Sunday, September 13, 2015

How to Counsel on Family Planning

Start by asking, “When do you next want to be pregnant?” or “How would you feel about pregnancy right now?” Based on the patient’s response, give prenatals and preconception counseling, or offer family planning counseling.

Assuming she doesn't want to be pregnant any time soon (because that's what this post is about), you'll cover all methods of family planning. I say:

"There are three types of family planning: short-acting, long-acting, and natural. Short acting ones like the birth control pill, the patch, and the ring all use hormones to stop your ovaries from working and producing an egg, as well as plugging your uterus with thick mucus, like in pregnancy, and making the lining of the uterus thin. Long-acting ones like the IUDs, the nexplanon, and the depo shot work for longer and you have to do less to make them work. Most of them use hormones like the short-acting types of birth control, but one IUD doesn’t.

"The natural or chemical-free methods mean that you track the signs of your own fertility to figure out when your body can get pregnant. If you know when you can get pregnant, you can choose to have sex on that day or not, depending on when you next want to be pregnant. This requires more work than any other method, because you have to learn to pick up on your body’s signs, but it’s cheaper and also clues you into your own health.

"Which of these would you like to hear more about right now?"

Depending on what the patient says, I go into effectiveness, perks, adverse effects, and cautions/contraindications of the method(s) she's interested in.

The Good
The Bad
Cost (cash)
Some with Fe, folic acid
Effectiveness based on pt (applies to all short acting and FABMs)
24+ h
estrogen warnings (never in daily smoker > 35 yo, h/o DVT/PE/CVA/MI, SLE with APA, migraine w aura + FNDs)
POPs (progestin-only pills)
Safe in lactation (applies to all progestin-only)
Intermenstrual bleeding, spotting
24 h

Ortho evra (patch)
Simpler than pills
Doesn’t work well >90kg, double risk VTE compared w/ OCPs
7 d
Lactation, estrogen warnings
Simpler than pills
Vaginal discharge
7 d
Lactation, estrogen warnings
Depo provera
Amenorrhea in 55% at 1 yr, 68% by 2. Decreases crises in SCD
Irregular bleeding, wt gain 3lb/yr, reversible bone loss
3 mo
possible pregnancy, local cellulitis
No GU tract procedure. Palpable by patient
Unpredictable bleeding that doesn’t Δ w/ time. 10% rule for 1) irreg bleeding, 2) wt gain, and 3) acne
3 yr
possible pregnancy, local cellulitis
0.2% for yr 1
0.7% by yr 5
Amenorrhea in 20% and oligo in 60% at 1 yr
Irregular bleeding first 3-6 months
5 yr/ 3yr
IUD contraindications (<6wks postpartum, uterus sounds >8cm, possible pregnancy, untreated GU infxn incl PID in past 3 mo) plus brca, anticoagulant use, liver dz/tumor
No hormones
Increased bleeding with natural cycle
10 yr
IUD contraindications plus Wilson’s
Translates into GYN managmt, distance teaching
Very involved charting and follow-up
Language barrier, h/o noncompliance

Needs follow-up
Language barrier, h/o noncompliance

Objective, online teaching available

Monitor $200
Strips $35/30 (need 10+/mo)
Language barrier, h/o noncompliance, not good with devices

Thermom $10
Couples only
Most difficult rules
Language barrier, h/o noncompliance

I always put something in her hand if she wants to try a natural method. That's the way the prescriptions and devices work: there's always a pill pack, a crisp, robust brochure, or a prescription at the end of conversations for contraceptives. When I refer a patient to an NFP teacher, I hand her a nifty little packet (I made a bunch of these) with the person's business card and a page detailing her new method of family planning and singing its praises.

Prices for FABMS vary by location and teacher. I called around to get prices for each of the teachers I refer to (MM, CrMS, and BOM in my new metroplex) so that I can tell the patient what to expect.


Cost estimates: 1 and 2.
Mirena data: PI.
Depo data: PI.
Nexplanon data: PI. (No pregnancy rate, so I used the norplant datum from the paragard PI, which matched the CDC data linked below.)
Nuvaring data: PI.
Patch data: PI
Paraguard PI is here, but there aren't any numbers on increased bleeding.
Effectiveness: CDC (6% for depo)
The big chart you might see everywhere is from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Kowel D, Guest F. Contraceptive Technology: Seventeenth Revised Edition. New York, NY: Irvington Publishers; 1998.
FABM review here.

Saturday, August 29, 2015

Two months in review

In the past two months, I've been on night float and on the ultrasound service. I've worked an average of 68 hours per week and used 1-2 servings of caffeine per 24 hour period. I've delivered 35 babies, done 5 C-sections (as primary surgeon), and done about 160 ultrasounds of various types.

