Paper

This post reflects a real encounter, but it has been heavily anonymized.

"There's someone coming in for anxiety," Dr. H said. "You want a challenge?"

That didn't sound like a challenge to me. Challenges are chief complaints with differential diagnoses that are full of conditions with long names and specific treatment regimens and prognoses and diagnostic techniques...none of which I know! And most conditions patients have, and most new ones I learn about in clinics (salpingitis isthmica nodosa?) prove my disastrous lack of knowledge. But anxiety? That's not like "headache," or (heaven forbid) "chest pain," which have are important, enshrined, carefully-built differential diagnoses. But anxiety is not something I know nothing about. All you have to do with "anxiety" is talk to the person. And that, I can do.

"Sure," I said happily to Dr. H. Maybe he thought I was being a good little aggressive medical student, because he smiled and chuckled, nodding me toward the exam room.

Dr. H's office uses electronic medical records, but because I don't know the system, I just bring in sheets of the same lined paper I use to take notes in lecture. (It has AMDG and JMJ printed at the top, but no one notices because it's very faint.) This has turned out to be a blessing: I can sit and face the patient and ask them questions without the computer as a third wheel. I was especially glad to have paper this time, because it allowed me to really pay attention to the person in front of me.

I walked in and saw that she "looked her stated age, appeared non-traumatic and well-nourished," to use some stock descriptors from presenting clinical cases.

But I noticed that she moved very little and her face was not very expressive, although I shifted my weight occasionally during the conversation. And while the layout of the room placed my stool at an angle to her chair, she did not rotate her body to face me, just her head. Her voice was more monotonic than most persons'.

Her eyes were loaded with questions. I don't know all of them, but I wondered whether some were "Will you listen? Will you believe me? Will you judge me? Am I broken? Am I in trouble? Can something help me?"

I was struck this time more than usual that this was a person of great value, perhaps because she seemed very fragile. I softly introduced myself and asked her to tell me about what brought her in.

And she did. Although I remained calmly empathetic and did my job, her story moved me very much. Undeniably, I was moved largely because she and I were so similar. She was very close to my age. Her life was like mine in a few little ways (although hers had been much more crushing, in terms of pressure and tragedy). And later she said, "It's funny that you're a medical student. That's...what I wanted to do before...this."

So although I didn't even unpack these thoughts until I sat down to type this, I was struck by the kind of identity I found between us. She could have been in my place, and I could have been in hers. How was it decided, and why, that she would suffer and submit to describing all this to a stranger? How was it decided, and why, that I would ask another self "have you ever thought about harming yourself"?

Providence is a mystery to me this time.

Raining Grace

The other day I had my first day of the Family Medicine preceptorship. (Last semester I did an Internal Medicine preceptorship, and this semester I have Family Medicine. Same routine, same program: once a week for five weeks, I go into a physician's office and see patients and learn what I don't do well, and reinforce what I already do well.) It was awesome! But it didn't start out that way.

At TAC, it did rain once or twice a year for several days
in a row. It was so much fun.

It was pouring rain on the second day of a huge storm.

Granted, I love weather in general, and especially rain. I associate it with grace. (St. Scholastica and St. Therese are right!)

Yes, rain is plenty of fun if umbrellas and roofs are useful.
Not so fun otherwise. Exhibit A: Useless curb. Hatt

But having spent four years in a legitimate desert (with phenomenal artificial irrigation powers) I have forgotten how much it can rain at one time.

The curbs were useless. The little creek nearby was level with the sidewalk. No matter how acrobatically I tried to avoid the river flowing past my car, I knew I would still got a shoe full of precipitation.

All this when I'd like to make a good first impression by not walking in drenched and frizzled by heavenly moisture. So, on this day I was not so overawed by the grace of rain.

Whatever. I got in the car without dignity, my big poofy, soaking coat bunched awkwardly on the wet seat. I am so glad I have a truck! I drove through a small river as I got onto the main road. After I reached the highway, everything was very safe and I made my way to the hospital. In the lobby, I ran into another medical student: she was (as she always is) beautifully put together, with her white coat safely stored in a dry clean bag. Inwardly rolling my eyes at myself, I took off my ridiculous coat and rejoiced that my copy of Differential Diagnosis of Common Complaints seemed unhurt. In fact, I seemed generally presentable: my white coat (although not transported via hanger and bag) was dry and clean, and my skirt looked like a skirt, not the mop that I feared.

