Friday, July 24, 2015

What Can a Catholic on OB/GYN Do and Not Do?

Let's be practical: what can a Catholic medical student on his OB/GYN rotation do? What about a Catholic resident working in OB/GYN settings (including family and medicine residents)?

The Do's

Be confident. You have the truth, which is not only a set of beliefs, but a Person who is pleased that you want to do the right thing, and will protect you.

Answer test questions as if you toed the party line on contraception, sterilization, and abortion. We can "prescribe" on paper.

Prepare an elevator speech so that whenever you must state your choices, you can do it smoothly and briefly.

(For residents) Tell your program director.

(For medical students) Do not tell any higher-ups unless you know they will be receptive. Tell clinic attendings at the beginning of any day (the evening before if possible) when there is an objectionable procedure scheduled; tell surgical attendings before the first sterilization you do with them.

Be an awesome person and a hard worker. We must "be perfect," to challenge those who think we're bizarre.

Find as much in common as possible. For instance, be loud proponents of "teens shouldn't get pregnant" and "STDs are terrible," and "no, condoms aren't enough!"

Counsel patients on family planning. To counsel is to present the dosing, routes, side effects, and mechanisms of action of available options. Counsel patients as frequently as possible, because only our counseling is truly presenting the whole truth about all three mechanisms of action (MOAs) of hormonal contraceptives (including thinning the endometrium which may lead to post-fertilization pregnancy loss, per the package inserts) and the existence and benefits of NFP or fertility awareness.

Happily volunteer to take out IUDs and nexplanons.

(For medical students and interns) You may observe one or two insertions of IUDs, nexplanons and Essure. Your participation is remote, it improves your counseling (i.e. you won't remember to mention ibuprofen premedication before IUD insertion if you don't realize quite how much cramping can occur), and you can pray for the patient and physician more vehemently. Students, t's best to speak with your preceptor beforehand, as soon as you see an IUD/nexplanon/Essure insertion on the schedule. If somehow that doesn't happen and you're offered the chance to do the procedure, just say, "I'm not comfortable." (Residents, your PD should already know.) But (students) if they press you (and residents, if this attending didn't get the memo), say confidently: "Thanks for the chance! But I'm choosing not to prescribe contraceptives."

You can participate in endometrial ablations. These are usually done for gynecological pathology (e.g. excessive menstruation) and are not a form of sterilization; however, they do have a sterilizing effect. If everyone's intentions are correct, the principle of double effect at work. Because we cannot see into other souls, we can pray for the best and operate as if the principle applies. (If the patient makes it clear that she wants the sterilizing effect, it's your duty to tell her that this procedure does not sterilize and you cannot guarantee that.)

You can participate in hysterectomies. Everything that applies to ablations applies also to it. Our bodily integrity is important, but this procedure is sometimes necessary for patients who fail conservative management (i.e. ibuprofen, lysteda, napro).

You can scrub into C-sections during which they plan to do a tubal ligation (BTL). You can assist with the section, but do not do anything during the BTL. To protect yourself from acting during the BTL, speak with your attending or chief resident (whoever the highest person in the room will be) beforehand.

(For medical students) Some attendings will not let you scrub because you're refusing to participate in the BTL. This is unjust, but take it gracefully and ask if you can observe. If they say no, go peacefully back to the floor or L&D.

(For residents and sub-interns) You can scrub into a BTL to practice laparoscopic access techniques. Make it clear to your attending that you will not be participating in the ligation, but are grateful for the opportunity to learn from their experience in entering and closing the abdomen safely.

You can participate in dilation and curretage (D&C) when done for missed abortion (miscarriage). There is no moral quandary here, if fetal death has been verified by lost heart tones, absent cardiac motion, negative hCG, obvious ultrasound findings (e.g. separation suggesting the decay of remains), or obvious history (e.g. three days of heavy bleeding with fetal parts). Always say to the mother and father of the child, "I'm sorry for your loss." Not only is this what they feel, but it builds up the identity of the unborn child as a person.

