A Limit to to Primary Care?

Ever wonder why the pictures of offices are so weird? Me, too.
Somebody put some better free media on wikimedia, please.

As a future specialist, I'm struggling with letting go of primary care. As a pre-med and medical student I got frustrated when my OB/GYN didn't refill my albuterol for mild intermittent asthma. In response, I promised myself that I would not forget basic medicine.

The other day in continuity clinic, I saw a woman with a few medical problems. I wanted to do her age-appropriate USPSTF screening, which is germane to primary care. I had to look up the recommendations because I don't do a lot of screening and immunizations. I care for a single sex population which is largely of reproductive age, and my anticipatory guidance and lifestyle modifications are almost always about pregnancy and sexual behavior.

But I like being a responsible doctor, so I've modified my well woman templates based on age and USPSTF and CDC recommendations. I've built in HEADS screens for adolescents and breast and colon cancer risk scores for older patients. I remember how to read EKGs and do when I order them. I remember how to read chest X-rays and do when I order them. And I know the first few options for medical therapy for the most common problems: community-acquired infections, hypertension, diabetes, obesity, asthma, hypothyroidism, depression, early heart failure, and high cholesterol. I can respond to a heart attack or a stroke.

I'm not pretending I could be a successful family medicine or internal medicine resident. I have to look up the screening recommendations every time. I don't remember or know more than half of the medications they use, I'm sure. I can't ever remember the childhood milestones and immunizations. Don't look to me when someone's in kidney, liver, respiratory, or late heart failure. Find someone else for the endocrinology zebras and for the love of the patient, please have someone else run the code.

But I can look up what the evidence says when I have a well woman exam. So I looked up the tests I was supposed to order. When I went to staff the patient, my generalist attending scrapped most of my plan. "There's a limit to how much primary care we can do," she said.

This made me sad. Most of these women don't have another doctor. If they do, I begin to wonder why that other doctor can't do their pap tests (until things get surgical). I wish women only had to see one doctor unless they had more advanced medical problems. I enjoy continuity of care and building the physician-patient relationship. I find preventative screening a fascinating topic and a very satisfying intervention to execute. I love discussing lifestyle modifications because they knock at the door of virtue.

That said, I'm heading for fellowship and leaving primary care further and further behind. I think that primary care is an excellent sphere for midlevel practitioners, even though I love it.

In the future, there will certainly be a limit to how much primary care I do. If I become an MFM, I will do basically zero primary care and I will rely on specialists to help me manage the medical problems for my high risk patients with heart disease and other problems. (I'll still manage plenty of hypertensive disorders, obesity, diabetes, and thyroid disease myself.) That's a little hard to swallow, but I still dream of extending myself by joining a multidisciplinary practice that can be a hub for a woman's healthcare, so she doesn't have to spread out her time, energy, and medical records.

Ultrasounds before Abortions

Have you ever been so angry you couldn't speak? I have been meaning to write about a talk I attended, given by Dr. Rebecca Kukla on ultrasound viewing before abortion. Dr. Kukla argued that ultrasound screening has become a ritual in our society to establish parenthood and add (prematurely and irrationally) a new member to the family. Performing an ultrasound and explaining the findings to a woman desiring to end her pregnancy would thus cause unnecessary and severe psychological trauma. She also argued that this imposed moral harm on physicians as it required them to violate their fundamental duties to patients.

I have been meaning to write this post since January. I have kept the folded-up flier from the talk in my desk since then. There it sat, outlasting the semester, my STEP studying, and my move to a different city. Usually, when I keep a piece of paper as a reminder to complete a task (e.g. a blog post, or mailing something, or running an errand), the having of the paper bothers me just enough to make me want to complete the task. But this time, I preferred to keep the paper rather than write the post. I just couldn't do it.

Every time I sat down to do it I would formulate the ghost of an argument, take out the paper, unfold it, look at it, and recall the tone and content of the argument. The first few wisps of a post that I had would evaporate as I would become angry. Not desiring to be angry, I would just put the paper and the idea away.

Today I realized the pattern. And now the flier is in the trash, but I have a decision to make (I am literally making this decision as I type). I can either write the rebuttal now, or I can just forget about it.

I am still too angry for a level-headed, reasoned argument, so if you read this, Dr. Kukla, please excuse me as still young and full of idealism. I will strive to be professional, though.

Before most minor surgical procedures that require general anesthesia (e.g. cholecystectomy or gall bladder removal), an ultrasound or other imaging is done. Vaginal ultrasound is quite common in gynecology. It also doesn't stand out as uniquely invasive. (Ultrasound for cholecystectomy gets to the bile duct via the mouth, and I'm sure you can imagine how they stage colon cancer). Abortions actually become more like the minor surgical procedures they're touted to be when an ultrasound is performed. I would hope they're done anyway.

Adequate bedside manner during any exam or procedure in which a person is awake but unable to interpret the findings includes explaining the findings. "Mrs. Anderson, your lungs sound normal." "Ms. Patel, the skin biopsy is almost over and your back looks good." "Mr. Deere, this darkish color on the ultrasound means you have a lot of fat in your liver." Let's encourage abortionists to have good beside manner by requiring them to describe the findings. I would hope most of them do anyway.

