Monday, October 21, 2013

I Wish I'd Known

Prayer will make you beautiful!
It might not give you flowing dark hair,
though. Sad face.
I wish I'd known that prayer is like all other types of socialization: we learn to do it as children in a rudimentary, sweet way. As we grow into middle-schoolers and high-schoolers and college students and young professionals and spouses and middle-aged people and elders, all our friendships advance and flower. Prayer (intimacy with God) should, too! I wish I'd known that I was living the prayer life of a child into my late teens.

I've thought about this several times recently: I listened to a talk from the School of Faith (get the talk by creating a login here; it's Faith Foundations I Lesson 9) and I read this post about prioritizing prayer and then I heard my parish priest give a homily saying pretty much the same thing just yesterday.

Do you live an age-appropriate prayer life? This article might be a good help towards a beginning to grow up into spiritual adolescence. And asking someone who is a little further along in the journey was helpful for me; hopefully God will (or has already) placed this person in your life. If not, pray that He will!

Now you know what I wish I'd known. God bless you today!

Tuesday, October 15, 2013

What is formation like for consecrated virginity?

Disclaimer: you are now reading a post about formation by the one being formed, not by the formers, which is kind of like asking a second-grader about the objectives and milestones required to advance to the third grade. </disclaimer>

Formation for consecrated life is formation for the whole person, to prepare them to live as a spouse of Christ on earth and a mother of souls. Forming the whole person includes spiritual, intellectual, and affective components. For example, I am taking a Faith Foundations class through the School of Faith (it's free and available to you, too!) for intellectual formation right now. For affective and spiritual formation, I am following a rule of life and meeting with local focolarine weekly. Each week, we review and share on practical applications of topics like:
  • God loves me immensely (where? when last week? even when you were suffering? how do you know? do you trust Him?)
  • doing God's will in the present moment (even in the car? are you patient in the present moment? do you stay there with Him?)
  • loving like God: first, unconditionally, with a smile (this is how you spend the whole day with Him! If only I knew anything about it....)
  • the Word of God lived out in life (we're on this now and I'm totally confused)
Med school is also a help with affective maturity and discipline. When I read about old-fashioned religious obedience and humility (e.g. when St. Bernadette would be told "kiss the floor and leave" or when St. Therese would not excuse herself for misdemeanors she wasn't guilty of) I think, "oh, perfect. Med school is just like that." The third year med student is in a year-long postulancy where no no excuse is valid and no credit is given. And who needs hair shirts when you have to give up your personal time to do practice questions, study, and drive? It's very hard to keep a balanced lifestyle, so it really tests your discipline and prudence. (When should I study? How much? Am I doing my duties? What comes first: morning prayer, or morning report??)

Formation has been challenging but amazing. I am shocked at the changes I see in myself just in the past 12 weeks. The most important part has been having spiritual mothers to set an example of unconditional love. God is radiantly generous!

Academic Medicine 101

Before I started medical school, I had no idea that "academic medicine" is the segment of medicine that researches and teaches. Some physicians see patients all day, every day while others do research (either clinical, basic, or translational) or teach (e.g. lecture, and supervise the practice of residents and the visits and notes of medical students rounding under them). Most of my experience of academic medicine is with the teaching physicians. Let me tell you about it.

First of all, I haven't had my big academic rotation yet. This is the famous "Internal Medicine" rotation (shortened in speech to "IM" for some schools, "I-Med" for us). From what I hear, that is twelve of the most intense weeks of seeing patients, giving presentations, writing notes, being humiliated, and learning the minute mechanics of fluid and medical management.

Did you catch the "being humiliated" in there?

Although I haven't had IMed (and so I feel like I can't really talk about this?), I have had one week of adult inpatient and one week of pediatric inpatient. My attending last week (pediatric) literally said that medicine is taught by shame. "That's how you remember things," he said, "by being put on the spot." I like to think that it's not shame, but responsibility that teaches us. When a person in need, in front of you, is your patient and your attending asks you "how are you going to replace his potassium in light of his serum creatinine?" and you blanch and have no clue, you're going to learn it well and know it next time.

Last week, for instance, I had one week of pediatrics. I got up early to report to the hospital an hour before the attending scheduled "rounds." I was assigned one patient each day, and went to talk with them and examine them and prepare a presentation and admission orders, including IV fluids, drugs and doses, and special nursing instructions. (All of these orders were practice; none were actually carried out except if someone else, e.g. the resident or fourth year, had the same idea/agreed with me and ordered them.)

All the people standing behind the attending (who is actually
examining the patient) are the med students, etc. A nurse happens
to be adjusting the IV fluids at the same time.
"Rounds" is when the attending physician (the doctor in the leadership chair, over the third- and fourth-year medical students and residents on the "team") and the lowerlings meet to review everyone's work. Last week, there were three third-year students, one fourth-year (doing an elective in peds, his specialty choice), and a family medicine resident (doing a rotation in peds), along with a pharmacy student (?) and a recently-hired NP (rounding to get the feel of the unit, I guess) followed the attending from room to room. At each room, the lowliest person who'd seen the patient would present them. Each of the third-years saw one patient, the fourth year saw two or three, the resident saw almost all the patients, and the attending was responsible for all of them. This means that the patient I saw was seen by the fourth-year (sometimes) and the resident (frequently), so that when my presentation was over that person would add findings, challenge me, or critique my plan (instead of the attending).

