The Things I Never Wanted to Do

I mentioned that I rarely discussed my choices about contraception, abortion, and sterilization during medical school. I never told my OB/GYN clerkship director, attendings, or residents anything. I think that made it easier to make friends, but it got me into trouble at least twice. I'm telling these stories for future Catholic med students, even those who aren't becoming OB/GYNs. With more forethought than I had, you can save yourself from some dangerous situations.

Cesarean Tubal Ligation

A babcock. Notice that it is made to hold a
tubular organ without crushing the tissue.

On my L&D rotation, I scrubbed in on any C-section that happened. The first time that a woman had chosen to have a bilateral tubal ligation (BTL) after the birth of her baby, I did nothing and nothing happened. The second time, the attending held out the handle of a babcock clamp, which encircles the tube, and told me to hold it. Reflexively, I did; after all, as a med student, you hold any retractor you're told to and wish you had reached for it automatically before you needed to be told. The babcock does not have anything to do with the actual tying of the tubes, but I was definitely participating in a sterilization.

Miserable, I held the babcock in space, wondering what I should do. Should I speak up? I didn't feel empowered and didn't want to be disliked. Was this remote and unwilling enough for me to be quiet and save face? Would speaking up be making a selfish scene? Remember, the patient is awake for a cesarean section; it's sort of too late to discuss ethics, especially when this patient has chosen to do the objectionable thing. But this is grave matter! And I know it to be grave matter! And I am doing it anyway!!

The babcock is at 2 o'clock in this picture.
The other two things are strings being
tied around the tube. The strings are clipped
and the tube between them is removed.

CCC 1857: For a sin  to be mortal, three conditions must together be met: "Mortal sin is sin whose object is grave matter and which is also committed with full knowledge and deliberate consent."

It was over before my analysis was over. So I said nothing. I still didn't cut the sutures. I went to confession before receiving communion. The conclusion of the priest was that this was remote and not "deliberate consent" enough to constitute mortal sin, but I was very, very determined not to let this happen again. It was careless not to say anything to the attending. I did better in the past, when I spoke up discreetly before a mirena insertion. But this wasn't the worst thing that happened.

Birth Control on an Away Rotation

Fourth-year med students occasionally spend weeks at a time at other med schools or residency programs. These "aways" are often done to make a positive impression on the residency program there and are called "auditions" in that case.

I was doing an audition rotation at a school and got waaay too close to prescribing contraceptives. I didn't realize that the clinic would be so pro-birth control, but I found more than 75% of the patients taking some form of hormonal birth control, and a strong culture supporting "safe sex" with 100% condom usage. I was at a loss.

I was on a month-long rotation trying to get people to like me. Med students are always sent into the room first; if I go in first and share all my contraception-why-not knowledge and then the attending goes in, the patient will ask one of two things: "So, is that med student just crazy?" or "Have you been lying to me, doc?" Worse, the patient will decide not to use contraceptives (yay), the attending will ask why (uh-oh), and the patient will explain that "the med student said...," and the attending will (annoyed) have to re-explain all the falsehoods and (red alert) rebuke the med student.

(Nexplanon)

You might argue that this course of action might have been good: it might have created a chance for me to bravely say, "Well, Dr. X, I was actually reading a paper that says (insert pro-family stuff here)...." But I expect those things would fall on deaf ears of the highly experienced, academic, and culturally blinded physicians I was working with. Worse still, I would have confused patients, possibly discredited the arguments against contraception, and possibly eroded their relationship with their physician.

So I clammed up and tried to say true things and not recommend contraception. I tried not to be excited when people were sexually active and using condoms and birth control. I tried to encourage people to think about whether they wanted to be pregnant and let that inform their decision to have sex. I was about the only one in the clinic to continuously tell teens that the most effective way to avoid pregnancy was to avoid sex. 

