoxy. 

But each child is different. I have a sister who went to truth through logic. She loved to read, too, but she loved arguing and problem solving. I have a sister who didn't like to read as much, but loved to play and spend time with people. My fourth sister loves to write, and my parents were good listeners. 

Finally, it comes down to love. If you can show your children that there is love and that there is an objective truth, they can want to follow you on the good path. It may not even matter if they get a liberal arts education--hundreds of saints were uneducated, and most of my siblings are getting or got traditional college degrees. 

Easter Fire: In Which God has a Laugh

I notice things; maybe you do this, too. Maybe you always know where the fire exits are. Maybe you notice the elderly priest at Mass and think about what you would do if he fell or fainted. Maybe you notice the pregnant lady in the car next to you and think about what you would do if she got in an accident (maybe you even keep a scalpel in your car to do a stat C-section...).

Easter fire. (Stock photo, obviously not the situation I was in.)

I think it's neat that I can notice these things and be ready. But sometimes I think God makes fun of me for it, just to keep me humble.

I worked days this past Easter, but I had the nights off. So, after I got off on Holy Saturday I drove to an abbey not far from my city for their midnight Easter Vigil. It was going to be my rest: for just a few hours, I had no responsibilities. I didn't have to cantor, talk to people, or even stay awake! Thank God, I prayed.

This is the abbey where I made my week-long retreat before my consecration. It was an otherworldly week, partially because the abbey really lives the vow of poverty and the life of silence. Each member lives in a tiny (6x10ft) hermitage without heating or air conditioning. They also have foundations in Africa, and they live the same way on both continents. 

Given this spirit, I wasn't surprised to see a make-shift, but lovely credence table for the lighting of the paschal candle. In a broad stew pot were some coals, and this was placed on top of a cheap card table, covered with a white tablecloth.

I felt strange coming back after so many months in the world. I was then more than halfway through intern year: I was a competent, resident, I paid bills and bought stuff, and I was neck-deep in ethical questions, all far from ethereal prayer. That night, I re-entered the world of silence feeling like an outsider.

I slid in a few minutes early next to another woman. It was hot (remember: no air conditioning), and she had brought a water bottle. The plastic crackled in the monastic quiet before Mass. When the time came to light the candle, we all stood. Because I'd slid in the back, I was only a few feet away from the humble credence table. An acolyte poured some lighter fluid on the coals and clicked a lighter. My face and the faces of the whole back row were illuminated, and I felt even more exposed. Hide me, God. Please, just let me cower in the back and absorb the Mass.

All was well for a few minutes. Then the fire blew out of the pot and the tablecloth caught fire. The same sense of duty that makes me notice pregnant and elderly people was immediately awake: DO SOMETHING, it said.

What? I thought immediately. God, are you joking? 

The seraphic abbot and acolytes all stepped away in refined surprise. Inwardly, I groaned playfully at God, because it was as though He was nudging me lovingly. It had only been half a second since the fire started, and I grabbed my neighbor's water bottle, tore the cap off, and emptied it onto the table. There was just enough to put out the fire. I have residency to thank for the reflexes, and God to thank for His sense of humor.

Stories from the ER: Bedbugs

In college, I devoured books written by medical trainees. I read Singular Intimacies, Complications, and A Not Entirely Benign Procedure (and others) as a college student. Having read these, I think I could've said about medical school what St. Therese said about the convent: I went in with my eyes open, and I was right.

When I read Danielle Ofri's story of a homeless, bug-covered man who came in through Bellevue's emergency department, I thought, "I know med school is an experience, but that's too crazy to happen to anyone but people who write books." Crazy books about crazy NYC hospitals.

Nope.

A disclaimer: this story contains a few nasty things, including bedbugs and elder abuse. There will be no exaggeration. There's a happy ending.

During my ER rotation, a woman was brought in covered in bedbugs. The attending sent me in to see her and I went into the room at my usual busy pace. One of the EMTs, still packing up his stretcher, halted my progress with a few words. "You might want to...." the EMT started, then tried again: "She's sort of...covered."

Then my eyes registered the hundreds of mini-M&M sized insects swarming in and out of her clothes, around her arms and legs and fingers, on her neck, and on her sheets. I stopped short, my shoes almost squeaking on the lineoleum with the abruptness of my deceleration.

The woman herself was moaning.

"What's the story?" I asked the EMT.

"She called about pain. We had to break the door down. Found her in a chair, in feces and urine and--" he gestured to the insects "--those. Vitals were stable in transport."

With that, he left. From a safe distance, I took a history as best as I could. (I was a little disgusted.) The woman lived alone. She was unable to get out of her chair. She didn't eat or drink. Everyone once in a while a neighbor brought a sandwich. The last time he'd come was three days ago. The neighbor doesn't get too close. Nobody cleans her. Nobody cleans her house. She had home health, but they didn't come too close. She had had pain "in her seat" for a while, but didn't talk to anyone about it. She called 911 about it today.

I left the room without doing a physical exam, as the ER nurse was posting a "DECONTAMINATION" sign on the door. I was angry; elder abuse is something I feel very strongly about. I went to my attending and told him the situation.

"Someone's going to get sued," he said, meaning the home health organization.

"I'd like to help decontaminate," I said.

"Be my guest," he replied.

Outside her door, nurses were gowning up as if the patient had Ebola. I joined in: boots, cap, two gowns (the flimsy ones that only cover half of you; one for each half), and mask with face shield. None of us were wanting to take bedbugs home. We were already itchy.

I turned my anger into zeal and worked alongside the nurses, overcoming my disgust and turning myself into Love to this woman. We brought in large trash bags and a dozen packets of moist skin towelettes. Then we took off and threw away the woman's clothing and all the sheet's she'd touched. We wiped bugs and bug carcasses off her body. I cleaned where the nurses didn't. It turned out she had two decubitus ulcers from sitting so long.

It was a terrible day (that patient, plus a death, plus family troubles). That night I told Jesus all about it. "What was Your day like?" I asked, in a slightly complainy tone. And He answered, in my imagination. (This is the happy ending.)

"Someone cleaned Me."

More on Guessing and Pride

As a follow-up to the last post, I made a flowchart of all the little worries and calculations that can go on in a med student's head whenever someone asks a question. The more pride, the more anxiety, timidity, pompousness, envy, and regret. Right-click>open in new tab/window for full size.

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.