I'm learning how to admit patients to triage, evaluate them, "dispo" them (send them home or keep them), answer dozens of types of nurse and patient phone calls, and "update the board" (keep abreast of what every patient is doing in labor and delivery). I'm also working on ways to wash laundry only every other week, recycle in my small borough, cook only once a week, make a bed while getting out of it, and shower in the time it takes to sing a Credo. I've replaced a car battery, hung blackout curtains, and bought several loads of furniture. And most importantly, I'm trying to make space in all this work for the liturgy of the hours, meditation, the rosary, confession, and Mass. I've made a lot of mistakes, but I'm being patient with myself as I try to do better. It's been a challenge.

I enjoy the work, especially when the deliveries are beautiful or I get things right. I'm at a good hospital with excellent and friendly nurses and my upper levels and chiefs are paying it forward, being kind to me so that I can be kind to the students and the next generation of residents in the future.

Things to learn in the future are how to not miss morning meditation, how to write discharge summaries in ten minutes, how to round on a dozen people in an hour and a half, and how to do dishes only once a week without starting an impromptu microbiology lab. I am also working on having local NFP resources printed for handing to patients in clinic (which is happening in the next two months) and having my elevator speeches together for when I am doing nothing but seeing postpartum and clinic patients. Any prayers would be appreciated!

Friday, August 14, 2015

Consecrated Virginity FAQ

On June 20, 2015, I became a consecrated virgin living in the world, according to canon 604 of canon law (the body of legal principles governing the Catholic Church). This vocation is ancient and new, and it's viewed positively by traditional Catholics. There is already an excellent FAQ on consecrated virginity in general, but because of previous posts and the very worldly nature of my schedule, I wrote this post.

What do you do?
As of this writing I'm an intern in obstetrics and gynecology, so I work fifty- to eighty-hour weeks at a hospital in labor and delivery, the emergency room, the operating room, and the women's health clinic. I also pursue research in fertility. But what I do is less important than what I am: a bride of Christ. I will live a life of prayer and penance and remain without marrying a human person (and without physical children) in this life.

You're a consecrated virgin and you spend seventy hours a week with pregnant people and researching fertility?
Yes. God has a sense of humor. (But there's also a long precedent of consecrated women caring for women, mothers, and children, so I'm not that strange.)

So! You're childfree?
I suppose it depends on how you define "childfree." If you mean "without children," then yes. I have made a permanent, irrevocable commitment to preserve my physical virginity, so I will never voluntarily have sex and thus won't have children. (Not only will I not bear my own children, but I cannot act as a surrogate or adoptive mother, since these actions don't dignify children according to their right to be raised by their father and mother. Accepting the moral teachings of the Church is part of being a Catholic, which is a prerequisite to consecration.)

But I thought "without children" was the meaning of the word "childless." I am not an expert, but I thought "childfree" meant at least two things besides "without children." I thought it implied 1) sexual activity and 2) a belief that children aren't desired. Even though childfree men and women often sincerely acknowledge that they love children (and some choose to be childfree to care for children of others), they have decided that for them, or for now, or forever, children are not desireable as a fruit of their sexuality.

Although I'm a sexual being and still live my sexuality, I don't have a "sex life," so I can't make the decision to be childfree (as I understand the word). Of course, if "childfree" only means "without children," I am childfree. (So's the pope, and he has plenty to say about the decision not to have children.)

So, you pretty much just had a wedding ceremony by yourself?
No. Human persons are meant to give themselves completely to the infinite Love that is God. Whether they do this through another human or directly (by God's grace!), they must make a total sacrifice of self so that nothing is left. To "marry oneself" is impossible--one can't give everything away and also be receiving it. The woman in the story I linked to was having a wonderful epiphany about the independence of her strength and happiness from the lives of other persons, but she wasn't marrying herself.

So no, I'm not marrying myself. Am I marrying anyone at all? Yes. "Virgo est qui Deus nubit," St. Ambrose said, "the virgin is she whom God has married."

Oprah covered the final vows of several Dominican sisters and pointed out that their vows are a marriage. However, she said that "the groom is present only in spirit." I remember watching that episode and laughing a little sadly. God the Son is more present and more real than any human person, even far away from the blessed sacrament.

God is not some imaginary thing we think off to. He stands under and continuously creates everything. It's because He has you in mind that you're existing right now. So no, I'm not marrying a vague spiritual idea. I'm marrying He who Is, who is more terrifyingly real than any thing.

Is this because you want to be a priest? Would you be a priest if you could?
No and no. I want to be the saint that Christ has in mind when He loves me. That saint is feminine, and has quite a lot on her plate without trying to be an alter Christus as God shapes only men to be. I love my call. I think it's probably the most fantastic one He's ever created!

I don't think the second question makes sense. It's like "what animal would you be?" It might tell a little about me, but it's bound to misrepresent me if it's taken absolutely. Just as I can't (and don't want to) become an eagle, I can't become a priest, since God gave us a fatherly priesthood. But just as I could (and might) say at a dinner-party "I'd like to be an eagle" because I would love to fly, I can say (like St. Therese) that I would love to be a priest because I want to resemble Him in every way I can imagine.

