Thursday, March 21, 2013

How do pro-choice doctors think? (Part II)

(Part I) A lecturer mentioned the Mirena IUD as a good therapeutic for lots of gynecological problems, especially dysfunctional uterine bleeding. Over a few emails, I asked him about how the Mirena works and gently probed him about the abortifacient properties of Mirena. "If the Mirena can thin the endometrium in a patient who is still ovulating, couldn't this cause loss of an early embryo?" I asked.

 "Yes, it could," he answered. He beat around the bush, though, so I asked him point-blank: "Is blocking implantation abortifacient?"

Here's his answer. The two ellipses are his own, almost as if he's hemming and hawing in discomfort:
That's an ethical discussion, [mmatins]. I think most patients who are concerned and ask about it think of it in that me, it's not quite the same as intentionally ending an existing pregnancy, but it gets at the argument of when life begins: is it at conception, at implantation, at birth, etc...
How can someone say "that's an ethical discussion" and mean "that's a discussion I can't have?" Ethics permeates everything we do; it is the science or art of acting well! Ethics is so important to reproductive medicine, and it is precisely there that it is treated like it is irrelevant or relative.

When Obama tried this move I thought "psh, come on." When an OB/GYN tries it, I moan and think "who gave you a license??"

And imprecision we wouldn't put up with elsewhere: "it's not quite the same." Not quite? So how much? Should we put up limits? Should we establish best practice guidelines? Should we pass a law? Should we at least tell patients it's "not quite them same" instead of telling them "no, Mirena doesn't cause abortions"?

The insanity continues, though. I emailed a second professor. This woman is a brilliant maternal-fetal medicine OB/GYN with whom our whole class is in love over her funny (and manageable!) lectures. Here is what I asked her:
In your work you monitor, treat, and even operate on babies during delivery or even longer before they're born. I'm trying to reconcile this concern we have for fetuses with medical and surgical abortions. Sometimes we make sure babies are okay; other times we make sure they regress or are removed. How is this consistent?
She replied:
That is a big question and [there are] so many debatable topics possible there. I think a lot of the answer, from my standpoint, goes into counseling patients about what we know about certain diseases and therapies for intrauterine treatments. There will be many more in the future I'm sure, so right now, sometimes we are limited in fetal therapies. As for elective terminations, the same applies for extensive counseling for the patient. risks and benefits for terminations as well as for fetal procedures are key for patients making these decisions. Not sure if that answers your question. MFM is a very challenging field as there is very seldom a distinct line that helps us decide what therapies work....and very rarely, if ever, is there a predictive fetal test that is 100%! This makes the job of an MFM always challenging, and I am sure the role of the pregnant patient very frustrating and complex.
The advice to counsel patients completely is good (I will always do that) and the words about difficulties should be appreciated as coming from one with experience. But finally, she didn't answer my question. I replied, clarifying my question to
..."is the fetus a patient?" The answer is "no" in elective termination but "yes" in laser ablation for poly/olis (for instance). Why does the answer change?
And she said simply:
So, it seems that in the OB world, in regards to procedures, many decisions are made regarding the viability of the fetus (ie: would it be able to survive outside the uterus) at the time of the procedure.
I asked her whether elective terminations will be threatened by advances in NICU, and haven't heard back yet. But the answer to the question "how do pro-choice doctors think?" seems to be...they don't. When I ask them a question, they skirt it, and refer to vague principles about patient counseling and changing technologies that don't hold water.

I don't read intentions onto this omission (rather, I will hold that they are doing their best with what they have been given and I pray that they live long and never resist grace). At the same time, they just don't put two and two together. Stay tuned. We had the contraceptives lecture today, so this blog will scale the cliffs of insanity again before May.

Monday, March 18, 2013

Pope Francis!