It was very easy to find the practice, and once I was inside a nurse led me back to Dr. H's office. The space about the same size as Dr. F's and was also crowded with paperwork and evidence of a busy life, but what a difference in first impression! This one was tastefully furnished with a large dark L-desk and credenza. The chairs matched and were handsomely upholstered. A green marble and gold desk pen set took center stage. The doctor himself was a rotund, older gentleman in a pristine and pressed white coat. Were it not for the laptop, desktop, and Keurig, I would have thought I'd been transported to the 1950s.

Dr. H was very busy that day and (because he was a good preceptor), so was I. It was a great day in the life of a soon-to-be-third-year! I saw six patients and felt confident to ask questions and examine them, plus form a differential diagnosis. The learning curve was extremely steep and fun to ride. And I think I actually made a difference, even if very small.

I became very glad that I was just getting over a wretched cough. Apparently, the same thing is going around, so I was able to ask the right questions because I'd just had all the symptoms. And St. Joseph of Cupertino must have been interceding for me, because all the patients had things I knew about, like rheumatoid arthritis. I'm sure that won't always happen, but I was glad it happened on this first day of a new preceptorship.

Going from room to room, talking with people, asking the right questions, examining them, and taking notes is so awesome. I love it. And having someone (like Dr. H) place their confidence in you is a really big help toward having confidence yourself. I felt like a junior colleague, instead of like a student. I was late leaving, but I couldn't imagine a better afternoon. It makes me really look forward to third year!

I guess it was raining graces.

Sneaking Catholic teaching into Humanities paper...

The prompt was "Comment on the appropriateness of transplanting organs into a patient whose diagnosis has historically been associated with a poor prognosis."

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Transplant ethics (especially concerning patients who may not live long after their transplant) are complicated by benefits and burdens that are difficult to weigh, and the confusion surrounding scarce resources.

A patient considering a transplant should, with his loved ones and his healthcare team, try to determine the potential benefits gained and burdens incurred with the procedure and life after it. Would a several-hour surgery, the associated recovery, and a strict regimen of drugs and behavior modifications overwhelm him? If not, does the procedure treat the disease or alleviate suffering to a degree worthy of these burdens?

Assessing how much the patient will benefit from the transplant includes estimating his prognosis with and without the transplant. Additional years of survival are likely worth a few months of intense suffering and rehabilitation; an additional few months may not be. Patients who have comorbid conditions, who are likely to be noncompliant with post-transplant medication regimens and behaviors, or who are very likely to die shortly in spite of a transplant make decision-making more difficult because the benefits after the procedure are quantitatively smaller, but hard to qualify. Is a moment alive greater than a year alive?

Transplants are also complicated by scare resources: only so many organs are available for the number of patients waiting for relief. Should one person receive a liver before another? Should the youngest on the list be preferred? The healthiest? The sickest? The ones in greatest need?

Finally, decisions must be carefully made on an individual basis. A patient with desires to reconcile with members of his family may value even a few weeks of extra time in life, but a patient who is satisfied with her life may be willing to choose palliative care. Considering a group of patients, a transplant center may prioritize a healthy child, but may move up a man recently placed the ICU if he has a good chance of recovery. This individual approach should always be motivated by the proper goal of medicine: not to blindly prolong life, but to improve it so that in it, persons can achieve their purpose and maintain their dignity.

This goal has its source in a truth that this culture has largely forgotten: the purpose of life is not life itself, but beyond it. It is that highest happiness which, if pursued, makes us clutch life less and look toward virtue and self-sacrifice more.

I am having trouble blogging.

Amazing things happen, but I am having trouble tell you about them.

I walk into rooms where strangers are waiting, which is a feat for me. Not a miracle, just a feat, like a diver diving: she does it frequently, but to do it well takes focus on technique in the beginning, and every time takes a leap.

The strangers tell me about problems they have, which astonishes me. I know I am becoming a doctor so that people can do just that, but I am still occasionally astonished along this protracted transition that I could ever be the receiver of so many personal things.

The list of amazing things goes on and on, and I won't have a paragraph for each one of them because that would tire out the parallelism, the author, and the reader. But I ask questions and examine people's bodies. I connect with some people, not with others. I figure out some problems, I hugely miss others. I watch people leave with feeling lighter, or more frustrated, or very heavy. And (right now at least) I watch the person's doctor as a third person and see how they tick: their choices, their omissions, their wisdom.