But I began to echo my attendings' speeches and advice about birth control as I counseled women about "the options," which was a requirement.  I was at fault for not knowing enough numbers to give to patients myself, though. I seemed to morph into someone who was pro-birth control: it decreases the risk of ovarian cancer and uterine cancer, I'd say, and the only side effect is possible irregular periods. When people asked me about future fertility, I said that "our professional organization [ACOG] instructs us that future fertility is not affected." (That was the most painful thing.) Working twelve-hour days in this place for four weeks wore down my defenses.

The ultimate result was the day I was almost running the adolescent medicine clinic and writing notes and plans (only missing the formality of writing the script and signing it) that included birth control of all flavors. After that, I found myself crying in a confessional again. This time, although the priest never said "that was a mortal sin," he did extract a firm purpose of amendment and my intention to say the penance. And he did tell me that I, like pharmacists, lawyers, and some others, stand in danger of losing my soul in my profession. It sounds harsh, but as I knelt in the confessional I felt and knew that he was very, terrifyingly correct.

So, Catholic medical student: discreetly inform your intern/upper-level/attending/preceptor/whoever. If it's too late, you are allowed to say something like, "Oh, I prefer to just observe; I'm happy to explain afterwards." And if you get into a sticky long- but short-term situation like my away, you need to do a little research (I'm hoping to put something up here with quick facts on contraceptives, etc) and be unafraid. Don't break up doctor-patient relationships, but do offer an alternative. I'll share a positive story in the a next post (because I have one).

How to Discern whether You should Become a Doctor

Our healthcare system is changing. If you know a young student thinking about medical careers, help them make an informed decision about what type of medical professional they should become.

Child life specialist.

First of all, think outside the box: not all medical careers have to be preceded by getting MDs, DOs, PAs, or RNs. If you like the operating room, consider becoming an OR tech. If you love children, think about becoming a child life specialist. If you like the intensity of the ICU or EMS, try respiratory therapy or becoming an EMT. If you love helping people and have another special talent, think about music therapy, speech therapy, pet therapy, or occupational therapy. If you love sports or movement, try physical therapy or massage therapy. If you want to work with the elderly, consider LVN and hospice or nursing home work. If you like chemistry, think about becoming a med tech, a lab tech, pharm tech, or getting a PharmD. And if you like ambulatory medical care that is flexible enough for a family, consider dentistry or dental hygiene. Phlebotomy (including dialysis and donor), medical assisting, billing, hospital or practice administration...there are many medical careers that require various gifts. At the beginning of your thought process, use your imagination to try on a wide variety of careers and ask people in those careers what else they thought about.

Now, let's talk about MDs, DOs, PAs, and RNs. A person with one of these degrees can choose from a wide variety of practices at the completion of their degree. For instance, MDs and DOs ("doctors" or "physicians") can become primary care doctors (for children, adults, or both), specialists (in a particular time of life, like geriatricians or obstetricians; or for a particular organ system, like cardiologists and endocrinologists; or for a particular disease, like oncologists). PAs ("physician assistants") can do almost anything doctors do, from surgery to private practice. RNs ("nurses") work in all kinds of settings as well, especially inpatient settings like nursing homes, adult/pediatric/obstetric hospitals, surgical settings, ICUs, PACUs, NICUs.... Some RNs work call centers, which is a good option for those who want to work from home and have a family. RNs can also become nurse practitioners (NPs), which enables them to take on the responsibilities of a clinician.

Let's clarify the word "clinician." A clinician is a person who physically examines patients, diagnoses their conditions, and prescribes a treatment plan. Unlike a technician who may perform specific tests (like measuring blood pressure, taking an X-ray, measuring an ABI, or performing an ultrasound), a clinician is responsible for combining the results of tests with findings from his physical exam to create a plan of care and manage that plan. Doctors, PAs, and NPs can all do this. PAs and NPs (sometimes called "mid-levels") require a physician's supervision, but this is very loose when the relationship is established and the mid-level's experience is solid.