Daily Meditation with 70+ Hour Weeks

After I realized during my third year that I needed to prepare better for prayer, I started to create a list of verses that were easy to use and fruitful for meditation. I then expanded it to over 365 verses and sorted them so that I could use my imagination as meditation directs us.

I'm sharing the result on this blog because it is part of the experience of a Catholic medical student, and it might be helpful to some. This list is long, and it's got its own page: A Year of Meditation for Busy 21st Century Souls.

The list is still growing. The entirety of the life of Christ is present, but many Old Testament stories and many epistles are still untapped. It also needs the refinement and development that will come with use and time. But if you find it interesting to see how a 70+ hour work week can admit 30 minutes of daily meditation, take a look.

CMA Conference Summary

It has been over a month since the CMA conference. As I proceed through the interview season, I am so glad I went. I actually had an open conversation about NFP with a fellow interviewee on the airport shuttle and was unashamed and excited about it. Thanks, Courage in Medicine.

I'm going to review the five or so talks that I found most meaningful. Check out the entire program booklet here, and order copies of these talks here.

Cardinal Burke: Physicians as Standard Bearers in the New Evangelization
This opening talk was a spiritual alarm clock that I desperately needed. I took copious notes during this talk, and I can't squish it into a short blurb, but here are some pearls:

• Virtue is the primary method of the New Evangelization.
• If we have the heart of God, our patient care will transform us, our patients, and the culture.
• We are not saved by a discovery or work, but by a Person who assumes us.
• The moral norm isn't an abstract--it's Jesus, so get to know and love Him.

Cardinal Burke urged us to form our consciences with moral study to stave off doubt that there is a moral norm. Since I was thinking of my own timidity and upcoming interviews, the message came through loud and clear that I needed to comfortably, boldly live my faith, reason, and religion as the most formative part of my life. My responsibility (since I've been told the truth) is greatly increased, and I wasn't attending to much of the iceberg of my responsibilities to glorify God.

Mike Aquilina: Challenges Before Us in Historical Perspective
The recent changes in healthcare, pointed out this speaker, are a perfect storm to drive out the people who want to serve. He went through ancient history (especially Roman historians like Tacitus and Pliny) recounting some of the same cultural phenomena we see today, such as the increasing tendency to lavish attention on dogs and to go childfree (to be clear to childfree readers: I list those as two separate tendencies). Mr. Aquilina emphasized that the cultural changes we see now are not original: every time a culture forgot to separate what is good from what is desireable, it excluded some persons (females, elderly, unborn, infants, children, various races, prisoners) from personhood and devalue them. However, Mr. Aquilina also showed that there is a history of the aberration of Christianity upsetting dysfunctional cultures. He concluded that there is no better time for us to be alive and serve; God will equip us, as he has historically.

Father Roger Landry: Bifurcation of Faith and Reason: Unleashing Radical Secularism and Its Impact on Medicine
This priest is remarkable for his use of the word bifurcation and his Latin three-word summary of how we should live. We should live, he says, etsi Deus daretur, as if God was a given. (Obvious as this may sound, it is difficult to do in the sea of relativism that is mainstream education above the sixth grade in this country.) When we live this way, unafraid that robust faith saves and strengthens reason, our lives are integrated. We also reap the following benefits:

1. We rediscover wonder.
2. Technological advances don't outstrip moral development. (More on this in a future post, I hope.)
3. We don't forget the splendor of being a child of God, and we thus avoid devaluing persons.

We should challenge ourselves and our culture: what stands in the way of your practical atheism being carried into Nietsche's will to power? A hazy self-faith, godless altruism, natural law? Impossibly webby barriers to "might makes right." If you don't buy the CD of any other talk, get this one.

Father Robert McTeigue: Moral Courage in Medicine
Chosen to give the title talk at this conference was a very humorous Jesuit priest. Fr. McTeigue charged his listeners with duties to acquire the virtues (which, by the way, are humanizing and good for people). He pointed out that courage exists for the protection of the good. One of the most surprising things he said quoted St. Teresa (I think?) on the two beautiful daughters of Hope: anger and courage. This is why the evil spirit wants so desperately that we despair: when we hope, we have just wrath, and we pounce on evil! We defy it! We unabashedly judge deeds (our own and others'). Fr. McTeigue's final piece of advice: pray "Jesus, I trust in You," and mean, "I don't trust myself."

Dr. Fernandes: Catholic Medical Professionals: Reclaiming Surrendered Ground in Bioethics 
If I wasn't morally awake after Cardinal Burke and the other speakers, Dr. Fernandes would have gotten me out of any relativistic torpor left. This Wright State attending (gently, with humor) lit a fire underneath me. Like Cardinal Burke's talk, I'll just have to give you some soundbites:

• Make yourself reasonable. Confuse them [relativists and practical atheists].
• If people are worm food, why should we suffer, delay death, or respect religion as an add-on?
• Cultural relativism is wrong. What if a culture is intolerant?
• "Loving" "People" is easier than truly loving persons in front you in the present.
• Between good and evil, there is no safe place.

Dr. Patrick Yeung: Fertility and Infertility Within a Catholic Moral Vision
Dr. Yeung, who is a professor at St. Louis University and directs the Center for Endometriosis there. He, being a napro-trained OB/GYN, had lots of relevant advice for me. "Do not look at it as a bunch of things you cannot do. Make it green and holistic and positive." "For best results," he also quipped, "follow God's design." One more neat quote: "Optimal medicine is holistic and doesn't solve one problem at the expense of [creating] others."

The Third Year Manifesto, last part: An Analysis

There are days that I want to ask the hospital at large: “When do I get my personhood back? When am I treated like I have the dignity that everyone else does?”

I want to be comfortable where I work. I want to be safe to be myself and express my limitations. Instead, I cork up dozens of questions a week. I’ve violated the sterile field a half dozen times and don’t bring it up. I hate being told that I can’t do something because being so uninvolved, it's not what I’m paying for, and I have more to offer. I hate being told that I can do something because I will be watched, I will fear derision and misunderstanding, I will fumble out of fear, I will put on my game face and fumble out of incompetence, or I will get lucky and be deluded so that the next fumble hurts more.

I want is to be satisfied with the way my life is going. I want the basic esteem of others. “Oh,” is all I wish that people would think when they saw me, “she’s a medical student. You know, those people can’t do much. But they sure try.”

#

Once, I caught myself apologizing to someone in these exact words:

“I’m so sorry for taking up so much space!”