Dr. Kukla's concludes that ultrasounds like this impinge on the physician's duty to do no harm, but she happily supports the procedure that follows, which will leave 14% of the women who undergo it with full PTSD (slide 42). (For reference, 15.2% of Vietnam vets have full PTSD.) Abortion increases the risk of suicide to 650% (slide 74), substance abuse (61 and following), and depression (9 and following)  is considered desirable, so desirable that even medically legitimate restrictions are deemed morally intolerable.

I think that's all I have to say. Dr. Kukla and I agree that vaginal ultrasound cannot be considered a kind of "rape," and we also agree that it's not ideal that these regulations come through a governing body (we'd both prefer they come through professional organizations). But I find her basic attitude (defending abortion while objecting to an ultrasound) to be inconsistent.

Oh dear. Family Medicine.

So, on the first day of the family medicine rotation, the clerkship director gave a presentation about family medicine--what it is, why one would go into it, etc. And something seriously bizarre happened.

I have wanted to become an OB/GYN for something like eight years. Family med has always been the second choice, but it was always dismissed because of things like a preponderance of metabolic syndrome (ugh), no surgical components (double ugh) and excessive government oversight (triple ugh).

But as that clerkship director was talking, I began to seriously think family med deserved a more than serious look. I began to really want to be a family doctor. I began to think so seriously that I started making a list of pro's and con's on my orientation packet. And I didn't even call the con's "con's," I just wrote them under a list I labeled "Hm."

Hm

1. I would miss the OR and surgery. I really like anything that requires manual dexterity.
2. Every time someone suggests FM as a way to go, they mention rural care and mentally I go "ACK! NO!!" I don't want to do rural care. Sorry, but I want to stay in my city! I'm happy to serve the urban poor, and that's what I want to do, but no rural care until my parents are deceased. That's the law (right now).
3. The government looooooooves primary care. FM is the answer to ALL Obama's problems. Hence, I don't want to go into a field where I become Big Brother's employee or marionette.
4. SYNDROME X. Nuff said?

Pro

1. I love to educate, and that is what a lot of FM is. I love to bring people up to speed by going to meet them where they are and encouraging them. That was in my personal statement.
2. Better hours than OB/GYN!
3. FM is actually the answer to MANY of the nation's healthcare spending problems. I don't want to be a governmental employee, but it would be good to actually help with a big problem.
4. I used to want to be a family doctor but somewhere along the line I learned that the golden age was over and family docs were referral machines (it was a job for the dumbest med students). But I don't think that's true anymore, not after meeting some of the faculty here and elsewhere.
5. I was complaining after psychiatry that I wish I'd become a therapist instead of an MD, since they seemed to do more for people. FM would be more like the therapist and less like the drug pusher.
6. It's natural. It's basic. I like that.
7. It's the most helpful, in terms of morbidity and mortality.
8. I LOVE the idea that one person has one doctor, or at least one main doctor managing the team. The patient centered medical home model really appeals to me, as does the ACO, multispecialty practice, and group visit.
9. I like the idea of managing complexity. Although I don't want to manage everyone's unmanageable syndrome X, I do like to use my brain. (IMED, is that you calling?)
10. I like the idea of being able to everything (ish) for the poor.
11. It has a lower income.
12. It's almost all outpatient. One thing I didn't like about psych and a few of the docs I've shadowed is that they have inpatient and outpatient, and spend a lot of time driving.
13. It has a shorter residency AND (get this) you can do a year-long fellowship in OB and then *poof* I would have spent the same amount of time (four years) getting ready for prenatal care as I would in an OB/GYN residency. I'd miss the surgery (except C-sections) but I would be out from under the thumb of ACOG and not responsible for IUDs, sterilizations, and IVF while still managing what matters most to me anyway (prenatal care, birth, miscarriage, prenatal hospice, NFP, STDs, sex and abstinence ed, and postabortion recovery).
14. I might be able to do residency more easily in my home city. And that means, I might be rotating where I will eventually be a resident. (Better shape up!)

I still have a lot of questions, but that is a long list (and it surprised me how quickly I was able to write it out, as though I'd been thinking about this for a while). I'm still in the first week of the rotation, which has all been lectures, so I haven't seen a single real patient. Time will tell. Please say a short prayer so that I can see what God wants me to do.

Coffee with the Culture

Based on a coffee I had with a classmate the other day. All I did was omit her name.

The other day I met up with the Culture for coffee. She picked the place: it was a fashionable, relaxed coffeehouse, with catchy rock playing so softly that unless you listened, you would miss the profanities woven into the lyrics.

We got our steaming paper cups and sat down opposite each other at a round little table near the center of the room. Since we were only acquaintances, so I asked about her day. It was busy, she said; she'd been interviewed. I told her I'd been studying most of the day, and I didn't mention that I went to Mass that morning.

I asked about her background, to get to know her. She was very educated—in engineering, neuroscience, and medicine—but had complaints about the U.S. educational system, that no one learns to think. She wants more people to study philosophy and spoke much about recent scholarship and discoveries about older cultures. The books she recommended to me all sounded interesting, but they all sounded like negations of past assumptions. (I guess that's what still sells.) They all sounded like history and sociology, not what I know as philosophy.