Our healthcare system is changing, and the rise of mid-levels is a sign of this change. A mid-level can do now what a doctor did in the early last century; a doctor now has a different set of unique privileges. So why become a physician when you can examine, diagnose, prescribe, and manage patients as a PA or NP? What's unique about becoming a physician?

A physician (MD or DO) is, in addition to being a clinician, a supervisor of clinicians. In addition, he can be an entrepreneur (e.g. starting a practice, group, clinic, or even hospital) with greater ease and independence than a mid-level or other healthcare worker. Moreover, he can be an innovator: his depth of education (somewhere between the mid-level and a Ph.D. in several subjects) allows him to design new therapies for patients and legally try them. Finally, he can subspecialize or superspecialize: as an example, I could become an OB/GYN and then do a fellowship in maternal-fetal medicine or a fellowship in naprotechnology. If I start a clinic I can employ other physicians or mid-levels who practice general OB or general GYN, while I care for high-risk women or complicated surgical cases. In conclusion: in our day and age, the MD or DO is the highest degree in medical careers enables a person to be a supervisor, entrepreneur, innovator, and subspecialist. If you don't want to be one or more of these things, I suggest going mid-level: you'll still have your patients, you'll still diagnose and manage, but you won't have as many years of school, nor as much debt and liability!

I hope this is a helpful tool for anyone considering a medical career. I see that some of my classmates have the wrong reasons for becoming a physician, and others are fatigued by the amount of school. I don't want this to happen to you (or the person you think could read this and find it helpful), so I encourage you to think and pray about this carefully. Finally, thank you for considering a medical career: it's a corporal work of mercy and an extremely fulfilling path. Whatever you choose to do, I hope you enjoy it!

Summer Slowness

I'm officially done with the first year of medical school! Since I last posted, I passed a shelf exam, have moved (which took two days of moving heavy stuff down two flights of stairs and then up a different two flights of stairs) and am relaxing. During these days without classes, I have no internet in my apartment (frugality during the summer) and will post sporadically.

Although I don't have classes, I am not idle. I'm applying for the Pope Paul VI Institute Medical Consultant Program, which is usually offered to physicians and (at the earliest) fourth-year med students. Pray that, if it be God's will, I be accepted! I am also reading Pope Benedict XVI's first two encyclicals, Deus Caritas Est and Spes  Salvi, as well as St. Bonaventure's biography of St. Francis. Also on my reading list for these days without big commitments are Theology of the Body (Waldstein edition) and the last few pages of Introduction to the Devout Life. If I'm very good and finish everything that I have bookmarks in, I will move on to some St. Theresa of Avila.

Yesterday I teleconferenced with Kristan Hawkins and the president of my medical school's Medical Ethics club, which (unlike MedSFL) has funding from the Humanities Dept. We spoke about next year's activities, and it was very exciting!

I also created a folder of practice tests for incoming M1s. I hope to help everyone with pre-test anxiety and self-esteem. If you are a rising M1 or pre-medical student and would like a copy of this folder, email me. I have submitted my acceptance of the assistant-teaching offer in anatomy.

Also, I'm meeting with the assistant dean for student affairs this Friday to ask about residencies friendly to explicitly pro-life OB/Gyns. It's time to start hunting.... The same day, I am meeting with a second faculty member to share my experience at TAC; he was intrigued to hear that TAC holds classes in seminar style. Since the trend in medical education is towards PBL and our school is no different, I have been asked to share TAC's style. Please pray (to St. Thomas Aquinas) for the success of this conversation.

Recently I received news (from several different listservs at different times) about the 43 Catholic institutions who filed suits against the HHS mandate. I am also proud of TAC's open letter to the president.

Don't forget to vote on pro-life candidates in your primaries and local elections!