After uttering this ridiculous sentence, I went out the nearest door in a polite rush. Only after the door shut behind me did I shake my head and think, “what a stupid thing to say. I’m taking my own personhood away; apparently, I don’t need anyone else’s help.”

So, now that it is the fourth year of medical school, I am deciding: no one is taking my dignity away, least of all me. If they demean me in the OR, they are doing something inappropriate. I will graciously excuse them, like one ignores a person passing gas.

I am determined never again to agree with the lie that I am a worthless idiot. That lie leads to an psychological hell.

Part of the reason I became such a doormat/basket-case of self-critical emotions and permitted everyone else’s criticisms (petty or cruel) to sink me, was that I had a lousy idea about humility. I had this glorified picture of religious life in somewhere between 1600 and 1900 in which saints were made by kissing floors. Didn’t St. Bernadette, St. Jeanne Jugan, St. Therese, and many others have to be grossly misunderstood and abused to become saints? Don’t you have to believe all the derogatory things people say about you if you want true humility? Yeah! So, I was excited because I’d heard (correctly) that the third year was a lot like a floor-kissing novitiate.

But there is a basic misunderstanding there. Cultures that file away at personal dignity crowd out holiness! A person tossed around in such a culture becomes so distraught over himself and convinced of his incapacity that he can’t have the magnanimity a saint needs to become like the all-loving God. Believing himself to be a microscopic locket—always too small, always wanting, always disappointing—this miserable man can’t imagine becoming a vault, a temple.

It is a lie of Satan that I am worthless. I want to do great things for God. I want God, I want to be like Him, and I expect He will make us that way. So if I ever stoop to another floor for a kiss, it will be because Jesus is there, waiting to kiss me back and make me His gorgeous, eternal, perfect bride.

Third Year Manifesto, Part 2: Stories

In which I vent all the stories that I've kept bottled up so as not to be a whiner. The last part of this trio of posts is coming tomorrow.

#

I obediently submitted to being taught how to insert a Foley every time I inserted one. Today (the first day of fourth year) was the first time no one approached me and said, “oh, let me show you how….” It was disorienting. Wasn’t someone going to smother me with their preferences?

I breathed. I felt free! But the freedom was not to last. As I proceeded, I heard a very distinct “hmpf!” behind me, in the same tone people use when they raise an eyebrow and say “well, that’s interesting!” and really mean something much less benign.

#

The first vaginal delivery I attended on L&D, I did what the clerkship director told me to do: I protected the perineum and stayed close, in case I could actually be allowed to deliver the baby. This is called, good-naturedly, “being aggressive,” and it’s a good quality in medical trainees.

In that first delivery, a senior resident and an intern were also there. I guess if I were more shrewd, I would have known that it was bound to be the intern’s delivery. But who was I to know that what the clerkship director told me wasn’t right?

The senior resident decided to put an end to my aggressiveness. She put her hand on my hands and pushed them away from the field. Pushed. No exaggeration; the equivalent force could have shoved a gallon of milk several feet. The embarassment (and the sheer force) moved me to the back table for the rest of the delivery. When she asked me later, “did you see how the baby did xyz during abc stage?” I felt like saying, “No, of course not. If you want me to see things, don’t push me away.”

#

When a gentler resident was graciously allowing me to suture subcutaneous tissue in the OR, I put my needle driver down on the field, with the needle still in it. It was the first time I had ever done this, because it was the first time I had to cut off my needle to tie. (It was the first time I wasn’t using 4-0 and subcuticulars in the skin). The scrub tech slapped my hand, chiding me verbally. I blushed with angry embarassment underneath my mask, but tractably apologized, etc. Then, she said these words exactly (I remember them and you’ll see why):

“There are some people,” she said self-righteously, “who’ll slap your hand for that. I won’t, but there are some.”

I tried not to stare at her blankly. I guess it never dawned on her that she, SHE had ACTUALLY (not metaphorically) slapped my hand. I guess people who use that phrase end up acting on it without realizing it?? She has been the only one to do that.

#

One day in surgery I learned that the scrub tech, the scrub-nurse-in-training, and I were all within a few years of each other. I was the oldest. I was paying, snipping, uncomfortable, and chastised during the surgery. The other two, who were allowed to take a lunch break (during this six-hour surgery), were paid and thanked.

The fact that I’m paying to be there seems to some surgeons to mean that I’m not to be thanked and that I’m automatically incompetent. It seems to say, “she can’t do anything.”

“No, no,” one surgeon said when I reached for a towel to drape a patient. The scrub tech, who had offered me the towel, knew me better than that surgeon. He was being a pal, and he knew I have seen patients draped dozens of times and I could do it. But no! “She’s a medical student, she doesn’t do that,” the surgeon said.

“Excuse me, Doctor Bossy-Pants,” I burned to say. “I am a medical student and I can do that. Watch!” But it’s her sterile field, it’s her OR time, I’m her responsibility and (the real reason) she’s grading me. So I didn’t do that. I backed down. I abased myself.

The Third Year Manifesto, Part 1: Cutting Suture

I will now discuss the stuff of third year that is not happy and glamorous. Having a blog places slight pressure on a person not to whine. But not to disclose the negative parts of medical school would be dishonest. So it’s time to air a few grievances, and (because I can’t seem to not do this) discuss morality and holiness at the same time.

At some point during my third year, I got very demoralized. It’s hard for a person who wants to do great things well (and is used to doing great things well) to find herself unable to hope even for mediocrity.

One response to this predicament: Ah, what a chance to grow in humility!

THIS IS AWESOME.

"Ah," goes this response, "I have had many peers, past and present, who have struggled to get the things I’ve gotten, like A’s and letters of recommendation and leadership positions and success…. Now, God is making me more like them, to help me see that they are my brothers in everything. I have nothing of my own and am happy to have God, because I truly lack nothing."

Another and much more human response to this predicament:

THIS IS TERRIBLE.

In its severest form, this disappointment becomes sadness, loneliness, isolation, depression, and despair.

It was a war between these two responses for the second half of third year. However, it is old news that 1) I am a little soul and 2) there's a war going on in me between holiness and not-holiness. God is exerting Himself to the maximum and employing all kinds of things (sacraments, virtues, habits, circumstances, living people, dead people, people I’ve never laid eyes on, angels, and even me) to make me like Himself. On the other side are all kinds of things (occasions, vices, habits, circumstances, living people, dead people, people I’ve never laid eyes on, angels, and especially me) persuading me to stay in my nice little hidey-self-in-hell-hole.