Obviously, you can participate in D&C for non-obstetric indications or retained placenta.

(Not usually for students) You can induce labor for missed abortion. If the loss is verified as above, console the patient and father and help with cervical ripening and augmentation.

Counsel on elective abortion (EAB). You must know at what gestational age different procedures (RU486 (mifepristone), D&C, and dilation and extraction (D&E)) can be done. You must be able to describe these techniques to women gently but without euphemism. You must also know the rates of post-traumatic stress symptoms and PTSD among abortion victims, the rates of live birth following abortions, and (if you're a gunner) laws in your state about waiting period, parental notification/consent, ultrasound, and upper gestational age limit.

Care for EAB patients before and after their abortions. This includes preop and postop care in the hospital, and follow-up visits in clinic. Ask about how the patient is handling the loss. Be ready to offer local post-abortive healing information (i.e. carry the cards with you in your pocket), but don't push it.

You can participate in training activities for D&C. A D&C is a legitimate operation for indications like excessive bleeding and missed abortion, and scooping out a papaya to learn how to do it is not a big deal. Don't fuss about this. Use it as a chance to observe to your peers sitting next to you about how weird it is that you'd do this when there's still a heartbeat.

Counsel on perinatal hospice. Perinatal hospice should be offered to any patient with a fetal anomaly that is "incompatible with life." This is a period of parenting the unborn child and mourning the loss of the baby the parents hoped for. It also involves services like Now I Lay me Down to Sleep (a no-charge project). Students and residents have a particular power in suggesting perinatal hospice (which is uncommon at most centers that offer termination for lethal anomalies) because we go in before the attending and can make suggestions that the attending would not.

(For residents) You can consent patients for BTLs and IUD/nexplanon insertions. To consent (like to counsel) is to offer a full picture of risks, benefits, and alternatives. We are the ideal people to consent for BTLs, nexplanon insertions, and IUD insertions, because we can stress that these things affect something valuable (fertility and integrity of lovemaking), and we can emphasize the permanence of sterilizations, and the fact that many regret their procedures. If you help a patient opt into a less permanent form of birth control, you've helped! It's painful to consent and counsel when people make the wrong decision. But we can only offer the truth (the whole truth), and allow our patients and our superiors to make their own decisions.

Wikimedia. The contributor writes:
"This is an image of my child, he died
and this is how I remember him."
You may visit and learn in IVF clinics. REIs are very intelligent and know a lot about physiology. If you are taken on a tour and see freezers and incubators, use it as an opportunity to pray for the little souls trapped there, and the adults who are trapped in confusion.

Pray every day. 30 minutes of mental prayer keeps you moving towards sanctity. (St. Theresa said that if we meditate, we will either become saints or stop meditating.) If I'm an OB intern and I can do it, so can you.

Talk it out with a friend. If the attendings are making you feel unwelcome, if you're stressed, if the culture is asphyxiating...get it off your chest! Get coffee with a friend and vent! If you don't have anyone sympathetic, email me. (That address is permanent, so even if you're reading this ten years after I wrote the post, I'll get it.)

Contact Alliance Defending Freedom if you're truly discriminated against. 

Be patient with yourself. You can't solve all the patients' problems or correct all your own inabilities all at once! Christ has the power to make up for your defects. Ask Him to do so, go to confession, and move forward in peace.

The Don'ts

Don't make assumptions about sinners' intentions. (This includes patients, peers, and attendings.)

Don't proselytize. Be attractive as a good student/resident, then be unafraid when people ask about NFP or the Catholic Church's ideas on contraception.

Do not advise the use of any hormonal contraceptive (e.g. mirena) in sexually active patients. Period. This is because of their post-fertilization effects.

Do not promote barrier contraceptive use as a good in itself. As Pope Emeritus Benedict wrote, condom use can be a step towards chastity, but always hold up abstinence as an ideal for the unmarried and NFP as an ideal for the married.