In reality, I have that flight of priestly glory in my consecrated virginity. Each of us has it in our calls to sainthood--we just have to take it, and bowl between the rails.

Did you choose this for more freedom from obedience? Habits?
No. Consecrated life developed from the second half of the first millennium to the end of the second. The developments were beautiful and helpful for the Church and the world of that time. And, like every development that the Holy Spirit rolls out, there is something perennially helpful about it. It is good that some wear "distinctive dress." It is good to have a structured community. But it is not necessary. Otherwise, how would so many early virgin martyrs and anchoresses have become holy?

In North America, most Catholics in the new evangelization associate orthodox consecrated life with full habits, thriving communities, and a return to the rigors of the evangelical counsels. All these things are fantastic and support orthodox religious life! However, living the counsels to the fullest, as Raniero Cantalamessa and Thomas Dubay point out, does not have to involve obedience to men, or a set degree of exterior poverty.

This was a hard pill for me to swallow, because I was wary of "consecrated women" who didn't wear habits, live in convents, have a rigorous rule of life and schedule, and exhibit the forms of obedience and poverty. Slowly, I began to recognize that I this state in life entailed complete submission to the counsels, although in a way I did not understand.

Is this something for ex-nuns?
I know consecrated virgins who left convents. In one case I know of, this was because there was not enough contemplative prayer after the novitiate in the order she joined. Consecrated virginity is not something for people who don't want to love our Lord.

Are consecrated virgins basically nuns?
Consecrated virgins have been called brides of Christ since the years of the early Church. This title that has also been accorded to nuns and religious sisters for centuries as well. But in important ways, we are not like nuns. Important aspects to the religious life include the charism of a founder, community life, and distinctive dress. Consecrated virginity does not have these elements of consecrated life, which developed later in Church history to adorn religious life.

So, you're a layperson (or in a lay movement, or you're a lay consecrated woman)?
The words "lay" and "layperson" have changed in the past century. "Lay" used to refer to anyone who was not in orders (anyone besides priests, deacons, and bishops). It then came to mean anyone who was not in consecrated life or in orders. In either sense, a consecrated virgin is as lay as a cloistered Carmelite.

Is consecrated virginity the same as making private vows?
No. Vows are made by a human soul to God; God consecrates a consecrated virgin. Because consecration is an act of God, it is permanent and irrevocable.

I do make a threefold propositum during the consecration, which beautifully lines up with the three counsels. However, I am not made a bride of Christ by my propositum. I am passively swept up as God deigns to consecrate me at the hands of His bishop.

Why isn't this a sacrament?
There are seven sacrosanct signs producing grace (signum sacrosanctum efficax gratiae). These are primary channels of grace God gave to save us, that will not change until the end of time. At the end of time, their purpose will be complete, and there will be no more baptisms, no more marriages, no more ordinations, and no more Masses. Sacramental realities will give place to non-sacramental realities.

Consecrated virginity is a non-sacramental reality. It belongs to the world to come, which is why it seems like a lack-of-something (e.g. like being childfree) here on earth.

What do consecrated virgins wear?
They wear modest clothing that suits their time, place, and work. They might dress a little more modestly than a faithful Catholic woman in their age group. Practically speaking, I wear scrubs in the hospital, conservative professional clothing under my white coat in clinics, and long skirts and modest shirts to Mass. Some consecrated women do not wear pants so that they can witness more completely to God's love in the gift of femininity. I wear pants because otherwise, I'd put up unnecessary barriers to friendships and evangelization.

Do you have a rule of life? An horarium? Superiors?
I do have a rule of life. My spiritual director approved it before my consecration. I do have an horarium, although prudent direction helps me adjust it as rotations change. I do not have superiors, although I treat my bishop as a loving father, for whom I would do anything that wouldn't jeopardize my moral or fiscal stability.

How do you live the evangelical counsels if you don't make vows?
This deserves a post all on its own! The counsels are meant to change our hearts to Christ's and make us thirst for God the Father. I live poverty by leading a radically simple life; this was rather easy as a medical student (living on loans) and is still easy as a resident (living to pay back loans). There is no money spent that is not spent for Christ and with Him in mind.

I live chastity by working to increase the purity of my intentions, so that I can be chaste in body and mind as I become single-hearted like Christ, wanting only whatever the Father wants. For instance, I often want to ask my upper-level residents for feedback because I want praise. That thirst for confirmation is better quenched by Him, so I choose chastity when I purify my intention and only ask for feedback when I want it.

I live obedience by constantly looking for the will of God. Paying attention to the circumstances and holy desires I find in the present moment, I look for ways to advance God's mission to save souls. For example, perhaps I choose to listen carefully to a patient's slow explanation of what is going on, even though I have so many more to see. Perhaps I accept my ignorance during my training as a way to be with Him during his humbling human childhood.