But morality aside for a teensy moment: seriously! This year was so demoralizing at times!

Do you have any idea what it is like to stand in a surgery, not allowed to do anything except trim suture? Somebody ties a knot around [whatever], and I come in with scissors and snip it. That is 90% of my intraoperative action. This is especially painful because I’ve been given great responsibility and responded rather well to in the past. I wish I could speak my mind in those ORs.

“You know, I am a person.”

Snip.

“With an intellect.”

Snip.

“A rather good intellect.”

Snip.

“And I have pretty good hands, too. Did you know I paint? And I’m handy around the house.”

Snip.

“And if you let me stick-tie the ovarian vessels/close the fascia/dissect adhesions/use a bovie/debride dead tissue/MANY OTHER EXAMPLES, I bet I could do it.”

Snip.

The worst part is, I am not even permitted to stupidly cut as I like. I am chided because I am not doing it properly. Since the clinical years of medical school are a dizzying merry-go-round through services and surgeons, I can never acquire expertise in one thing. Many have pretened to, but no one ever has, given me a comprehensive lesson in how to properly cut all types of suture in all places according to the preferences of all surgeons. (I expect even the Eternal Father would have difficulty with this one. Just kidding, Abba.)

“Whoa!” says one surgeon. “Too short.”

Or again, the surgeon is uncomfortably silent after I cut. I timidly ask, “too long?”

At least I have never cut someone’s knot. There was once when I took the blame for a broken knot. A few minutes after I snipped, one of the resident’s knots came undone. To save the resident face, I said, “Oh, I cut your knot, didn’t I. I’m sorry.”

I became the queen of taking flak this year. There was an “Oh, thank you,” after every correction; there was a sincere-sounding “I’m sorry,” after every action someone objected to.

Today, while snipping, I grew less and less successful. I began to wonder whether there was a problem with the scissors. Surgeons and residents are quick to ask for a different instrument if the one they’re holding does something silly or inefficient. Not being a surgeon or a resident, I waited out my silly, inefficient instrument for a good five more snips. While I waited, a new scrub tech clocked in. This meant I lost the rapport I’d built up with the first one (my pulling a gown and gloves, helping in setup, etc) I didn’t think anything of this at the time, but now I wonder whether er shift change made a difference in the answer I received when I eventually asked, “Do you have another pair of scissors?”

There are at least four pairs of scissors in almost every set. I know because I know their names: curved Mayos, Mets, tenotomies. There are also Potts and Dietrichs, but even I wouldn’t use those for suture (now I’m just showing off how many types of scissors I can name without looking things up). The suture scissors are called “heavy sciz” by some, but their real name is straight Mayos. Technically, you’re supposed to use the straight Mayos for stuff, like foam, suture, and mesh. Cutting these undelicate things with the better scissors would dull the blades and damage tissue. But I’ve seen surgeons get frustrated with a pair of straight Mayos. They drop them to purposefully exclude them from use, then start to use the curved Mayo’s or the Mets. I’ve even seen someone use the tenotomies. So certainly it would not have been absurd for me to use a different pair of scissors. But what did the scrub tech say?

“Is it the scissors, or is it you?”

I felt like exploding.

“Please,” I wanted to say, “even if it is me, could you think of a different way to say it? Maybe ‘show me how you’re cutting’? Or maybe, just maybe you could humor me? I humor people to ridiculous extent. Could you just hand me the curved Mayos? Maybe then I’ll learn that it is, in fact, not the scissors. And you know what else? Even if it’s not the scissors, I don’t like that you said ‘me,’ as if I/me/my person is a problem. My technique might be lousy, but why the ad hominem? Why do I become a problem because I don’t cut suture properly? And anyway, who has taught me how to cut? No one! I have had to cobble things together myself!”

See the med student, doing nothing?
Oh wait, I forgot to get them in the camera view.

But I said, smiling doormat that I have become, “Oh, probably me.” And she said what I should have been doing. My success was unchanged: some good cuts, some lousy ones. In retrospect I think the scissors were fine and I was fine. The problem was that the incision was getting deep (down to the retroperitoneum) and therefore the sutures were getting further and further away from me. When you have to stand on tiptoe and crane your neck and reach to cut something, nothing works quite as well. I can’t wait to be the surgeon or the resident and have a legitimate place to stand so that I can see the operative field all the time.

Fruits of the Flare-Up

1. This.
2. I discovered I need to be way more compassionate with patients. I had no idea the depth of the terms "malaise" and "fatigue."
3. I used to wonder how patients could stand just lying in bed all day, not doing anything. Weren't we boring them to death, like kenneled animals? Nope. Nope, when you're sick, you don't care. Bed is good, or as good as it gets.
4. Life is only about becoming more and more dependent on God. That is all. And even when all I could do was lie in bed and stare at the wall, I could still depend on God. So I was still able to become a saint, even with near-zero function. Wow!
5. In fact, it was easier to depend on God when I was sick. Now that I'm closer to better, I keep thinking I'm the captain of my life again. (The pill box is a good reminder.)

Catching up: IM is hard

I am now ending my Christmas break and have finally decompressed enough to blog. (Or, I've finally realized that if I don't specifically carve out time to blog, it won't happen and all I will do is hang out with siblings, clean the kitchen, and do errands.) I am now one sixth of the way through internal medicine: two weeks down, ten to go.

Internal medicine (IM or "I med") is the meat and potatoes of the third year: it represents most of Step 2, and it teaches us basics of adult medicine. Our rotation is made up of one week of palliative care, two month-long rotations with an inpatient team of residents, and two weeks of outpatient care with a practicing physician in the community. Because our Christmas break landed in the middle of one of the month-long rotations, I have one fewer inpatient weeks and one additional outpatient week. (Cue the Alleluia chorus, because inpatient is much more intense and demanding than outpatient; this coincidence will give me more time to study and less time with resident team 1, which is keeping me hopping although I'm learning a ton.)

In one week on this residency team, I saw patients with stroke, sickle cell crisis, cellulitis, heart attack, heart failure, pericardial effusion, leukemia, sepsis, coma, and disseminated cancer. One patient died (I was not present).

The resident quizzes us a lot during the day, so studying is a must. We write notes on the three patients we see, and we see them before 8:00am, which means I'm getting up at 5:00, and that also means I'm usually missing Mass. I'm struggling to work until 5:00pm or 6:00pm, study, pray, and relax. IM is challenging me!