And I'm having trouble writing all these things down. They're too delicate and too powerful for written prose meant for the internet. A kingfisher can't dive through a train tunnel.

These stories can come out in speech to people close by, like my roommates. And maybe poetry or song would help (I don't know and neither will you, because all I am only a chorus voice who follows poetry haltingly.)

I'll keep trying, because I have seen beauty that would shake the earth. Bear with me while I try.

Fascinating Professionalism Class: We Learned Stuff

So, the other day I had my first EXCELLENT professionalism class. We were told to wear professional dress and come to the Simulation Center. (And that was all we were told.)

I'd heard about this professionalism class from an older student last year. She told me that they put you in ethically sticky situations and see how you perform. I shouldn't say any more specifically, since not all of my classmates have had this session and we're supposed to keep the standardized patient cases secret. That would be like giving away the beginning of a speed chess problem before the tournament. 1) Against the rules, 2) Especially in professionalism class, and 3) Lame anyway.

So although I can't tell you about the chess game, I can tell you about the human-human interaction between the players. This interaction is especially interesting in a standardized patient setting, because one player is an actor, and the other is being tested. To begin the test, we are walked from a waiting room to a hallway of exam rooms, which look (on the inside) just like a room in any real doctor's office. We are placed in front of preassigned numbered rooms. On each door is an introduction of the situation, e.g. "Mrs. Spazz is the patient of a physician who recently left your practice; she is a new patient of yours today. You have a very busy clinic day today and only have ten minutes to see her. Her previous medical records indicate [some ethical issue that sends cold sweat shooting out of every pore, or just makes you moan and say 'gaww, you're kidding, I have no clue what to do with this.']."

To my right and to my left down the hall of doors stand other medical students like me, reading about other sticky or apparently-not-sticky situations. Then, a voice announces over the intercom: "Students, you may enter the rooms to begin your encounter." A chorus of polite doctor-tapping on the doors is succeeded by the clacking of ten door latches and the faint cheery "Hello, I'm..." before the other students disappear from me and I am entirely wrapped up with the patient-actor in front of me. They are extremely ordinary people, who are chosen to match their pretend situation ("script").

During each of yesterday's sessions (and I saw four "patients") was videoed by two cameras and was at times watched in real time by the lawyer who teaches the class. Each standardized patient fills out a form after I finish with them, and I can watch the video footage later.

I love these sessions, because I get to act like a doctor. I love acting, and I love (or think I love?) being a doctor, so it's an awesome combination. And the standardized patients are so good! One guy seemed so stressed out that I passed him the tissue box after bumblingly following the instructions on the door (then the illusion sort of ended as he pretended to have to blow his nose). Another person seemed so truly fragile that I hesitated to complete my ethical duty. (I did, just...not very gracefully.)

There's a definite sense that the Sim Center is a game, though. I knew certainly in at least two of the four settings that I had a goal and if I obtained it, I would "win." I knew that I needed to leave the room with Thing X done, and if I did that, the encounter was a success.

I've had this feeling occasionally in preceptorship. Like "Achievement unlocked: Rapport with Patient," or "Achievement unlocked: Held Uterine Manipulator." But although natural to being in a student's role and growing up, learning, and living on a constantly-changing permissions (one day you can't scrub in, the next day you can), it's finally an immature attitude. An adult would work with patients and not count successes in terms of thrilling achievements or personally exciting lists. (Given: an adult can have milestones and recognize when something important happens in an encounter or a career.) I hope that my success in medicine and life does not depend on a little shelf of invisible trophies.

Rather, I hope it depends on being made like Christ and becoming love for others. Even in my workplace, I hope "success" is "love." Otherwise, what an unsatisfying life, never complete! Even now (after a lifetime of school) I'm already realizing that living in expectation of the next prize is a completely stupid way to live. I want to be full all the time, not at some unspecified future time that might never come.

All that heady thinking aside, though, it was wonderful to anticipate a life of working with people all day--going from room to room and touching lives. I can't wait to be a doctor!

Med school strategies to learn the faith (A Summary of Dei Verbum)

It is the Year of Faith, so I'm giving some time to studying the documents of Vatican II. (Laudate makes this really easy.) I just finished Dei Verbum, which reiterates the Church's teaching on God's revelation. Because storing information for application is not the same as reading information, I applied my medical school strategies to Dei Verbum so that I could use and remember the teaching, not just read it and check it off a list. To learn things in medical school, I summarize important points and go over them again and again, then do some practice questions. I didn't write any practice questions for Dei Verbum, but I did summarize.  So, if you don't have time to read Dei Verbum:

1. Read this.
2. Realize that Dei Verbum is so awesome and short that you should probably just read it now.
3. Read the rest of the council documents.