(For medical students) Try not attend more than two IUD insertions, more than two nexplanon insertions, and more than two essure insertions. Frame it as sharing with the other med students, or go find something helpful to do on the floor. Make something up if you can't find anything legitimate to do ("I have to go bring this down to the radiology library," "I have to fax this paperwork"), because it's important to not overexpose yourself and dispose yourself to think these things are okay.

Do not participate in egg harvests, male masturbation, intrauterine inseminations (IUIs) and other gamete transfers, or in-vitro fertilization. Medical students should not put themselves in this situation: do not do an REI rotation at a facility that does IVF. Residents: if you must observe, make it clear to the attending that you cannot participate, even by holding the transducer.

This is a miscarried baby, not an EAB victim.
Never be present at an elective abortion (EAB). This is not because your participation is any different from your participation in BTLs, essures, and LARC insertions. It is because it is much more dangerous for you to be exposed to a sin of the gravity of an EAB. Two former abortionists have told me that the first one is repulsive, the second one isn't as bad, and the third one they make a pass with the curette. Never participate. Say, "I'm choosing not to participate in abortions (or "terminations" or "electives" or whatever word your resident/attending just used)." Fake syncope if you must. I'm serious! Prefer disciplinary action to observing an abortion.

(Mostly for medical students) Don't disrupt a patient-doctor relationship. This means that if your attending has prescribed contraceptives for a long-time private patient, don't go into the room and talk about the carcinogenicity of hormones and the irresponsibility of using them. This will scare or frustrate the patient, make your attending unhappy with you, and cast a shadow on the truth about fertility awareness. This item not is on the list is because we want to be happy and comfortable. It's because a trainee has limited abilities to help people make good family planning choices; trying to break out of those limits will likely not help you become a physician, or a saint.

Don't dump any other task on others.

Don't be frustrated when people assume you're making these choices for stupid reasons. Most will assume you're choosing unfounded cultural/personal opinions over science. Take it gracefully, and remember that when you suffer it is because Christ is bringing you close to Him in His Passion.

I hope this post is helpful. I will edit it periodically to reflect new devices and laws as the need arises. I want to fill in some of the numbers and am working on finding the literature behind them so that I don't put unfounded figures in your mouth. Please leave a comment below if you've run into a situation I haven't covered.

Monday, June 29, 2015

On the Eve of Residency

On March 15, I was hired as a doctor. Sort of.

March 15 was Match Day. I walked up to a stage (to a mandatory 30 seconds of music that I had to buy; I picked "Son of Man," by Phil Collins) and picked up an A6 manila envelope. I opened it, with all other medical students nationwide, at noon and discovered where I will spend the next four years learning to take care of patients. To my great joy, it was my first choice: my discernment had been correct, and God chose what I'd chosen. I left the Match Day ceremony early (before I even pinned my picture over my new home) and went to Mass with my mother. I spent thirty minutes after Mass in deep happiness in front of the tabernacle, thinking of how good God is and how much He loves us. He had loved me into a program that had everything I wanted, and (so I've already discovered) far more than I knew. I'd signed a contract as a physician. So I was hired as a doctor, sort of.

On May 9, I became a doctor. Sort of.

May 9 was graduation. I walked across another stage in a tam and robes with green chevrons. (As a TACer or maybe just because I like "distinctive dress," I appreciate the meaning of regalia and feel honored and dignified in it.) It was deeply satisfying to accept my diploma and attain the goal I had hoped for, however vaguely, since I was four. I remarked to my father that I enjoyed this graduation more than my TAC graduation, because I did not understand what the last year of TAC was for, but I had understood my medical education. Medical education is an imperfect but powerful experience, and I'd completed it. Sort of.

On June 16, I started my new job as a doctor. Sort of.