Her mother identified with one religion but supported her when she chose to follow no religion at all, keeping only some remnants of her culture's behavioral standards. Her father was not much a part of her life. She'd chosen no religion, and told me she would never indoctrinate her children. "No scripture is true," she said once or twice. I felt like I was being used for archery practice and started praying with my fingers in sign language under the table. I l-o-v-e Y-o-u. I l-o-v-e S-a-c-r-e-d S-c-r-i-p-t-u-r-e.

Currently her studies were focused on medical ethics, she said. She spoke about conscience boundaries and patient autonomy (a few more arrows, right to the heart). She spoke about changing cultures and values, and the need to adjust what physicians are expected to do to include not only contraception and abortion but euthanasia. It was, after all, only a choice that should be available to patients. She was permeated with relativism. I didn't turn anything into a debate, but when she literally said, "there are no absolutes," I pointed out that this is an absolute. She seemed mildly confused and thought that she must have made a misstatement.

But she was polite and asked me about myself. I told her that I had a bachelor's in liberal arts and studied philosophy and theology; as usual, I expected that she didn't know what I really meant. And she didn't. How could she? I studied the objective and absolute truth and began to learn to find it; she does not believe that such a thing exists. To her I have a bachelor's degree in Fairies or Heliocentrism. I had to work to avoid feelings of embarrassment whenever she mentioned a philosopher that I hadn't heard of, since I spent most of college reading Aristotle, with a few landmark treatises before 1900.

Our conversation touched practical ethics, too. She told me how appalled she was to learn that a certain pro-life physician she'd discovered did prenatal ultrasounds and hid bad news from patients (fearing that they would abort). She though this was horrible.

Happy to find some ground for agreement, I agreed that he was not serving his patients well. (I didn't state why I thought so, but I will for you: a good pro-life doctor should share what he finds with patients and refer them to perinatal hospice, so that they could prepare for the birth of their child and parent them well). I didn't go into my reasons because I had a burning question to ask her. "Is this behavior always wrong?" I asked her.

"Yes," she replied.

"But you think good is relative," I responded. "Why would this always be wrong?"

Many words followed my question, but no answer came with them. The right thing is dependent on circumstances and culture and values, but there are some things that she would never do and which offend her, and which...no one should do.

"I think there is one right thing and one happiness," I said, "and that's why some things are undeniably bad for everyone."

She was quick to say much about how different people pursue different things and that she doesn't agree with me. But eventually she asked me, "What is happiness?"

"Love," I said. We all hunger for it, and try to find it in all kinds of ways.

"And what is the opposite of love?"

I looked at her levelly. "Apathy," I answered. I wanted to explain more, but she did not want to hear it today.

As we left and went out to the parking lot, she was still puzzling that "nothing is absolute" is an absolute. But I am not sure if a thousand coffee dates would ever sway her, so deeply ingrained is everything. Finally, coffee and words are just occasions; grace changes and intercession and penance open the gates to it.

The Call to Holiness = The Foundation for Catholic Health Care

St. Basil, one of the founders of the
Catholic hospital (a.k.a. one of the
founders of modern hospitals)

This was the title of the talk given by Fr. Joseph Johnson at the CMA conference last week (except he used a real predicate instead of an equals sign).

I completely agreed with his thesis before Fr. Johnson ever stepped behind the podium. Ever since reading How the Catholic Church Built Western Civilization and being floored repeatedly by the chapter on the Church and healthcare, I've agreed with this thesis.

Thomas E. Woods, author of the above, chronicles saints' work to build hospitals and fill them with the sick, especially the poor, the family-less, and the homeless. Importantly, Woods emphasizes that this work stemmed directly from the saints' understanding that their faith demanded it. Becoming holy required God-like deeds which (for a religion proclaiming a God who was Mercy itself and had exhibited that Mercy in countless healings and acts of supreme self-sacrifice) meant works of mercy.

(This makes me want to spiral off into a discussion of love, and how true Love is only had by mirroring Christ and anyone who agrees should readily understand the doctrine that there is not salvation outside the Church...but we'll stay on-topic.)

Medicine, Fr. Johnson said, is elevated from a career to a vocation because healthcare workers earn their daily bread by touching Christ in their patients and being Christ to their patients. Asked what the solution was to the healthcare crisis, Fr. Johnson simply said, "we need saints." We need people who will restore compassion to healthcare and repair the patient-doctor relationship to the Love with which it was inflamed in the first hospitals.

A Catholic doctor wishing to become such a saint seeks more than good bedside manner; he seeks a sincerity that stretches him and makes him more Christ-like.

Isn't it naive, an objector might ask, to approach the culture of death (so many problems!) with only these scant recommendations?

Hardly, Fr. Johnson retorts. The above is a full-bodied prescription for sainthood. Here are its ingredients:

1. Formation. Nemo dat qui non habet, and action follows contemplation just as it did for the saints Woods discussed. Prayer and study of Scripture and theology fill us and motivate us to love others and teach others. Without prayer and study, all our frenetic activity lacks meaning!
2. The Sacraments, especially the Eucharist and Confession.
3. Sacrifice, which allows us to learn to love as He loves.
4. Adherence. Never excuse yourself from this! This represents a change in the spiritual diet, but be a compliant patient of the Divine Physician. Remember that your patients need a doctor who is Christ-like.