My favorite parts are bolded.

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Purpose of the document: following Traidition, to teach on revelation and how revelation is handed on in order to promote its spread and increase the theological virtues of the whole world.

Chapter 1 defines revelation. It is the act of the supreme and hidden Trinity to share with us Himself. This act is realized in human fashion: in history. God prepared us for the fullness of revelation from Eden through the entire Old Testament, and perfected revelation in Christ, who made clear by His every word and action that "God is with us to free us from...sin and death, and to raise us up to life eternal." There is no new public revelation forthcoming. Revelation includes truths that trancend human deduction as well as truths that  reason can attain alone but with difficulty. Our response to this revelation is total, free submission, an act of faith which requires God's grace. Turning thus to God is a lifelong conversion, deepened constantly by the Holy Spirit.

Chapter 2 explains how revelation is passed on. From Christ's first charge of "preach to all men" to the Apostles, revelation has remained in its full integrity in sacred Tradition and sacred Scripture. both of these are from the same act of God and tend toward the same end. Tradition comes from the observances handed down to the Apostles from Christ and the Holy Spirit, passed thorugh their successors; Scripture is the message of Salvation committed to writing under the same Spirit. Scripture supports Tradition (see 2 Thess 2:25, Jude 1:3) and vis a versa. The two form a single "sacred deposit" which the Church treasures, contemplates, and serves: treasures by keeping its precpts and spreading its message; contemplates by continually growing in understanding its contents; and serves by exercise of the teaching office, which exclusively authentically interprents the Word of God. This last guards revelation scrupulously, listens to it devoutly, and explains it, faithful to the inspiritations of the Holy Spirit.

Chapter 3 epxlains the itnerpretation of Scripture. The Old and New Testaments have God as their author and teach without error His revelation. God composed sacred Scripture by choosing men who made use of their powers and, as true authors, wrote in human fashion with literary forms of their time, writing only what God intended. To rightly receive Scripture, its Truth must be searched out. This Truth coheres internally and with Tradition, but is variously expressed in texts of different times and styles. All exegesis is subject to the Church, which guards the word of God, "for the words of God, expressed in human language, have been made like human discourse, just as the word of the eternal Father...was in every way made like men."

Chapter 4 states the puprose of the Old Testament. It tells of God's works "to prepare for the coming of Christ, the redeemer of all and of the messianic kingdom, to announce this coming by prophecy and to indicate its meaning by various types." The New is hidden in the Old and the Old is made manifest in the New.

Chapter 5 states that the New Testament "stand[s] as a perpetual and divine witness" to the Word of God, who was made flesh to manifest God and draw all men to Himself. The fourfold gospel, a selection of the acts of Jesus, is of apostolic origin and faithfully hands on what He did and taught for our salvation. The other contents of the New Testament confirm and more fully state the true teaching of Christ (an example of the Church's mission outlined in Chapter 2), begin the history of the Church, and foretell her fulfillment.

Chapter 6 describes the place of Scripture in the Church. It is to be venerated, and maintained with Tradition the supreme rule of faith. It nourishes and regulates the Church (Acts 20:32, see 1 Thess 2:13), and since it is an encounter with her Bridegroom, she is eager to delve deeper into it. She recommends it as the foundation of all theology and preaching, and encourages all (especially theologians, clergy, and consecrated persons) to study it following "the mind of the Church." It should be made available to all (including non-believers and separated brethren) in various languages in order to spread the Word of God. Finally, all study should be accompanied with prayer, "so that God and man may talk together" and "we may hope for a new stimulus for the life of the Spirit from a growing reverence for the Word of God, which 'lasts forever.' (Is 40:8, see 1 Pt 1:23-25)"

Computer Coded.

 So, I've been trying to eke out a few more months on this laptop that I bought during college. I'm trying to get five years out of it. And it was laughably slow and old fashioned, but I was determined. And I can put up with slow! All was going swimmingly until a few days ago.