I spent spring break (the past week) studying neuroscience and the drugs affecting the brain, nerves, and psyche. On Wednesday morning I finished some practice questions and answered all the emails, texts, and notifications on my phone before I took a break for lunch. I came back to find a few new emails (a rate of two emails per hour isn't unusual, but I also had about nine texts, which was weird).

The first email was from an intercessory prayer address connected to the Ordo Virginum. There were two new requests. The chronologically prior email was "Please pray in thanksgiving for such-and-such and so-and-so," and I started to say a dutiful prayer. Before I finished, my eyes wandered down to the second request (mea culpa). And I stopped mid-Hail Mary because the second email said, in big bold letters: "Habemus Papam!"

And then I seized my phone and read the texts, all of which were friends, facebook, or FOCUS telling me that I was no longer a sedevacantist.

I was alone in the apartment, but I wanted to share day this with someone! Who was still in town?? I texted a friend who lives in the next apartment complex. It was a long shot (she works), but it turned out she was home. I quickly got ready and drove over, fearing that I would be too late if I walked the (very walkable) distance.

She works in media, so I was unsurprised to walk in and find that she was using two laptops and a TV to virtually transport us to St. Peter's Square. Youtube, radio, and various apps helped, too. At several points she took out a phone to text friends the details, and this made me laugh (four screens in one room for one event!), so I took a picture.

We had plenty of time to feel anticipation with the rest of the crowd in faraway Italy (and in the rest of the waking Catholic world). Finally, the protodeacon came out and announced something, and all I could understand was "and...Francis." My heart soared. Francis? Pope Francis? Did I translate that correctly?

My desktop image the week of Pope
Francis' election. Source
I love St. Francis of Assisi, although not as well as I should and not in the way I'm sure he would like. He is poor, he was asked to rebuilt the Church, he is chaste, he is Christ-centered, he loved reverence, he loved the Gospel, he was radical, he loved the sick....

Usually my desktop image is the week's schedule of classes. Since I had no classes last week, I downloaded one of Zurbaran's St. Francis paintings.

People love to talk about whether this pope will be liberal or conservative or this or that. Everyone's spilling so much ink (pixels?) over it. Why can't we just allow God in him to shape us? Why search his words and actions for things we might not agree with? Why form an idea of Catholicism and try everything on it to see if it fits our style? It feels more fun, but it's laborious and seems militant, repulsive, and divisive to non-Catholics or not-so-involved Catholics. Besides, the humble "fiat" of being shaped by God through his Church resembles reality much better. </preaching>

I am amazed by the humility and simplicity of this Pope, before and after his election. My favorite work of literature opens with the description of a fictional bishop much like him. The first time I read Les Miserables, I fell in love with Bishop Myriel and wished that all Catholics were like him. Then, I thought, we would really win the world for Christ! He lived with minimal expense, he gave his allowances to the poor, and he walked so that the poor could also use his transportation stipends.

Courtesy of HuffPo.
I was lit up with desire to do the same thing! I got the same passion when I watched a documentary on Mother Teresa and saw how poor her sisters were. Opening a convent in New York, they uninstalled the water heater saying simply, "we will not need it." When the sisters moved in, each carried a cardboard shoebox tied with string instead of a suitcase. That's poverty! Pope Francis' example renews my hope that this is possible, and that it's also important. Poverty coheres with the rest of the Christian life and it's attractive to others. St. Francis and Pope Francis evidently know it! Maybe poverty is an important part of the new evangelization.

Final observation on the papal election: if I prayed as hard and as much for my local bishops as I did that day for the new Pope, I think it would help my diocese. So, one resolution born out of the conclave is to pray and offer sacrifices for my diocese and bishops. I should've been doing this already!

Let's pray for each other, our local bishops, and our Pope. Viva Christo rey!