A crucifix in Vilnius. (The triumph of love.)

Simple, but not easy. We need to learn to love better, or we need to learn to allow Christ to love for us. Luckily, medicine presents constant opportunities for the physician to increase in love, Fr. Johnson said. The need of others becomes an opportunity to serve Christ. In fact, some of those early hospitaller saints would call patients "my Lords, the sick and the poor." This reminds me of the additional Divine Praise that Missionaries of Charity say at Benediction: "Blessed be God in his most distressing disguise," meaning that each poor person they serve is God.

To become a saintly doctor, Fr. Johnson concludes, is exciting. It is to realize St. Teresa's poem; it is to become a lover, not a fixer (because Jesus is a lover, not a fixer); and it is to triumph, because we already know that Love has triumphed.

Stories of Cooperation in Evil

During an IUD insertion the other day, I may have assisted without my will. I placed gel on the physician's fingers as she performed a pelvic exam before the insertion. It was almost robotic; I'd worked with her for weeks and placed gel on her fingers during almost every exam she'd done in that time. When she held out her gloved first two fingers, I reached for the gel and squirted some on obediently. Then I came to my senses: what had I done?!

Almost immediately, I felt relief, because a pelvic exam is not part of the insertion; it was just this physician preparing herself for the particular patient.

But today I read in the informational leaflet about Paragard that this, in fact, the first step of proper insertion technique.

Thinking back on this now, I can't remember whether the medical assistant, to whom I'd explained my beliefs, was in the room with her back turned to the doctor (doing something else, like looking in the cupboards for a speculum), or whether she was out of the room briefly.

I abstained from Communion for the intervening days before I asked a priest to hear my confession after morning Mass. (He was a young priest, just ordained not less than a month ago, so all his moral theology was still fresh!) I explained that I thought I had materially but immediately assisted and described everything. He said that he thought this might be remote and that he "wouldn't hold that against me," and I felt much better, because he speaks for Jesus!

Affordable Care

Obamacare was passed and deemed constitutional as a tax. I do not feel like political commentary today, however, and I just want to talk about healthcare and patients. This post is a lot of lists.

We have a problem in the first world. The problem is: healthcare has gotten very expensive. What would make care affordable? I posit that this is impossible without a change in mindset. The first world must re-learn a few things (I placed negative principles next to the positive counterparts and bolded what I though were the two:

1. Death and suffering are not the greatest evils (not even close).
   Rather, holiness is the greatest good.
2. Simplicity is a great means to the greatest good via the second greatest commandment.
   This means acquisition of wealth is not the greatest good, or the greatest means.

This is, simply stated, justice and righteousness. I'm asking for a lot, and it's not going to happen in every soul in the next twenty years. However, the more we realize these truths, the better off we will be. Just to give some examples of the potential effects:

1. Physicians' (and other providers') motives shift from moneymaking to taking care of patients.
2. Legal professionals' motives make the same shift (albeit to protection of justice) and medical malpractice insurance goes down, lowering fees for service.
3. Patients are less afraid of death and place an appropriately higher value on conservative (cheaper) treatment.
4. Anyone affected protects the sanctity of life (abortion is chosen as an alternative to a kind of death, or suffering).
5. Perspective reigns and people across borders are truly equalized: the phrase "first-world problem" is an embarassing testament to our lack of perspective. Although some medical problems are objectively distressing, some that are currently treated ($) could be tolerated if a mindset change occured.

Practical suggestions are almost futile without this large-scale change of heart, but here are a few:

1. Payment in kind to healthcare providers
2. Increase in charitable involvment in healthcare
3. Subsidiarity in healthcare insurance
4. Movement toward the master-apprentice model of medical education to decrease physician loans

The first steps to affect the change of heart in the medical professionals are probably:

1. Improve ethics training in medical education (improves physician's choices of medical procedures)
2. Improve bedside manner (improves patients' self-value and ability to make good choices for their health)
3. Protect the traditional family (health outcomes are vastly better when families are intact) including elder care as the population ages

I feel like God's calling me to a crusade....

3 Reasons Obamacare is Bad for Patients

One problem with Obamacare is that it is very hard to find out what it will really do to my future. I feel like almost no one can summarize it without bias and when I find someone who can, I can't take that knowledge with me because others believe that I am biased.

Happily, however, I belong to a profession which is supposed to put aside all interests besides those of the patient. Let's talk about patients. Here are the top three reasons that Obamacare is bad for patients, especially young adults and the poor (parenthetically, it's also bad for young doctors, since we are in both of those groups):

1. Community ratings
2. Weak individual mandate
3. Increase in Medicare coverage to 133% of poverty line

The law requires that insurance agencies cover individuals with pre-existing conditions. (Right now, it can be hard for people who are already sick to get insurance, because insurance companies know that those patients will not profit the insurance company.) To avoid lawsuits from insurance companies, Obamacare also requires all healthy people to purchase insurance to offset the expenses of the sick. This is the individual mandate, and without it I cannot see how the law will stand.