Med Student Life and Premed Questions, pt 2

Third and fourth year. Today I shadowed a third-year as she rotated her fourth week in pediatrics. I followed her in an outpatient setting. She had a good deal of independence. (She plotted growth/height milestones, decided which shots the child should have, saw the patient, took a history, did a physical exam, counseled parents, and then presented to the doctor. The doctor then checked her work and repeated an abbreviated version of this to make sure everything was covered satisfactorily.)

She told me that she spends about half her time in the hospital (inpatient) and half in the clinic (outpatient). She is on call two weekday evenings (5:00pm to 11:00pm) and one weekend (8:00am to 11:00pm); during this time, she has to be within 20 minutes of the hospital and have her cell phone with her (they can now use phones instead of pagers). On the weekend call day, she visits each hospitalized patient (a.k.a. she "rounds" on them or she "does rounds") and assesses their progress. The doctor checks her notes and she goes home (just a few hours in the hospital). Overall, her assessment of peds was "pretty gentle."

She impressed me. She wasn't as smooth as the physician but she knew all kinds of questions I wouldn't have thought to ask, she could listen to heart sounds in the right places, and present like a pro. "This is a six-year-old male who came in with a firm, non-erythematous swelling of the third digit of the right hand, retaining full range of motion...possible bone fracture, rule out...." At the same time, I knew that she was not too different from me. She was a little nervous, she reviewed her books between presentations, and she half-bluffed some of those heart sounds (I'm not completely blind...). I have a lot of hard work to do, but I think I can become like her eventually. (By the way, I didn't know there were books like hers, books not on science but just about clinical pediatrics or obstetrics or whatever. How nice! That means I don't have to store it all in my brain. Just most of it....)

Ask third- and fourth-years what their rotations are like: what is a typical day? are you in the hospital or the clinic more? are you independent? how much? do you like that? are you on call? what nights/days/weekends are you on call? do you rotate alone or with a group? how many students per faculty member on these rotations? do you enjoy their time or feel pressured? why did you choose to do rotations in the order you did? did you get your first choice of rotation orders? do you know what specialty they want to enter?

Med Student Life and Premed Questions, pt 1

First and second year. One of the things I really wanted to know as a premed was what med students' schedules look like. I have attached my schedule for this week and next week as pictures. We have a block curriculum and have tests every two or three weeks. Click to enlarge.

Premeds: ask the first- and second-years (not the people who present the curriculum) what the curriculum is like: how often do you have tests? do you learn by system, by region, by clinical presentation...? when do you get clinical skills? do you have problem-based learning or clinical correlations? are you required to shadow or volunteer? when do you see standardized patients or use the simulation center? are the students competitive?

Thoughts on the first test

Our first test was August 19 (a week ago today). Outwardly, I sometimes became pretty nervous: during a private review my tank (my lab group assigned to a cadaver) had with one of the anatomy professors (the most respected one), I thought I was going to fail. He quizzed us mercilessly: some questions I couldn't answer, others I was too squeaky and scared to answer, and still others made me worried I hadn't studied any of the right stuff to the necessary depth.

He asked some verbal questions, but would also just hand one of us a pin and say "find the [insert structure here on the cadaver in front of us]." He asked me to find the left recurrent laryngeal nerve. I looked in the right spot, and everything seemed so shredded and uniform--I pinned my best guess and straightened up. He gave a cool and casual look at my attempt, then met my eyes with a look that drilled fear into my soul. "Wrong," he said simply. I felt like jelly. I bent over the pin again and (motivated by sheer terror) found the nerve the second time--thank goodness.

I tried to put my fear behind me. But it seems like everyone thought this test was impossible. The M2's said things like, “don't worry, the first test--everybody messes up. It gets better.” “Don't cry.” "There's a learning curve.” “You just have to figure out how to study.” “The last in the class is still called ‘doctor.’” I thought I must be doing something wrong, since I felt pretty normal about what I'd learned. I would get to the test and the questions would be impossible, involving tricks and slips that I could only dream of.