Wednesday, March 13, 2013

A Car Accident Shows Me the Real Purpose of Life

Last Saturday began like any other Saturday. After I finished praying I went to my car to drive to Mass. I knew I needed to gas up. At the exit gate for the apartment complex, I could either turn right to go to Mass first, or turn left to gas up before going to Mass. It was 7:30 (really, time to go to Mass), but I figured I could squeeze in the errand on the way. I was very confident in the time--I was nearly there at 7:33.

I was nearly there when I was involved in a car accident.

Monday, March 11, 2013

How do pro-choice doctors think? (Part I)

A lecturer mentioned the Mirena IUD as a good therapeutic for lots of gynecological problems, especially dysfunctional uterine bleeding. He stated that it does not suppress ovulation.

I was puzzled, because per the package insert "[o]vulation is inhibited in some women using Mirena. In a 1-year study approximately 45% of menstrual cycles were ovulatory and in another study after 4 years 75% of cycles were ovulatory."

So I emailed him to ask.
Thank you so much for your lecture today.... I have a question about Mirena.

You said that Mirena does not suppress ovulation. But if it has contraceptive benefits, doesn't it have to suppress ovulation? I've heard defenses of Mirena against arguments that it is abortifacient, stating that its effects are primarily antiovulatory.
And he replied in a very timely manner!
Great question.... In a small minority of patients, the Mirena can suppress ovulation (probably from a "local" effect on the ovary), but in the majority of patients, it does not. The primary mechanism for contraception is complex, but is thought to be primarily by preventing sperm from being able to navigate up to the egg. This is by: 1) progestin effect on thickening cervical mucous 1) progestin thinning of the endometrium to the point of "near atrophy," which doesn't allow for a substrate for sperm to swim on 3) slowing of motility within the fallopian tubes due to progestin which prevents sperm and egg movement. 
The possible abortifacient effects of IUDs is a common question that comes up in counseling patients. If fertilization had already occurred, and an IUD was then placed, it could act in that regard. However, that is not the primary mechanism for IUDs (again, they prevent sperm penetration to the egg). The copper IUD is actually FDA approved for emergency contraception because of that effect. That is one of the reasons that we try to place IUDs following a menstrual cycle. That way we know it is not acting as a potential abortifacient. Hope that is helpful.... 
So, per the package insert again:
The local mechanism by which continuously released levonorgestrel enhances contraceptive effectiveness of Mirena has not been conclusively demonstrated. Studies of Mirena prototypes have suggested several mechanisms that prevent pregnancy: thickening of cervical mucus preventing passage of sperm into the uterus, inhibition of sperm capacitation or survival, and alteration of the endometrium.
I wasn't trying to trap my professor or anything (I only looked up the package insert this morning as I typed this post). But the insert doesn't say anything about capacitation. It's quite likely he's read something else since the package insert came out.

But my professor didn't say anything about the possibility of a woman who had ovulated with a Mirena inserted during a previous cycle and who conceived. So I emailed him again.
I looked at the package insert and saw that 45% of women are ovulatory during the first year of use. If the Mirena can thin the endometrium in a patient who is still ovulating, couldn't this cause loss of an early embryo?
And he answered,
Yes, it could. As I mentioned, if fertilization did happen, an IUD can prevent implantation (ie, the copper IUD is FDA approved for emergency contraception). The main point is that that is not the primary mechanism for how IUDs work. In addition to preventing implantation, a bigger gyn concern with the Mirena is the risk of ectopic pregnancy if fertilization occurred. As mentioned motility is slowed in the Fallopian tube, so a pregnancy is more likely to not "make it" to the uterus, and implant in the tube. We would have a high suspicion for an ectopic if someone conceived with a Mirena in place. Still, the contraceptive efficacy of IUDs is extremely high (similar, in fact, to tubal ligation), so all of this would be significantly rare.
"Significantly rare"? "The main point"?? "The bigger...concern"???