However, offsetting the expenses of the sick drives up costs for the healthy. Community ratings require that companies not charge their elderly or sicker clients more than three times what they charge the young and healthy. In order not to lose money under this requirement, insurance companies may lower the more expensive patients' premiums, but will certainly inflate cheaper patients'. This is unfortunate for young people, who now leave their parents' policies at 26. It's especially bad news for the patients I am very interested in caring for as a future OB/GYN: the young women, especially those made vulnerable by poverty, homelessness, abuse, or pregnancy.

Community ratings, combined with the weak individual mandate, create what Forbes' Avik Roy calls the "adverse selection death spiral." Simply speaking, the fine for not purchasing insurance is cheaper than insurance premiums. This is especially true for the young (whose incomes, from which the fine is calculated, are relatively small, and whose premiums are inflated) and the poor. Suppose I, who am living on loans, choose to pay the fine rather than purchase insurance. If I have an accident or get sick, I can purchase insurance easily (since there is no discrimination against pre-existing conditions) for the duration of my treatment. I then return to paying the cheaper fine, or stay on insurance for my lifetime. If many healthy people follow my example, then who is subsidizing the sick? If many chooses the fine, the sick and those who feel obligated to purchase insurance (e.g. young families) will still pay high prices for their care.

Finally, the increase in Medicare coverage, while in theory benevolent, is probably going to be awful for those it aims to serve. Already, many physicians do not "take" Medicare patients because Medicare reimburses services and drugs below their market cost. If the number of patients eligible for Medicare increases in a community, the population of people trying to make appointments with doctors will reflect this shift. Doctors will be faced with more under-reimbursed hours. Many physicians deal with this problem by refusing to take Medicare, or by limiting the number of Medicare patients they see.

Ultimately, Obamacare doesn't seem to change the status quo much, except by increasing the number of regulations and government-paid employees. The poor will still have trouble getting into doctor's offices (some offices may topple in the shift). The sick will still pay heavy totals for their conditions (now they will pay the insurance company instead of the hospital). The young will still be the largest group of uninsured (though now they will pay an annual fine for being that way).

In short: Obamacare is problematic, and I, as a future physician (and as a young, poor, relatively healthy patient) want a different solution to our national dilemma.

Deadly Medicine: Creating the Master Race

On the final day of the IBPCA week of lectures and research, my fellow externs and I visited the U.S. Holocaust Museum. While there, we saw the “State of Deception: The Power of Nazi Propaganda” exhibit and spent a little time in the Wexner Center on the Nuremberg Trials. Unfortunately, there was not enough time on our schedule to see the entire exhibit. I hope to return some day and complete my tour.

We also had a special presentation on medical ethics by Dr. Patricia Heberer (some audio clips of her here). As is well known, The Nazis carried out experiments on eight to ten thousand involuntary human subjects. According to Dr. Heberer, these studies were often not soundly conducted and frequently were testing racist hypotheses (she gave an example of an attempt to prove that Aryan immune systems were better than French ones, which were better than Slavic ones, and so on down the supposed racial hierarchy).

Maternity Homes: Reverse Morbidity with Hope

This is the presentation I gave at the Research Summit of the International Institute for Bioethics and Patient Care Advancement, modified slightly for this venue.

---

I am currently involved in the preliminary efforts to open a maternity home in my community and I would like to explain that I am taking that particular step because maternity homes are among the best remedies to the profound needs of special pockets of the female patient population—namely, racial minorities, adolescents, and the urban poor. (For the sake of brevity, I will only speak about a smaller group made up of adolescent women who are impoverished and among the country's larger racial minorities: non-Hispanic black and Hispanic.)

First, some numbers from 2009, the most recent year that the CDC provides birth and pregnancy rates. Of every 1000 women between ages 15 and 19 in this country, 39 give birth to a child. This number is not evenly distributed among the various racial groups in the US. Of 1000 Hispanic teens, 70 give birth; of blacks, 59 do; of whites, only 25.

Birth rates are not the same as pregnancy rates, since some pregnancies end in abortion or miscarriage. Pregnancy rates are not available for 2009, but if rates have remained relatively stable since 2005 (the latest year the CDC provides), then we can estimate even more distressing statistics: the differences between racial groups are even more pronounced, and the abortion ratios are probably also skewed, as high as 50% among black adolescents compared to maximums of 43% in whites and 36.5% among Hispanics.

Abortion in lecture

We had a lecture on teratogenic viruses last week. Our professor's presentation listed each virus, the birth defects associated with it, and the relevant prevention or treatment. As I previewed the lecture the night before, I read about congenital rubella syndrome (CRS). I was in my usual medical student study-mode (loading information into my brain via conveyor belt) when the conveyor belt suddenly stopped:

 

And the next day, my (mild, talented, knowledgeable, personable) virology lecturer taught us to advise abortion. He said,

Typically, the medical recommendation for first trimester infections [is] abortion, therapeutic abortion, because most of those babies would never have a  functional life [or] existence.