Formation is stressing living as Christ and being the Eucharist for others, though, so I am definitely getting a chance to do that. And St. Faustina says that one Eucharist lasts until the next, so I'm at peace as far as Mass goes. Praying the litany of humility (and just being a third year med student) is also helping me have realistic expectations of what I can and can't do, and how much I should or shouldn't know at this time in my life.

In other news, all during the OB/GYN rotation I either avoided or bumbled through explaining why I wouldn't prescribe contraceptives. Today, at coffee with my high school friends, one of them asked me about it and I explained *~beautifully~* why I thought what I did. Yay! I can have that conversation! (One down, a million to go.)

I Wish I'd Known

Prayer will make you beautiful!
It might not give you flowing dark hair,
though. Sad face.

I wish I'd known that prayer is like all other types of socialization: we learn to do it as children in a rudimentary, sweet way. As we grow into middle-schoolers and high-schoolers and college students and young professionals and spouses and middle-aged people and elders, all our friendships advance and flower. Prayer (intimacy with God) should, too! I wish I'd known that I was living the prayer life of a child into my late teens.

I've thought about this several times recently: I listened to a talk from the School of Faith (get the talk by creating a login here; it's Faith Foundations I Lesson 9) and I read this post about prioritizing prayer and then I heard my parish priest give a homily saying pretty much the same thing just yesterday.

Do you live an age-appropriate prayer life? This article might be a good help towards a beginning to grow up into spiritual adolescence. And asking someone who is a little further along in the journey was helpful for me; hopefully God will (or has already) placed this person in your life. If not, pray that He will!

Now you know what I wish I'd known. God bless you today!

Pediatrics: An Inspiring Rotation

Although pediatrics has not felt as relevant as other rotations, I've certainly had a lot of chances to be humbled and amazed by the parents I meet.

"Lupita"

In the outpatient clinic I worked in, my preceptor had me shadow for well child visits. One afternoon, I followed him into a well child check, only to see no child in the room...only a middle-aged woman sitting in the corner chair. She and the pediatrician began to speak and I slowly began to understand what was going on.

This woman was adopting a distant relative's child, "Lupita" after discovering that Lupita and her siblings were being neglected. Raised in a small town in south Texas, the children were left alone often and had to choose which children ate at meals. Lupita didn't speak English very well and didn't know what grade she was in. The woman said that at home, Lupita talked nonstop to whoever was around her and ate voraciously, almost choking on a sandwich in her haste to eat it. Drug use and deportation played a role in her mother's absence.

Lupita came in after the pediatrician had received all this news. She was a grave child, obeying the doctor in everything she could understand without smiling or showing any embarrassment that a girl her age would typically show. She spoke freely but only when spoken to. In her hand, she held a little charm, and when I asked her what it was, she opened her hand and showed me a plastic star the size of a die. "Mi estrella," she said simply.

I was very amazed by Lupita's new adoptive mother. This woman was also planning to adopt Lupita's baby brother, who was still in Mexico. And when my preceptor asked, "how do your twins feel about all this?" I was completely amazed. Pray for them!

"Aaron"

In the same outpatient office, with a different preceptor, I saw a follow-up with eighteen-year-old "Aaron" on a stress fracture. Aaron was a young adult with autism and a lot of sensory overload. He was in a post-high school program designed to teach adults to ride public transport, interview for a job, and use a basic skill set in an employment setting. He had come in with his mother, who I learned (and could see by difference in race) was his adoptive mom.

As the doctor conducted the history from his mother, Aaron would constantly interrupt: "what's going on? I don't understand," or "I have something to say. I'm going to explode. I still don't understand," and his mother would quietly redirect him or ask him for input. She was very skillful at letting Aaron talk as much and as constructively as possible, while also advancing the discussion of his painful foot.

During the physical exam, however, the doctor had to palpate for swelling and tenderness to palpation (an X-ray was inconclusive), and the pain began to be more than Aaron could communicate. Unable to say "stop it" fast enough, he screamed loudly, then began to cry. The doctor stopped and we stepped out of the room for a time, while Aaron and his mother re-grouped.

After a few minutes, we came back in. "Aaron wants you to know he's embarrassed," his mother said gently, "but he wasn't prepared for you doing that today." The doctor nodded, apologized to Aaron, and the interview went on. It reminded me of a video I'd seen about a nonverbal girl with autism (at right and also online: Carly's Cafe). It was as if Aaron's world was too overwhelming, and processing it took so much time that he couldn't ask the doctor to stop pressing, and the pain and the inability to stop it became very distressing.

Throughout, the mom was a calm and loving help to this young man who she was barely helping to function. At one point in the interview, she became tearful when she talked about Aaron "falling through the cracks." Where would Aaron be without this woman? This is another story of someone I'll not forget easily, someone whose generosity was humbling.

"Helen"

I just finished the week of newborn nursery time that's sandwiched between the other weeks of pediatrics. I rotated through the NICU and saw some very incredible moms there, too. I spent some time talking with one in particular, "Helen," who had delivered two preemies. Her first child was born at 28 weeks and she spent months in the NICU fighting lung problems and sepsis. While her baby used IVs and NG tubes, Helen pumped breastmilk from the day he was born, hoping that when he was mature enough he could take it. It was a nightmare, she said, something "I wouldn't wish on anyone." Fortunately, her son is now caught up in growth and milestones, and has no residual CNS effects except some possible learning disability.

During her second pregnancy, Helen received weekly progesterone injections (thick, oily, slow gluteal IM shots) and underwent cerclage, but still went into labor at 28 weeks. After trying every drug her MFM had to offer, she started a terbutaline drip at home and stayed on bedrest for six weeks. Helen told me she has a propensity to contact dermatitis and the indwelling needle for the terbutaline drip was a constant irritant in her leg during that month and a half. And at some point every week, she would go into labor again and the terbutaline dose would have to be increased in the emergency room.

"Was it worth it?" I asked.

"Oh, absolutely," Helen said emphatically. "My daughter was born at 36 weeks, and it was so worth it to have her that much farther along. Oh, absolutely." This woman has her priorities in beautiful order. The generosity of soul of these mothers astounds and humbles me!

Mass for the Primitive Pagans Today

I recently went to Mass in a Christian community emerging from a pretty entrenched pagan culture. It was primitive and there were some (less than Christian) parts of the culture that shone through in their particular celebration of the Mass...but on the whole it was actually pretty beautiful to see that many of them were using the faith to christen their culture, themselves, and their children.

