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.

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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.

Don't Rock the Boat! Homosexuality and Gender Identity, Medically Speaking

Caution while challenging the freedom of gender identity! You get called in with three attendings and they have a very polite discussion to make sure you toe the party line.

After our lecture on psychosexual disorders during the psychiatry clerkship, the faculty physician asked whether there were any questions. She is a prim older woman, an excellent and compassionate clinician that I had the privilege of shadowing for a week.

I piped up, because she had just talked about gender identity disorder. "I know homosexuality isn't in the DSM-IV," I said, "but I'm confused about the stage a gay or lesbian person is in right before they come out, when they're uncomfortable in the societal role they're in. Isn't that GID? What I mean is, why is GID a disorder and not homosexuality?"

Oops. I didn't mean to finish that way. I wasn't trying to evangelize or start anyone's wheels turning. Seriously. I just wanted to know how this was consistent. (It turns out there is an answer and I understand that this is sort of consistent now. More on that below.)

Well, the prim psychiatrist asked my peers whether they could answer, and they could. After I had been given an answer, the professor said we could take a break until the next lecture. I stood to get a glass of water as my peers also stood to stretch or get a snack. But I was stopped before I got my drink by the lecturer, who said, "why don't we go ask Drs. J and K about your question?" I obliged, and followed her to another room, where two other psychiatry faculty were lunching and talking.

The lecturer and I sat down, completing the four points of a square. "I will share with you," she said to her colleagues, "a question [mmatins] brought up about gender identity disorder." They mused. They gave the same answer my peers had.

Somehow I got the impression I was being given a talking-to. I was suddenly acutely conscious of my conservative dress and crucifix. Perhaps it was the arrangement of the room, or the abruptness and apparent formality of the meeting, or the fact that they gave the same answer my peers had, or the fact that I was alone with three faculty members, all of whom (I am reasonably confident) disagree with me about whether homosexuality is a disorder.

Anyway, nothing happened and everything was pleasant. I and the professor giving the next lecture left the room. Just an interesting experience....

So, FYI, GID is something described in younger patients (i.e. children under twelve) who are uncomfortable with their gender and its non-sexual dimensions such as dress, play, and future societal role. Homosexuality is described in patients who are sexually attracted to members of their sex. They can identify as masculine or feminine, a unique combination of both, a fluid (throughout life) combination of both, or neither but the defining characteristic of homosexuality is sexual attraction to members of the same sex. GID patients are uncomfortable in their bodily gender; homosexual patients are sexually attracted to the same sex.

It's not impossible that a person with GID be later attracted sexually to persons of their same original biological sex, nor is it impossible that a homosexual person have some discomfort with all the accoutrements of their biological sex. But these persons may carry two diagnoses. I still do not understand why "trans" adults cannot be diagnosed with GID. My attending raised this question but I didn't press it.

So, the moral of the story: pray for children with GID whose parents may be tempted to permit the children to undergo sex-change surgery. Pray for "trans" adults with undiagnosed (not-medically-real-according-to-DSM5) GID who are doing the same thing. Pray for LGBQ adults, who are attracted to members of the opposite sex. And be careful as we (prayerfully and charitably) rock the boat.

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AS ALWAYS THIS BLOG IS NOT TO REPLACE THE CARE AND DIAGNOSIS OF TRAINED PROFESSIONALS.

A day in the life of Family Medicine

Whew! Family Medicine is over and I am now 12 weeks into third year. I am so tired! This post is not unified or well written; it's a journal entry and nothing more. My advise: skim or skip.

Most of the mornings started at 8:00am in Family Med. I would go to 6:30 am Mass and then drive to a suburban hospital where there was a family practice group and a family practice residency program. I spent two weeks in the group and two weeks with the residents. A week of lectures and one week with the residents on their inpatient medicine service rounded out the clerkship.

I would eat breakfast in my car, parked in the church parking lot. Sometimes, I would see my mom as she arrived for work at 7:30 (she works at the primary school associated with our parish). I arrived at work at 7:45 and started clinic at 8:00.

I liked working in the residency clinic more than the group practice because it was more education-driven. I was also more like my preceptors: in the group, I worked with a doc who'd been practicing for ten years before I was born. He was so experienced (and maybe a little sloppy) that he hardly collected any history before announcing a diagnosis. He also typed with two fingers, and so was really slow with the EHR. I pitied him--even though I had about twenty minutes of training, I picked up at least as much as he had in the few weeks I was with him!

I was closer to the residents' age and experience level and, although I always treated them with the respect their degree and position commanded, I felt more comfortable imagining myself in their shoes. "Family medicine wouldn't be so bad," I thought, when I worked with them. (When I worked with the older doc, I thought, "this definitely isn't for me.... Advising all these old people to take mustard when they have a cramp even if they have stage III CKD and typing notes until 12:00am...no thanks.")

Morning clinic would wrap up around 12:30 or 1:00, and clinic would resume at 1:30 or 2:00.

During the day I would see between five and ten patients: I would read their chart a little before tapping on the door and introducing myself. I'd ask them what they came in for and question them about their health or problems, and then I'd decide how to examine them and perform the exam. I documented my findings in the EHR and excused myself to "present" the person to my preceptor.

"Mr. So-and-so is a such-and-such-year-old white male with a history of hypertension and diabetes who comes in today complaining of a four-day history of tingling in his feet," I might say. I would describe the pain (or the cough, or the relevant details of his chronic disease) and then the pertinent positives and negatives, before describing my physical exam. "His heart has regular rate and rhythym without murmurs, gallops, or rubs, and his lungs are clear to auscultation bilaterally." Then I was supposed to say my assessment and plan, but frequently I didn't have to do this.