And when summarizing, restated

...therapeutic abortion is the standard recommendation for first trimester rubella infection...

Between lectures, I struck up a conversation with a peer about it. I knew he was a Christian, but I assumed he was pro-choice (I was correct). I mused aloud that abortion was like a deliberate miscarriage. He agreed. And I further mused that a miscarriage was the death of a baby. He agreed again! Then, I wondered whether there was any reason to cause a miscarriage if that was the natural end of many CRS pregnancies. I felt like he kept repeating the words "option," "beliefs," "have to," and "if you were the only one" in various combinations, and when lecture began we stopped talking.

I thought about linking this with Good Friday and editorializing about redemptive suffering, mercy, and persecution; but I'm too tired. (Probably should've made my "normally-sized meal" a little more substantial.) Since you can probably make the connections yourself, I just say: this has been your report on the status of the U.S. medical school. Please pray for us.

Crumbling dreams in a world of turbulence

Medical school is fascinating right now. We're in our first systems block (several weeks of intensely studying one organ system): neuroscience. I'm learning about adrenergics and T1/T2 weighted MRIs! By itself, "neuro" would be interesting and manageable.

But I'm not just going to medical school. I'm a Catholic, a leader, a dreamer. I care about the Church and the fate of souls and of my country. I feel the suffering of mothers and children and families affected by our culture.

There is too much going on. It's not all bad: there are evil measures going on, but these provoke a lot of good thought and pruning for the springtime of the Church. Even so, I feel like a boat about to capsize.

• The HHS mandate. This video of Gloria Purvis is excellent. She gets politically incorrect, but she stays with the truth.
• Persecution is now. Vatican.va taken down by pro-choice hackers, and The New York Times ran an ad "in odium fidei."

Nationally and globally, turbulence is increasing exponentially. I see my dreams of a Catholic women's clinic, maternity home, and/or hospital crumbling. I want to love others by my prayers, my hands and my study! Why am I being prevented from love?

God + come to our assistance. Lord, make haste to help us!

Listening

Last week I woke up and it hurt to walk. Whenever I swung my right leg forward, I got a jolt of pain that took my breath away. I hobbled through my morning routine and made an appointment at the health center.

It's interesting to reflect on the episode, because I realize my brain has already begun the transformation into a doctor's brain. My thoughts weren't: dang, I'm missing class...what could this be...I have to drive and pay a copay.... Instead they were:

Subjective:

•  ** y/o female presenting with R hip pain
• Attributes of pain:
• Onset: this morning; had some slight pain yesterday in the same area, but was not concerned
• Duration: lasts less than a second as she moves her leg
• Timing: during flexion of R leg
• Location: "in the joint"
• Quality: dull "but powerful"
• Severity: 8-9 early this morning, 5-7 now
• Modifiers: better when standing; constant soreness when sitting
• Pain does not radiate
• Stretched yesterday
• Has experienced similar, minor episodes w/in past year 

Objective:

• Pelvis is posteriorly tilted during gait; patient doesn't know when pain is worst during motion
• Minor scoliosis

Assessment:

• Ddx: muscle strain, hemorrhage, erosion, malignancy
  (I don't know if all those are even possible...but since I don't have much education all I can use is my imagination!!)

So...I went to the doctor. She was extremely rushed and it seemed like she concluded that it was a muscle problem really early on in the exam. She asked for ONE of the attributes of pain (location) and what I did to myself to cause it. Granted: her patients are mostly young college students and probably mostly suffer accidents, not disease. And while she may have ruled out other possibilities, I felt like "muscle strain" was a foregone conclusion before she came in.

Without looking at me, she went through an H&P as she sat in front of the EHR on her computer. It was more like an interrogation. (Like when you donate blood and they read off the questions at a mile a minute! "Between 1980 through 1996, did you spend time in the United Kingdom that adds up to six months or more? Have you ever had yellow jaundice, liver disease, viral hepatitis, or a positive test for hepatitis?") After a few questions, I just started to shake my head continuously as she kept rattling off questions. I was sort of upset at this point. It hurt to walk here, I wanted to say. I had to park far away because it is so hard to park on campus. I walked here, and no one asked me anything about my pain except where it was.

But then, I had to answer, "oh, yes," to a question. And she said rather loudly with obvious exasperation, "ah ****, that changes everything! Since when [have you had that]?"

That was the last straw. I burst out in tears. She began to worry and passed me a tissue and wanted me to tell her that it wasn't her fault that I was crying. I explained that I had an exam coming up and that the stress often gets to me (which probably contributed).

But I was seriously hurt! So, the thesis of today's rant: doctors, listen to patients. Listen.

A doctor's clinical acuity increases with listening. Someday, I want to become my patients' ally in a fight against their sickness. To treat a person I must (1) know them and have their trust, and (2) grasp their disease two hands: their experience, and my medical knowledge. To become this united with the patient, I must listen desperately.

But is this possible? In my experience last week there was a chasm between the doctor and the patient: the doctor’s mind quickly identified my condition, ruling in or ruling out items on an expertly narrow differential, but I, the patient, was new to the symptoms, frightened, in need of a little attention.