Mass was in the vernacular with a few Latin parts (just Agnus Dei, actually). I admire these people for learning even little bits of a language that must seem totally foreign to them.

The church building was no classic European cathedral, that's for sure! I would criticize them for their very mediocre architecture, but that probably wouldn't be fair to the people actually worshipping in the space. They probably don't have as rich a patrimony as Michelangelo! So yes, the Church was all brown and plain, but that's not the most important thing, no?

The music....well, it was no Gregorian chant. There was quite a bit of percussion with instruments native to the people, as well as some strings and lots of voice. It's very important to this society that each person has an equal dignity, so everyone in the congregation sings and says as much as possible in the Mass (they might have stuck in an extra "Amen" in the Eucharistic prayer?). This includes the hymns, so sometimes quality is sacrificed for participation. Theologically, there's better stuff (Adoro Te, Christus Vincit, O Sacred Head are some favs of mine) and even musically, there's better stuff, but they use hymns written by their people and I think they might be better for it, at least until they grow into the Chuch's rich musical heritage.

The people sit in family units, which I think has to do with this culture's historical foundation on the family in agriculture. Or maybe they sit in family units just because they travel to Mass that way from home. Who knows! But either way, it's a quiet and helpful way to reinforce the sacredness of the family.

Also of note, they exchange an already culturally-established sign of peace. (I've also seen a Korean community give peace by bowing. That was really fun. Do Europeans kiss?) They also do this at the Our Father with their neighbors, even though it isn't in the Ritual. Is this bad? Not sure...you could argue that they're adding to the Mass, which not even priests should do, but you could also arguing that they're Christianizing an otherwise secular gesture.

There is a great understanding of the sacredness of space in this culture, so it's natural for them to have LOTS of space between the people and the altar, and for this to be totally cool. (In contrast, some Africans or Hispanic cultures love to go right up to tabernacles and monstrances to touch and pray.) Here, there's a definite "holy of holies" and something untouchable about the Blessed Sacrament. That attitude in their culture (that everyone has their space and you don't trespass) is probably from their history, but it's serving them well at Mass!

Everyone is quiet during the homily. Academic achievement is prized in this culture, and I suppose that's probably helping them. On the other hand, they love partying, so perhaps a third of them are dozing off or distracted, bored. I wonder which one will win out as this little community continues in faith!

Hmm, there are female altar servers and women on the altar. Don't get me wrong, I love women. But I don't think this culture has a huge understanding of priestly celibacy and the otherness of Holy Orders as alter Christus capitis. There hasn't been much interest amongst the young men in vocations to the priesthood, either. Could it be that the female presence on the altar is a sign or symptom of this misunderstanding? I hope the gentle teaching of the Church can help the whole community understand the value of celibacy and the value and uniqueness of the priesthood.

Although there is much singing during the Communion of the faithful, almost everyone is reverent. There is no altar rail in this church and the people mostly receive in the hand, although some receive on the tongue while standing. Almost everyone receives communion. Maybe this is a childlike trust; possibly, some are receiving our Lord unworthily, but who am I to judge? I leave it in the hands of the pastor of this young little flock. There was a great deal of singing (even by the people) after all had received--which is not ideal, since some moments of silent communion are appropriate with the Divine Guest--but this is a child's form of prayer, so that might be the intention and the best thing to do. Some of the people abstained from singing and were silent.

After Mass, there was an enormous hubbub as everyone talked about life, children, schools, activities, and everything else. What a vibrant community! There are flowers at statues of our Lady, the Sacred Heart, St. Joseph, and St. Anthony. I think I'll go back soon.

---

This might not come as a shock to you, but I am describing my home parish in the post-Christian west. Does your home parish impress you when conceived of as a small and newly-converted community in a deeply pagan culture? In some ways, that is what we are. So two pieces of advice:

1. To traditionalists: do not worry. Our culture is now mission territory; don't be shocked that we have primitive churches. Instead, sweetly nurture the poorly catechized and see the good in them to help increase it.
2. To those who have no idea what a "traditionalist" is: you might also not know how amazing the Church's history, liturgy, and theology can get (not to mention the art). Strive for maturity in the faith and dig into the patrimony of our Church.

My Brush with Euthanasia: Forget Not Love

Euthanasia is a terrible thing. I had a brush with it about a month ago while on a geriatric ward. This might surprise and scare you. Just to clarify, this actually happened. I am exaggerating nothing.

I was reviewing an older patient's chart at the nursing station before rounds. This person was on dozens of medications. The home medication list was three pages long. Everything was carefully listed by doses, times, and routes (oral, otic, ophthalmic, topical, nasal...), but the sheer volume was overwhelming. On top of the drugs for medical and mental problems, there were various  prescriptions and OTC remedies to cover side effects of the first drugs.

(If polypharmacy is new to you, then let me explain how these lists grow. A man of 64 on no medicines has some chest pain and goes to his doctor. He leaves with instructions to take a baby aspirin every day. And, because his blood pressure was high, he also leaves with a prescription for a water pill and a blood pressure medicine.

(Fast forward four years. Despite his daily three drugs, the man ends up in the hospital with a heart attack. He leaves with a stent, an antiplatelet agent, a pill for cholesterol, and an ACE inhibitor.

(Fast forward another eight years. Our man seems to be getting lost around the house and can't balance the checkbook very well any more. He's put on two drugs for dementia. Thyroid replacement is added because a thyroid test was high. His wife added a multivitamin, CoQ10, and glucosamine to keep him healthy after that fall he had last Christmas, and he also has nitroglycerin on hand, for that chest pain that started all this. He's now up to a dozen drugs, not counting any OTC painkillers, eye drops, or occasional antibiotics.)

Back to my story: I looked at the three page list of medicines in my hand, aghast. How burdensome this regimen had become for the patient and caretakers! What was this person's quality of life like, with so much intervention? This all seemed like artifice to replace the functions of a failing body. It seemed like torture to prolong a life. And for what?

I looked up from the page out to the patients beyond the nursing station counter. Half of the patients on this ward seemed over-medicated to me. They sat in their wheelchairs unaware of their surroundings. Other professionals I had learned from, including very compassionate hospice nurses, liberally took patients off medicines toward the end of life. I liked this palliative, simplifying approach. Too much medicine is a cloying thing, a clinging to numbers or days. I thought to myself, "why not just take this patient off everything and let her go peacefully?" No more surprise bruises from aspirin, no more dizziness from the blood pressure pills. No more bother with all these pills and suppositories and drops.