(Parenthetically, it's funny to write all that out, because all that text would become "Pt is a XXyo WM with 4d h/o tingling in bilateral feet....Heart: RRR s MGR, Lungs: CTAB" in the EHR)

The preceptor would ask me questions to which I usually didn't know the answers ("Does he have a family history of heart disease?" "What do you make of his elevated LFTs?"), and we would go see the patient again together. I liked seeing patients myself, making plans for them, and educating them. I really disliked presentations and not knowing enough.

I usually stayed past 5:00pm and got home tired and hungry. My family eats when my dad comes home, which is variable...so that caused some friction until mom told me I should just eat when I get home so that I can go and study. I would get to bed at 10:00 or shortly thereafter following night prayer. Usually, no recreation unless I stole some time to talk with my family, ride bikes, blog, or read.

I enjoyed working the inpatient week because I again got to see patients myself, examine them, and write notes in their charts with my own baby assessment and plan. However, this week I wasn't able to attend Mass, and so I asked our parish priest to give me the Blessed Sacrament before Mass began so that I could go to work early for shift change and rounding.

I was constantly readjusting and struggling to fit in all the things I thought I needed to do: morning and evening prayer, midday prayer, meditation, Mass, formation, work, and family took so much time that studying was almost eclipsed! I saw the result on my NBME, sadly. I would study on Saturdays and on occasionaly weeknights, but it never seemed to be enough. I always felt behind! Family Med contains so many subjects (acute and chronic diseases of every organ system in all ages and both genders! Mwaha!) that I was only confident in about a dozen by the end of the clerkship.

Where is God's will for this time in my life? I feel like I'm working two full-time lives: a medical student who needs to work and study, and a consecrated virgin in formation, who needs to study (different things!) and pray. And both are suffering because of the other! I work but I am tired because I don't get enough sleep and exercise; I study, but only a little bit, so that my work suffers; I study the Catechism (but am ten days behind) and listen to my Faith Foundations lectures (but they go in one ear and out the other b/c I listen to them in the car) and go to formation (where I am so tired they have been letting me go early); and I pray, but am so distracted and tired that I don't perceive God's presence. What needs to change???

My expectations, perhaps? Please pray for me, so that I can see God's will. I finally have a spiritual director here, and hopefully we will meet soon to talk about all this.

On to pediatrics!

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.

My Plans for the Future

For a long time, I've thought about where the best use of my God-given skills and education lies. How can I provide the best care to women, the best example to my peers, and the best remedy to our culture?

I want to be a doctor to the whole person and that includes maintaining education in primary care areas as well as in OB and gynecology. I also think having an in-house NFP teacher, in-house dietician, and in-house psychologist (IPS, anyone?) would be excellent. A multispecialty group practice appeals to me, so that whatever practice I have can be a patient-centered medical home.

Of course, part of the future is offering women's healthcare in accord with Catholic teaching, which is to say to offer the best women's healthcare. Perhaps I would imitate Mystical Rose or Caritas Complete Women's Care or the Vitae Clinic with my own private practice. Maybe I would imitate Tepeyac Family Center/Divine Mercy Care and become an ACO.

St. Guiseppe Moscati, doctor to the poor
(well, the very romanticized movie version)

Also, I see many groups of women who are frequently forgotten: the uninsured, the illegal immigrants and refugees, religious, the abused, former prostitutes and drug addicts, the incarcerated, and the difficult. I want to find and care for these women, even though I might have trouble keeping the lights on!

Becoming a subspecialist in a maternal-fetal-medicine (MFM) also appeals to me. As an MFM, I could operates on the unborn, work with infertile couples, and take care of very high-risk pregnancies, also appeals to me. I have this dream of showing people how human the unborn are, how like us and how worthy of attention they are. What if we could re-implant babies who implanted in the wrong place? What if we could treat things like Potter's syndrome? (What if we could pull out all the "medical reasons" for abortion?) There are other advantages to this idea, too: my refusal to prescribe contraceptives and refer for abortions might irk fewer colleages if I was in MFM and had fewer occasions to do these things.

♪  MFM  ♪

But as much as I like the MFM dream, a subspecialty (long fellowships, expensive services) take me a little away from the poor. So I always thought I would have to choose: to serve the poor in those impoverished or those unborn. But what if these didn't conflict?

If I started a women's healthcare center and used midlevel professionals (NPs and PAs) and allied health (nurses, MAs, psychologists, social work, and dieticians) to establish a large group of primary care and OB/GYN providers for women, we could serve the poor and offer cutting-edge infertility and prenatal service with excellent gynecology. That's the future I'm working for now. (Now, if you'll excuse me, I need to go study for a shelf exam so that people don't laugh in my face when I say I want to do a surgical subspecialty.)

Fatigue!

In the past five or six weeks I was dragging. It was hard to stay focused, hard to love others, and hard to do all my duties with attention and comfort. I felt sleepy during the day and everything took more energy. I was thinking, "I'm just in desolation," or "I don't really have what it takes to love others," and "maybe I can't be a physician...I just don't have it in me...." Finally, when two wise people (my biological and spiritual mothers) independently told me to go a doctor, I did. I was in sleep debt and had a microcytic (probably iron-deficient) anemia and had lost eight pounds. I really dropped the ball on taking care of myself!

Have you read Jen Fulwiler's post about struggling against circumstances? She says everything I want to say about this, and much more (about motherhood, etc).

I'm doing much better now, partially due to the relief that some of my sluggishness was physical (nobody's forgotten that a bunch of it is still spiritual...I still have a hard time loving people even when I'm brimming with energy and consolation). And now I'm getting more sleep and food and iron. Thanks be to God for bodily helps to holiness!