This level of devotion to the diagnosis may be impossible for a doctor bound by the current system of 10- or 15-minute visits. Nevertheless, this level of investment in each patient encounter stands to enhance diagnosis, compliance, and the success of treatment. I consider such investment a mandatory part of my future.

And the hip? It's better already; I guess she was right.

Found a hospital

The other night, my sister and I spent two hours on the phone talking about dreams. Big dreams. She described a wonderful school she wants to start; I admitted that I want to start a hospital.

Her school is very well conceived. She wants to make good use of students' time instead of stressing them out by keeping them in fruitless programs during the day and activities until late at night. She wants to pay teachers based on merit, teach practical skills (e.g. home ec), and incorporate service. I'm so impressed by her desires to mold better people without all the fat in our current schooldays!

My hospital was less complete in my mind. First, I am very unsatisfied with the nursing shortage, the over-technicalization of patient care, and the treatment of crises instead of persons. I'm especially fed up with these problems because of my visits to nursing homes. I want dedicated persons who will stay with patients and get to know them, instead of coming in when the light is on or when there is a form to fill out.

In addition, I want a hospital that is wholly Catholic—half retreat-house, half hospital! I want the chaplaincy to be about truth (not comfort), and I want it to be very available. I want to hang Crucifixes in the rooms instead of TVs, and place placards with good quotes from the saints and scriptures. Being ill is like beauty—a natural thing that jerks our attention to the supernatural. In a culture so bent away from God, sickness is an ever-remaining crack that Christ can use to pry His way in. A holy hospital can do great good in saving souls!

Then, my sister and I started talking about the breakdown of the family; then, we voiced hopes that our family of origin will remain close together (our extended family is stretched all over, and I think we don't want that for the next generation); finally, we ended up dreaming of creating a Catholic planned community outside some city. Think: if there were two thousand Catholic cities all over the nation, what sort of effect could there be! A concentrated effort can be better than a dispersed one; my hospital would be safe from legislation there (since it would serve primarily Catholics); studies could show how good social teaching improves economies, moods, etc.... So, pretty much I want to go start a city now. (This is what happens when two girls stay up late on the phone!)

God keep this desire to spread holiness in me; God show me how I ought to direct it.

FQHC's

A federally-qualified health center (FQHC) is a practice that receives grants from the Health Resources and Services Administration (HRSA, the same people that offer rural loan forgiveness to medical students and residents). I read more about them here.

When I first heard of FQHC's, I thought they were a good idea and even thought I'd like to practice in one. It's a good idea to provide care to people who need it, yes? And these are the poorest of the poor, yes?

But on Friday I shadowed a pediatrician in an FQHC. I'm not a fan any more.

I was surprised by the sick-child visits. Children came in with no true complaint. I thought this must be due to low health literacy. (A 99° fever is not a reason to worry, especially if the fever doesn't register on a thermometer and the only reason for the visit is "he feels hot to the touch.") I asked the the doctor I was shadowing about this. She agreed with my assessment, but added another reason for these empty visits.

"It's so cheap" to come in, she said, that patients come in at the drop of a hat. She added that sometimes they are using their visit to skip school. If I were a provider to this population, I would much prefer these patients get good phone advice and go to school! But the doctor again surprised me.

She laughs at these empty visits and says it's "good for the numbers." An FQHC must maintain a certain volume of visits, otherwise it loses its funding. Upshot: he better the education she provides, the worse the numbers. Moreover, the more FQHC's that are established in an area (the fewer visits at each one), the worse the numbers. "Bad for business," this doctor sighed when she told me three satellite clinics were being established this year.

Now I have problems with FQHC's.

1. The Republican in me: our taxes are paying for what? (Not all these patients are here legally!)
2. The ethicist in me: where money is on the line, who can provide patient, solid counseling to patients?
3. The patient advocate in me: this arrangement is worse for patients; they become dependent on the doctor because they are not taught how to take care of themselves, the underlying cause of their visit (problems in school?) aren't addressed, and they receive poor-quality care (this was my experience yesterday and might not be universal).
4. The idealist in me: why is the patient's good bad for doctors?

There must be some better way to take care of the poorest of the poor; some way that does not involve government programs and conflict of interest, some way to provide true education and quality care. FQHC's make me sad because they're so close to a solution, but at the same time so problematic! Our system seems so misguided.

Conscience Rights

A few newsbites:

• USCCB writes open letter to protect conscience rights. CMA, NCBC, Knights of Columbus, Catholic colleges sign on.
• An NJ hospital pressures 12 nurses who refused to assist in abortions.
• Christian Medical Association criticizes Obamacare's useless conscience clause (scroll down for Jonathan Imbody and David Stevens' editorials)

I got this summary from an AAPLOG email:

In a nutshell, Health & Human Services (HHS) has adopted the most limited right of conscience language ever to be used in federal law in its new contraceptive mandate to health insurance. Using language developed by the ACLU, the mandate now requires all policies issued to cover all forms of FDA-approved contraceptives, sterilization and counseling with no co-pay. The only entities exempt are those that:

1. Have the inculcation of religious values as their purpose;
2. primarily employ persons who share its religious tenets;
3. primarily serves persons who share their religious tenets; and
4. are non-profit organizations under section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii) of the Code.