Remember Freud's parapraxes? I did nothing else in the week leading up to the test.

1. T-7: lost my ID to the anatomy building (bad news for a room that's governed by state law as to who can go in; luckily a lady found it and I got it back the following monday)
2. T-2: hit a car in one campus parking lot
3. T-1: set fire to my toaster oven. Fire. I'd never been in a fire before. The apartment was full of smoke, everything (including me) smelled like smoke, the oven (never mind the breakfast) was blackened....
4. T-1: hit another car in the other campus parking lot
5. The day before our grades were scheduled to come out: locked my keys in my car, called a locksmith at 10:00pm.

Yet, I passed the exam. My studying strategies are apparently (largely) successful.

Bottom line  

(future medical students, especially TACers): 

DO  NOT  BE  NERVOUS. 

St. Pio says it like this: “Worry is useless.” And read Matthew 6:25-34! Do your best: truly make an effort, and this will be good.

Medical School application, personal statement

On the other end of the phone, a woman spoke with thinly-cloaked anxiety. Her voice didn’t tremble, but its composure was forced. I envisioned a woman accustomed to being in control and now robbed of it.

Most people wouldn’t like to be fielding this call, but I was excited. I was speaking with a patient about her blood test results. As a phlebotomist in the office of Dr. K, I worked with patients going through weight-loss surgery. Most of my time was spent drawing and processing lab work, but when this patient called, frantic and confused, Dr. K’s medical assistant couldn’t answer her questions. Helping this woman was left to me.

Without hesitation, I imitated what I do as a “talker” and a peer tutor at Thomas Aquinas College (TAC).

Every TAC class is a roundtable of about fifteen students and a professor, studying a common text. The professor asks a single question. With intermittent support from him, the students must collaborate to answer the question and to ensure that the entire class understands that answer. To learn, we must speak. Without teamwork and rapport, the class learns nothing. Without a clear understanding an opponent’s position, rebuttal is impossible. I became one of the “talkers,” and took a leader’s role in the section, organizing the class’ answer to the opening question and emphasizing positions that did not get enough attention.

By communication, I learn; by communication, I also teach. Many of my peers have difficulty in math and science and gravitate to me as a tutor. I delight in helping them. During the spring semester of 2009 I tutored two of my peers in stoichiometry and acid-base chemistry. I discovered that one explanation doesn’t fit all, so I conformed my sessions to their differences. When I tutor, I first assess the student: what are his particular mental talents and difficulties? What does he already know? Working from this and from simple postulates, I straighten out the material for him. The effect is invigorating for me as well as my peers: faces light up, smiles of sudden understanding appear, and distress over grades evaporates.

I wanted to see Dr. K’s patient through her distress, too. I wanted her results to seem clear, simple, and concrete. Together, we examined her labs at her pace. I gently explained to her that, for the most part, she was within reference ranges. Then I brought her attention to several numbers that were out of range. Some were not causes for alarm: she was borderline, I explained, and only needed a slight increase in her intake of certain foods. Next, I drew her attention to other, more genuine “low” values, and listed her options for supplements.

“But you said I have to add to my diet? I can’t eat very much!” she wailed. She was one year post-gastric bypass. Calmly, I reassured her: “You don’t need to add. You can substitute the foods on this list for foods you already eat.” I worked through what she needed to do, giving her examples. At the end of our conversation she felt she had more control, simply because she understood her next steps. That was the best day I had at work, because I did what I really enjoy. In a small way, I’d designed a treatment plan and explained it to a patient. I liked tutoring, but this was even better!

Patient contact, because it is a privilege, is exciting. But clarifying and compassionate interaction, together with the patient service and sciences that I love, is what drives me toward medicine. And, thanks to my unique undergraduate education, I can work this way on my feet, in a group, on my own, and with different subjects—as different as patristic theology and the theory of relativity. I think I am a good candidate for medicine—even better, I believe, for my TAC experience.