But today I looked at her three page list, I saw one problem with the remove-the-medicines approach. Two of this patient's medications were high-potency antipsychotics in high doses. And the rest of the regimen was like a teetering game of Jenga: remove one thing, no matter how extraneous, and the rest collapses. I groaned inwardly. We could not let this person off her medicines...it would not be peaceful or safe, and it would not improve her quality of life. If medication withdrawal couldn't be done, what could? How could this patient and her caregivers be relieved of all this?

"What if," I thought, "What if we just gave a little too much of something?"

Immediately I was alarmed. Where did that thought come from? Did I just suggest to myself that I should euthanize a person? I had. I was thinking about giving something (e.g. a benzodiazepine) to let her just slip away. I was horrified at the thought I had just produced.

How did I get to that point? I was thinking about burdens and quality of life! How did I go so far astray?

Looking back, I realized that in the few days I'd worked on that ward, I had taken on the attitude of the attendants there. They shouted at the patients from their chairs in the nurse's station and loudly talked and laughed about them like children or animals. Giving medications in such big and complex regimens was a chore. They didn't love. And although I detested this and really couldn't wait to be off that ward, it rubbed off on me! Writing so many orders--what a chore! Working on this ward--what a burden! So, as I was looking at that medication list, I was not loving the person, even though I was pitying them.

And as soon as I forgot about love, I forgot about the meaning of life, the dignity of persons, the mystery of each soul's holy journey, and the importance of suffering in salvation. Who knows whether that person on three pages of medication was becoming a great saint or mystic? Beneath the shroud of dementia and crippled limbs, under the veil of an incontinent, flailing old woman, perhaps God was adorning an exquisite saint. Perhaps in heaven her beauty and nobility will be breathtaking. And moreover, what if her suffering was saving my soul? Yours? Our country, our world? How could I dare to know? (Job 38 comes to mind.) Certainly, simplifying her regimen with palliation in mind isn't a bad idea, but I only safely stay in that mindset when I remember love.

So forget not love. It's a deadly mistake.

A patient teaches me how to trust Jesus

I just finished a week working on the trauma floor of the psychiatric hospital. On this floor, patients who have been abused or undergone some other traumatic experience undergo intensive therapy so that they can return to normal functioning. The hospital I am working at is one of the top in the nation for this, so patients come in from out of state to live on this floor and work through their pasts. If ever I went into psychiatry, it would be for this. It has been the most fascinating, intense, and beautiful week of the rotation so far.

There are several patients on this floor with dissociative identity disorder (DID, which used to be called "multiple personality disorder") because of their trauma. I am following three of them. One of them, an older woman named "Bernice," is unforgettable. She underwent a very difficult childhood and has several "alters," all of whom are children.

Bernice is a petite, white-haired woman who uses a walker for stability. I rounded on her the first two days of my week in trauma and learned about her past, her course of treatment, her marriage, her neighbors, her houseplants, and her alters. She was in the hospital now because she was beginning to dissociate again after being integrated for over ten years. She was not co-conscious with two of the alters who had recently appeared, and they had made frank or angry comments Bernice would never have made to others.

"Bernice, how many alters do you have?"

"I don't know," she said. "Before I came in, my therapist was trying to help me meet them. She suggested that, every night before I go to sleep, I ask them to come around a table, and we'd talk about how the next day would work."

My work with other DID patients reveals they often have an inner landscape, so that they can exile alters to islands, meet with alters, put child alters in safe places, and be co-conscious and supervise alters who come out. They describe their alters as "fronting" when they take executive control of the body; they can be "co-conscious" if one is in control and another is standing just behind or listening and thinking about the goings-on of the alter current in front.

"But," Bernice said, reflecting on the meeting strategy, "I would come to the table, but the children would never come." I found it striking that the personalities are different enough to seem to have their own wills. "So," Bernice went on, "my therapist suggested that I find a safe place for them, so that they wouldn't be afraid to meet with me. She had me read the Narnia books. So now we go to Narnia. Have you read the Narnia books?"

I told her I had. Bernice nodded and went on, "so now I go to Narnia, and I start at the lamppost. And Jesus follows me. He's always behind me. Even when I first started therapy, the very first time someone hypnotized me, Jesus was the first thing I saw. My doctor asked me, 'What do you see?' And I said, 'Jesus!' And when the session was over I saw he [the doctor] had tears in his eyes, and I asked him what was wrong and he said, 'Nothing, I just never heard anything so beautiful.'"

Parenthetically, I don't think Jesus is one of Bernice's alters, nor is she hallucinating. He is just such a strong part of her waking life that when she descends into her soul, she finds Him, real and vibrant, waiting to help her. She described her most recent meeting with her alters.

Src

"So Jesus follows me, and we go to look for Aslan. I think we have to find a different place, though, because Aslan represents Jesus and if I have Jesus...well, you see the point. Anyway, this time we went into Aslan's mane and there was a rocking chair and a baby. I sat in the rocking chair and rocked and nursed the baby, and then the children [her alters] began coming out of the shadows. I saw little Bernice [the first alter who ever appeared] and Lucy [an alter she had named after one of Lewis' characters], and about five or six others far off, beyond where I could see their faces. They looked like a paper doll chain, all holding hands. I didn't see Mattie, the one who was so angry. But Lucy I saw clearly for the first time. She had straight brown hair a little past her shoulders."

"And I think," Bernice mused, "Jesus gave me a gift, with the rocking chair and being able to nurse the baby. Because those children have never had a mother, that's the problem. And so when they saw a mother in me, they weren't afraid to come meet me."

I was struck completely speechless. She said more about Jesus: "He's so gentle," she said. "I'm never afraid. Sometimes he disciplines, but He's never unkind."

Another day I went to see her, I found her just as she was leaving group therapy early (which you're not supposed to do; the trauma program is very disciplined, and she apparently had poor group attendance). I softly called out her name.

"Bernice!"

"I hafta go take a nap--" she began, and then she saw me and her face lit up. "Oh, it's you!" she said girlishly. "Okay, I'll come. I thought you were going to be angry that I was leaving."

"No," I said. "Can I talk to you?"

"Sure," she said brightly. "But I have to get a ser'quel first." Seroquel is a drug that the patients are allowed to take as needed for sleep. She said "seroquel" in such a strange way, though. Bernice was an articulate woman and the way she skipped the second syllable was a little too...childlike.

When Bernice and I went into the little office and I closed the door, I asked, "so, who do I get to talk to today?"