June 16 saw the beginning of orientation. I'd moved in the day before, after a day-long drive to my new state, and a week-long retreat in solitude (final preparation for the consecration). I didn't have a stick of furniture, apart from my kneeler. I had to borrow the next month's rent from my parents. During orientation I scrambled in my new city to find Masses, grocery stores, gas stations, post offices, employee health clinics, pharmacies, train stations, and a dozen conference rooms in two hospitals. I ostensibly learned how to operate a new electronic health record, how to meet the expectations of me are on each rotation, how to resucitate patients during codes, how to do obstetrical procedures, and how to triage women who present to the hospital. So I was ready to act like a doctor, sort of.

On July 1, I will actually be a doctor. (Sort of.)

I will be one of the thousands of "interns," first-year physicians who are still learning the ropes of patient care. I will be rounding on antepartum and postpartum, and signing prescriptions. I'll work the night shifts over the holiday and I'll evaluate and manage (and maybe deliver) patients. During the rest of July I will be learning to perform ultrasounds, and in August I'll be working nights as one of the four awake OB/GYNs in the hospital. September, I'll be on labor and delivery during the days; October, I'll be working full-time in the resident clinic (30ish patients per half-day, NBD). November and December will be more time in labor and delivery, and some time in the OR for gynecology. And in 2016, we'll repeat those six months over again. By the end of it, I hope that I will have actually been someone's doctor. (There will be lots and lots of help to get me to that end-point, which is why I tacked on "sort of" again.)

Right now, I'm afraid. I'm excited to see patients and manage them, but that excitement is proportional to my confidence that this will be easy (i.e. that I have knowledge in my head about what to do when I see them). My confidence is quite low, so my excitement is very small. Instead, since I hear all these comments about how July is hard and interns start out slow, I'm very scared!

I'm trying to remember that God loves me, that slowness in the first few months of residency doesn't matter in the grand scheme of becoming a saint. That even if I am embarrassed and am the last resident in the class (which I may be; these people are all SUUUUUPER qualified and have advanced degrees and research and children), if I remain with Jesus throughout each day, it doesn't matter.

But prayers will be appreciated, because on Wednesday I'll be an intern. I am excited to begin this new chapter, but I need God's help to stay peaceful, more than I need my upper-levels' help to be a better intern.

Saturday, June 13, 2015

Dreams for a Catholic hospital

This is not exactly the heyday of Catholic healthcare. Then again, it wasn't exactly popular to set up hospitals in the days of St. Basil, either. So, ignoring the largely ambivalent-at-best atmosphere for Catholic hospitals, I have been dreaming of starting a truly Catholic hospital since college. I've been jotting down ideas for eight years.

The first thing I wanted, oddly enough, were placards with quotes from saints and Scripture on suffering. These would hang opposite each patient bed in every room, accompanied by crucifixes, and routinely changed. The hospital and have semi-private rooms for companionship with others, which is important in illness. (Of course, the hospital would also have private rooms, which are necessary in certain circumstances.)

The hospital would need a dedicated staff of the nurses, but also some employees who would spend time with patients, escorting them at the end of life or accompanying them on the way of the cross. For this purpose, I wasn't sure who I would hire. Volunteers? Nuns? Retired people? I'm still not sure. But I wanted someone to spend time with the sick. I thought about a renewal of Catholic religious sisters. The Sisters of Mercy, the Ursulines.... This kind of project cries out to be done, and it cries out for consecrated people. Who will do it?

I would look for doctors who know the purpose of their art: pro-life, and pro-family. I would look for pharmacists who would treat people as persons.  I would look for chaplains who would celebrate daily Mass in a prominent chapel and visit, visit, visit patients.

In college, I sort of wanted to be the person who would "do it" but I didn't think it would be me, and I didn't seriously want to do all that. I prayed that God would send an instrument, like he sent St. Pio to Italy. (When I heard all the work that Jere Palazzo had to do to try a similar facility in Kentucky, I was sure that this was out of my league.)

Now, I am not so sure. I am afraid that one of these "instruments" I prayed for, is me. I may be one of multiple instruments, but I am less and less able to escape the feeling that I should start something crazy, even while healthcare is falling to pieces and religion is intolerable.