Practically, this means that ROC protections are limited to churches. The one-in-six hospitals in the country that are Catholic must provide coverage for birth control and sterilization. Christian practices and non-profits that serve the poor must provide coverage for morning after pills.

Healthcare disparities

Finally! A good lecture in Medical Humanities. Most of our lecturers make three mistakes:

1. They openly lean left. This is pedagogical.
2. They do not defend their conclusions. This is a cross for the TACer (and any intellect).
3. They employ heavy filler in their presentations (this hurts the medical student soul; we're constantly thinking, "is this a good use of time?? I need to study G-coupled protein receptors!!").

Today, we had a woman who made none of these mistakes. She gave a stimulating lecture, had strong ethos to support her position, and reached beyond politics and academia for the good of patients. Some highlights:

• people do not need to look the same to treat each other without unjust disparity (she was asked before the lecture whether, if the racial distribution of doctors matched the racial distribution of patients, healthcare disparities would disappear)

Living wills and healthcare proxy

Our professors have asked us half a dozen times: "who in here has a living will?" Very few hands go up, and the professor berates us for being young and shortsighted. Every time we're asked, I diligently make a mental note: "I'm going to go home and do that...it's a good idea and I should set an example...." But every time, I forget! (So I still haven't raised my hand.)

Tonight (after the last exam of the first block) I had lots of time, so I looked up advanced directives. Three seconds of research tells me this: "Many Catholic bishops and moralists consider this [living will without healthcare proxy] an unsatisfactory approach, as it does not provide for unforeseen circumstances" (NCBC, ETWN; this page goes into good detail about artificial nutrition and hydration and "extraordinary means").

For reference, here is is a purely Catholic and legally sound healthcare proxy form (designating decision-making authority to another person in the case that you are incapacitated and expressing desires in those cases). It explains very carefully that

the statutory definitions are not always consistent with Catholic moral teaching. For example, the definition of “life-sustaining treatment” under Texas law conflicts with Catholic teaching because the Church considers food and water, even “artificial nutrition and hydration,” as ordinary care, not a “life-sustaining treatment.”

It makes general provisions in accord with Catholic teaching before offering the typical curt "I do wish" or "I do not wish" option.

Please note: these differ according to state. Search for "Catholic advance directive" and your state.

Unjust laws

I did a tiny amount of research on unjust laws between studying the leukocytes and reviewing the anterior abdominal wall. I found an incredible page: a compendium to Catholic social teaching, courtesy of the Pontifical Council of Justice and Peace. §399 and §400 deal with unjust laws, obedience, objection, and resistance.

§400 quotes St. Thomas Aquinas: "one is obliged to obey ... insofar as it is required by the order of justice" (Summa Theologiae, II-II, q. 104, a. 6, ad 3um). St. Thomas defines "the just" in II-II q. 57:

I do "the just" when I render to others what is their right or due, i.e., what is "commensurate with" them in their dealings with or relationship to me.

The order of justice refers to the order in the kinds of law (II-I q. 91): eternal law (God's providence), natural law (principles in us driving us to natural goods), and human law (public law, military law, decrees, statues, international law...).
St. Thomas considers the unjust law in II-I q. 96 a. 4.

...laws framed by man are either just or unjust. If they be just, they have the power of binding in conscience, from the eternal law whence they are derived, according to Prov. 8:15: "By Me kings reign, and lawgivers decree just things."

...On the other hand laws may be unjust in two ways: first, by being contrary to human good, through being opposed to the things mentioned above.... The like are acts of violence rather than laws; because, as Augustine says (De Lib. Arb. i, 5), "a law that is not just, seems to be no law at all." Wherefore such laws do not bind in conscience, except perhaps in order to avoid scandal or disturbance, for which cause a man should even yield his right, according to Mt. 5:40,41: "If a man . . . take away thy coat, let go thy cloak also unto him; and whosoever will force thee one mile, go with him other two."

Secondly, laws may be unjust through being opposed to the Divine good: such are the laws of tyrants inducing to idolatry, or to anything else contrary to the Divine law: and laws of this kind must nowise be observed, because, as stated in Acts 5:29, "we ought to obey God rather than man."

Where do inconvenient laws about ebooks fit? One could argue that control of intellectual property doesn't promote the common good, or is outside the authority of government, or is overly burdensome. These arguments don't seem iron-clad to me. And it's certainly obvious that these laws are not unjust "through being opposed to Divine good" or natural law, or Divine law. Other laws, like the court precedents and healthcare bill promoting abortion, are different. These are against Divine and natural law, and we may object and resist according to Catholic teaching, summarized in §399-§400 of the Compendium of the Social Doctrine of the Church.

It's back to blood cells for me; what do you think of this?

AMA Resolutions

Apparently, medical students can submit resolutions to the AMA. I'd love to work one up on breast cancer and contraceptives, or on contraceptives (and not prescribing them), or on abortion (and never advising it).

I am thinking about working on one of these (probably the first one) this summer. In the meantime, here's a treat for you: all the AMA's policies about abortion. (To search among AMA policies, which influence law in this country, visit the policy search.)