Here's how I hear what he's saying:
Yes, Mirena could result in death of a baby. As I mentioned, if a person was conceived, an IUD can prevent them from implanting. But the main point is that's not the way things usually go. The bigger concern is ectopic pregnancy and the danger to the adult person's life if a new person is conceived. Still, the pre-fertilization efficacy of IUDs is extremely high, so all of this would be rare enough so that we can ignore it and prescribe anyway.
I'm sure that's not what the professor thinks. He probably does not think human life beings at sperm-egg fusion, or he holds that premise but is like the man in Aristotle's categories:
There is nothing to prevent a man's knowing that A belongs to all B and B to all C, and yet thinking that A does not belong to C (e.g., knowing that every mule is barren and that this is a mule, and thinking that this animal is pregnant); for he does not know that A belongs to C unless he considers the two premises together. (Prior Analytics II.21.67 a33-37)
Is that's what's going on? I wanted to find out. So I emailed our best OB/GYN professor. More on that later.

Tuesday, March 5, 2013

The Unborn as Spoken about in Med School

Some interesting language touching unborn patients in my STEP 1 review book (emphasis added):
Week 4 Heart begins to beat (504) 
Aminoglycosides [cause] CN VIII toxicity. [Mnemonic is] A mean guy hit the baby in the ear. (506) 
Warfarin [causes] Bone deformities, fetal hemorrhage.... [Mnemonic is] Do not wage warfare on the baby... (506) 
Branchial arch derivatives [mnemonic:] ...children tend first to chew (1)... (510)
All that is pretty interesting, no? I especially think it's interesting that the mnemonics refer to fetuses as "babies" or "children" indirectly. The mnemonics are frequently student-made and they're also made by people who don't care about pleasing others, but who just want to know the facts. When you don't have to court readers, the truth shines more clearly.

On the other hand, fetal circulation is explained as though the fetus is an organ and magically becomes an "infant" upon exiting the womb:
3 important shunts: (1) Blood entering the fetus through the umbilical vein is conducted via the ductus venosus into the IVC to bypass the hepatic circulation.... At birth, [the] infant takes a breath....
And there have been a few interesting wordings in the practice test Qbank, too. I'm not sure how those are copyrighted, but here are some phrases:
[There is a birth defect in] the fetus at 34 weeks of gestation. The baby is born alive at term...
[Maternal diabetes caused some birth defects and the mother] blames herself for 'not caring enough for my baby.'
We had a female reproductive pathology lecture last week, and the lecturer referred to endometritis as largely a thing of the past in this country thanks to legal abortions, and said in a regretful tone that it is seen more often in places where abortion is illegal. (I believe she probably meant to say that endometritis is not often seen in places where abortions are not performed or are done antiseptically, and is often seen where abortions are performed without antisepsis. But "no abortions" cannot ever be spoken of for some reason.) And she used the term "products of conception" and its abbreviation "POC" for the first time in our medical careers.

And we had a lecture today by an IVF doc who said on one of his first slide: "Processes of cell division are prone to errors that are significant and uncorrectable when an individual is represented by one or few cells." and he said aloud in comment that errors like this are tough when "you're only one cell." (I added the emphasis in both quotes.) Yet, his lecture talked all about IVF, and he presented a case where a couple went through (shudder) six embryos for one live birth.

And will our OB/GYN lecturer please stop calling the unborn people "parasites," even in jest? Would calling anyone else a parasite be even remotely acceptable?

Figure A. Parasite

Figure B. Fetus

Sunday, March 3, 2013

SIM Center: OSCE, Hospice, and Bad News

I recently tried to make a busy person retreat. I say "tried" because I showed up for direction the first two days: on the first day I wondered whether my directress thought Christ was an ascending savior and on the second day we mutually decided that I was actually too busy for a busy person retreat (this was when STEP 1 was really beginning to overwhelm me). I was glad of this because 1) I needed the time and 2) I wasn't really sure if I was on theologically sound ground. 

School is beginning to wind down: my last (fourth) preceptorship is in the SIM center, and the Palliative Care class had its culmination in a lab, also in the SIM center.