And to my amazement, the person in front of me replied, in a pleased but bashful tone, "My name's Mariana."

Emily McGee

And for the next half hour, I talked with Mariana, a seven-year-old girl. Mariana's voice was a higher pitch, her sentence structure was simpler, and she sat like a little girl in the chair, legs drawn up like a little ballerina (whereas Bernice sat like any other older woman with osteoporosis). And Mariana used "we" instead of "I."

"We were thinking about you last night," she said, for instance. "We were thinking about how you have such pretty skin and thought you'd look good in pink, and now you're wearing pink!" And she beamed. She also related to me how pretty her therapist was and what beautiful skin she had.

"Mariana, is this the first time you've come out?"

"Yes," she replied. "It gets so noisy in that group and big Bernice goes away, so I came out. We don't like that group. We hafta talk about our bodies and," she said, looking down at the body of an older woman, "big Bernice used to be really pretty but thirty years of psych meds....so I don't like that group."

"How many girls are there?" I asked.

"There's seven of us," Mariana answered matter-of-factly. "Lucy and little Bernice and--oh! And the one that gets us into trouble when she comes out OOoh!" Mariana made a very exaggerated face of displeasure.

"Mattie?" I asked.

"Yes!" exclaimed Mariana with some surprise. "Did big Bernice tell you?"

"Yes," I said. I wanted to ask more about Mattie, but we ended up talking about the meeting in Narnia, and I got the story from another perspective. "Big Bernice was telling me she rocked the baby, and then she saw little Bernice and Lucy," I said. "And she saw some children holding hands like paper dolls. Were you one of those?"

Mariana was puzzled. I shouldn't have been surprised--after all, it was Bernice who saw the children in the shadows and was reminded of paper dolls. If Mariana was one of those, she wouldn't have that mental image. "I guess so," Mariana said eventually. "But we came because big Bernice looked so motherly. How were we supposed to come to a table if we didn't even know her?"

I learned a lot about Mariana. She told me a little about everyone's history, and how Bernice had to deal with her alters when they first started coming out. Mariana giggled as she recounted some of the troubles that little Bernice caused when she first came out.

"And she was only two! So of course, she di'n't know how to drive. So when big Bernice went somewhere and then we switched, little Bernice didn't want to drive and so we was stuck. And then once little Bernice finally had to drive once, so she got behind the wheel and drove probably twelve miles and hour all the way home. We were so scared! But then she grew up to five, and now we're all seven."

One of the most interesting comments she made was about the group dynamic. Early in the conversation, she saw the blank Progress Note form by my elbow and asked, "Are you going to ask me questions?"

"No," I said, pushing the form away. "I just want to find out more about you. Mostly I just write how people are doing and if they're having a big problem."

Mariana looked worried. "Do you call switching a big problem?"

I shrugged. "No."

She looked visibly relieved. "Some people do," she said secretively. "But it's not fair for only one to be out all the time. We should all get our chance."

Soon, Mariana began to look tired. "We want to go sleep," she said. "And when we wake up, big Bernice will come back."

"Okay, go get some sleep," I said, and sent her on her way. That was yesterday. Today I went to talk with her again (even though I wasn't supposed to round on her) and expected to see Bernice, herself, again.

But Mariana was still out. She looked very tired, even though it was just after breakfast. "I like your chair," she mused sweetly. "It's got a high back, like a queen's chair."

"A queen of Narnia," I said smilingly.

Her face lit up. "You read those books?" she exclaimed. I nodded, and she almost clapped her hands with glee. Just a few days ago, I had told Bernice (big Bernice) the same thing and got a very different reaction.

We talked briefly. "It's hard to look at all those people out there," she said, speaking of the other patients on the trauma unit. "We look at them and see that three-fourths of them will never be well. They will get better, but then they will go back to the hospital. Just like us: we thought we were well, but we weren't. Now we're back in the hospital. We will never be well. We won't."

I gazed at the person speaking to me who had the body of an old woman, the mind of a little girl, and a disease so terrible it ripped her identity into pieces. What an incapacitating condition! (She has trouble with adult friendships and jobs because children come out! Once so functional, she's now in a mental hospital, stuck with problems most people never imagine because they're one whole personality.) I wondered whether I should comfort or reassure her. I didn't, and I am so glad I held my tongue, because she said something I will never forget.

Src

"But you know Jesus? He only gives you what's good. One of the letters that Paul wrote, I can't remember what he says but he asked Jesus to take away something, I don't know what, he asked him three times but Jesus didn't take it away. And that's how it is with us. We think we're at our very worst but we're not. That's when we're giving him the greatest glory. We don't think we can do anything but we can and we do."

I was struck speechless again, this time completely overawed.

What trust! I decided that I have no idea what trust in Jesus really is. I recently read Consoling the Heart of Jesus and thought, "aha, now I know how to trust Jesus!" Formation has been focusing heavily on one simple concept: "God loves me immensely." And so I thought, "aha, I live like a beloved daughter of God so vividly now!"

Nope. I have no idea what trust is. I have no idea what living on divine love is.

Bernice and Mariana do. They walk with Jesus in total simplicity, attached to nothing in this world, not even the hope of being integrated or having a life back. With no vengeance, anger, entitlement, or greed, they walk like children, relying on Him for everything and thanking Him even if nothing seems to come.

At that moment, my attending poked his head in the room. "I'm in here talking with Mariana," I explained, so that he wouldn't address her by the wrong name.

(This is old hat to him; he's been in psychiatry so long that he still has a copy of the DSM-II (we're now in the DSM-5) and he's worked psychoanalysis and trauma for so long that he's apparently legendary. "People come from all over the country to be here," he said shuffingly to me one day, "and part of it's to see me.")

So my attending looked at Mariana and said nonchalantly, "so how long are you all planning to stick around?" He was asking about when she wanted to be discharged. I don't remember what Mariana answered; I was still struck dumb by what she had just said. My attending charted "young alter Mariana out" and we left, but I will never forget that conversation.

Therefore, that I might not become too elated, a thorn in the flesh was given to me, an angel of Satan, to beat me, to keep me from being too elated. Three times I begged the Lord about this, that it might leave me, but he said to me, “My grace is sufficient for you, for power is made perfect in weakness.” I will rather boast most gladly of my weaknesses, in order that the power of Christ may dwell with me. Therefore, I am content with weaknesses, insults, hardships, persecutions, and constraints, for the sake of Christ; for when I am weak, then I am strong.