Every session was between eight and 14 minutes long and ended either in the blue screen of death or in a freeze. I tried several strategies:

1. Ignore the problem. (This didn't work very well, since I couldnt' answer more than two Qbank questions in a row.)
2. Live without a computer. (This only worked for a few minutes as a castle in the air.)
3. Live in safe mode. (But Safe Mode doesn't have internet.)
4. Live in save mode with networking. (But then I can't open my Qbank!)
5. Uninstall some unused programs and see if that works. (Nope.)
6. Try to install windows updates. (Compy couldn't stay on for long enough.)
7. Run Defender and AVG virus scans. (See above problem.)
8. Choose a restore point and put the computer back to normal! (Then I discovered that there were zero restore points. That's never supposed to happen and I've never seen it before.)
9. Reinstall Vista.

Thank goodness I kept those reinstallation CDs!I resucitated compy late last night and it woke up with the problem gone. But at a price: it was as if it woke up after being in the ICU for a long time.

It was keeping time as though we were still in California where I bought it. It was installing software and sometimes noting the installation date as 2013, but sometimes 2008. And today it had to install four years worth of windows updates (which was a surprisingly modest 93). A very eery experience.

The plusses are manifold, however: I still have all my files (thanks to an external hard drive), the BSODs are gone, the computer might be a teensy bit faster than it was before, and I got to rename it. It used to be called "Secretary," since I was optimistic in college about having an efficient and helpful machine to minimize all my paperwork. This time around I called it "Belfry," being disillusioned and aware that this machine is absolutely batty.

(Make your own error message.)

Third year is coming!

Third year consists of six rotations:

1. Internal Medicine (a.k.a. IMED)
2. Surgery
3. OB/GYN, which is always coupled with...
4. Pediatrics (a.k.a. Peds)
5. Family Medicine, which is always coupled with...
6. Psychiatry (a.k.a. Psych)

They can be taken in 32 different orders, and today I ranked my preferences for which orders I most prefer. The order I finally get is chosen by lottery at the end of this month.

Our dean of student affairs told us that there's not really a difference in the orders, as far as impressing attendings goes. He said to choose an order based on significant events or personal preference (i.e. weddings, desires to get surgery over with, or wishes to do something easy first).

But I know that there is one variable at the teaching hospital that doesn't exist at the university campus: residents. Residents, who need to delivery so many babies per year. Residents, who are worried about their numbers early in the fall, but who worry less during winter and spring. Residents, who go on Christmas vacation.

So, I preffered orders (which are for some reason called "streams") that placed OB/GYN during or immediately after the Christmas/New Year's season, so that I can do a lot. And that is all I can do. As I finished, I thought how glad I was that God would finally choose the best one. It is in His hands now. I'm so excited to see what He will do!

I absolutely don't have a future in film.

I will now attempt to post about everything that I did over the winter break. 

1. I studied for STEP industriously and daily...for two days;
2. I celebrated Christmas;
3. I spent time with my family;
4. I beat Portal 2, one of the most engaging gifts of Christmas;
5. I filmed a movie; and
6. while in the middle of #5, I got sicker than I've been in years.

STEP studying showed me that I definitely needed to study a lot more. However, the filming was extremely demanding and family was also very absorbing, so I let it slip off the list of things to do. 

Every once in a while I get this idea that I can make an awesome movie. It happened in high school a lot: to win a scholarship (I made a lousy don't-drink-and-drive commerical...need I say I didn't win?), to catalog my entire senior year in a movie (which didn't get off the group because of senioritis), to make a documentary about physics in European history (which was short and in fake British accents and so was tolerable and even funny), to make a project about some Catholic moral teaching (NFP? I can't even remember but because this is me we're talking about I assume it was NFP), etc. In college, there were many brainchildren (the most notable being a music video of the Killers' Spaceman featuring Descartes and Aristotle), but no footage.

In med school, I got this idea to make a movie. I contacted a college friend with filmmaking experience and possible professional hopes in that area. Here's the conversation we had:

Me: I am thinking of [describes the film in a long paragraph from which I will spare you]. So, you're the filmmaker: is this doable? 

Friend: What you are describing sounds good, but would require a large amount of resources, both monetary and otherwise. I like the idea, however.

And thus I was foiled in foisting the project onto someone else. Well, then my choleric temperament and I decided to do it, even though I had neither large amounts of resources (monetary or otherwise), nor  filmmaking experience, nor or professional hopes in that area.

It was a roller coaster ride. We shall see whether it even comes to fruition! Meanwhile, please pass a cough drop and the orange tea, and let's study for STEP.