The preceptorship SIM center evaluation (OSCE) with a standardized patient was mixed. I missed the key finding because I forgot to do part of the physical exam. I definitely left with a feeling of "Achievement NOT Unlocked" because the red folder with the abnormal findings remained unopened. Normally, if part of the physical exam on the patient in the case would have resulted in a finding that the healthy actor can't simulate, the SP instructs the medical student to open the red folder if the student examined that (example: if you don't listen to the lungs, you don't get to open the folder and discover that you "heard" diffuse crackles). When she didn't give me that wonderful relief, I realized that I had missed something and I asked her, "Is there anything else I should know or any other questions?" She cheerily said after a little pause, "No, no other questions!" I felt like saying directly to her: "Uh-huh. I missed it, didn't I?" But of course, we were both in character, so I couldn't.


In the Palliative care lab yesterday, I was given the "chart" of an SP, took a brief history, and performed a physical exam. But it was different from the previous OSCE because my goal wasn't to diagnose the patient. Instead, I was to determine whether it was appropriate to refer them to hospice care. Speaking with the SP, I talked about her goals and her current life (bed-to-chair existence), and how hospice might help her life a little less tiring, boring, and depressing. It might help her husband worry less about her, it might help stop her rapid weight loss.

This stretched my limits. I like telling people "I know what's going on, and here's how we're going to work together to fix it," or "this isn't as bad as it seems," or "don't worry." But it's hard when I cannot say anything remotely resembling "this will all work out," and have to be realistic. There's a superadded challenge because I'm not sure whether I can talk about the true Source of hope, Who is never overcome by any dim future.

In addition to stretching my limits, my encounter brought out an interesting dimension of SIM centers and SPs. The SP I advised about hospice was the same SP I'd seen before for a prior OSCE. And I also saw her outside the SIM center between  the elevator to the parking lot, just a day before the Palliative Care lab. We chatted about her pet roosters and how they wake her up too early.


The Palliative Care lab also required us to give bad news to an SP.

Friday, March 1, 2013

Another Crazy Friday Night: Who but a Catholic?

I had another crazy Friday night recently.

I prayed Evening Prayer and went to Mass at the Newman Center. And then, because it was a Friday in Lent, there was half an hour of Adoration, followed by the Stations of the Cross. Who but a Catholic spends Friday night hoping to be conformed to God from their miseries, or doing reparation to the heart of Jesus?

There was a soup supper after Stations, and one of the Daughters of St. Paul was giving a talk on the Theology of the Body. Who but a Catholic can simultaneously mortify the flesh and drink in a teaching about how sanctifying and beautiful the body is?

I didn't stay long at the soup supper, because I and several of the other girls there had a previous commitment: a meeting of a small group of women seriously discerning consecrated life. There, we spent the next three and a half hours about the love of Christ and how he had worked in each of us carefully, gently, and lovingly. Who but a Catholic can understand this roomful of young women, ardently in love with a man largely considered insipid or mythological?

As we exchanged stories of how Christ had called us to be His own, I was amazed at how beautiful and unique each soul and each story is. "Unique love," mused one girl. "Everyone is made to love Jesus in a way no one has before; if we don't, He'll sort of lack that love." Who but a Catholic can humbly and truthfully that creatures so lowly are so valued by the Omnipotent?

I had hosted the meeting and I closed the door after the last guest left, exhausted and happy. It was almost midnight, and I prayed Night Prayer. And looking back at the day, I thank God for the Church. I never would have realized all these truths by myself; thanks to God, I received them. How gratuitous! Truth Himself imprints the Church with His image, and hands it freely to us, a garment of salvation.

"Head and members form the same mystical person" (St. Thomas Aquinas).

"About Jesus Christ and the Church, I simply know they are just one thing
and we shouldn't complicate the matter." (St. Joan of Arc)
The first crazy Friday night here.