When we came to my patient's room, the attending would face me and say, "go," or I would make eye contact with him and start presenting. "This is a 13-month-old white female who presents with a four-day history of vomiting," I'd rattle off. I'd then describe the history of the present illness (HPI), the pertinent positives and negatives, past medical/surgical history (including birth history for children!), currents meds and allergies, and my objective findings (vital signs, physical exam, labs, and imaging). Then, I state my assessment and plan. "This is a 13-month-old female with gastroenteritis. Plan is replace fluid losses with D5 one-half normal and attempt p.o. challenge today."

And then the education would begin. The attending critiques your presentation skills (if you're really new at this), asks for additional findings (and you better hope you have them), and corrects your plan (you feel awesome if this is all he has to say). Since I am new to this, I got lots of presentation-skills and additional-findings criticism.

Presentation skills are important because we're in medical school to learn to think in an orderly, analytical way about complex problems and not miss things. We're trained to think like a doctor by presenting and writing notes. Presenting skills are also important because communication to colleagues is made quick and safe by a universally-agreed upon format. The format in medicine is:
  • Patient ID sentence
  • Chief concern
  • HPI
  • Review of systems (ROS)
  • Past medical history (including birth history if pediatrics)
  • Past surgical history
  • Current meds
  • Family history
  • Social history
  • Allergies
  • Vital signs
  • Physical exam
  • Labs
  • Imaging
  • Assessment/Plan (A/P)
On the floor, you have to present confidently and quickly. The faster you go, the more knowledgeable you sound (although attendings aren't stupid and won't be fooled if you obviously skip a part of the presentation, a system on the ROS, or part of the physical exam) and the less chance you have of being interrupted. You really want to be able to finish that presentation and get that A/P critique, because that's the gold that makes you a better doctor. That's also the material that attendings want to talk about (not fussy details about presentations), so you make them happier while also looking good. Best of both worlds!

If your attending asks for additional findings, you are expected to produce them with ease. It looks sort of silly to shuffle through your papers, although that's better than having to say "I don't know" or "I didn't ask." We are supposed to know everything about our patients. (Was there green in the vomit? How far did it fly? What was her serum chloride on Monday? Did we get the results of the 99-technetium scan?) Not knowing a historical detail is not very excusable (it's a rookie mistake, only one level above the presentation skills problems); not knowing a lab result is only slightly less excusable. And one is looked upon as not up to snuff if you miss out on a social issue (e.g. illiteracy, bad home situation, poverty, mental illness, etc).

And A/P criticism, while desired, comes in very different flavors. "I think you forgot a decimal point on her IV fluids" is a lot better than "Now, if you give this potassium, you'll probably put this guy into acute kidney failure. You want that on your hands?" But even so, this is the best tier of criticism, and one hopes to reach it during every presentation.

One problem in this approach is stressed or nervous med students, or those who are shy or have thin skins or fragile self esteem, can get hurt. One girl last week cried! I have been lucky, since TAC and high school accustomed me to faking it till I make it (in terms of confidence, not A/Ps). I also have a good memory for medical knowledge. But I don't like that some med students have to learn by shame and embarrassment. I wish we could all take on responsibilities without being toughened by humiliation. Stay tuned for more about academic medicine in the spring, when I go "on the wards" for twelve weeks of I-Med.

Saturday, October 12, 2013


It's been forever since I put some cooking stuff up here! Last Saturday I and my sister made an apple pie. It was beautiful! We cut the apple logo into the hand-made top crust, but I didn't take a picture until it was mostly eaten. I guess that's a testament to how good it was!

Winter is coming, and I hope that means more pies in the future. I've got plans for pumpkin, peach-and-blackberry, cherry, pecan, and strawberry-and-rhubarb.
Right before the oldest brother snarfed the rest of it.

Monday, October 7, 2013

Lacey's Story

This post conforms to the blog rules.While working at the psychiatric hospital in admitting, I was sent to speak with Lacey, a girl who came in with her mother. It was up to me to fill out the interview form, do the mental status exam, and decide whether the girl would be admitted to the mental hospital or not. Of course, I would present the case to my attending, who would check my work and (hopefully) catch my mistake, but I still felt like I was being handed a lot of responsibility.

I went to the waiting room and called the girl's name. A middle-school-aged girl and a young woman, baby on hip, stood and followed me to a room. After introductions, I asked Lacey what brought her in. She did not answer, but only looked out the window, away from me. His mother began to speak, and told me a long and convoluted story about marijuana, bad crowds, running away, and fights.

As the mother spoke, I looked at Lacey, who skillfully avoided eye contact with everyone. I had just finished two weeks on the alcohol and drug dependence ward, and so my soul was full of stories that began like Lacey's and ended with hard street drugs, divorces, dead loved ones, and dead dreams. I looked at her and wondered: will you go down one of those paths, or is this just a slightly-more-serious-case of teenage rebellion? And another possibility: is your mom the crazy one? She's the one doing all the talking.

The baby had fallen asleep on Lacey's mother's chest by the time the story was finished.

"Thank you so much for helping me understand," I told her. "I know it's been a long wait for you, but would you mind stepping out so that I can talk to Lacey?"

She left, and I turned to the silent teenager in front of me. She still gazed out the window. Was that a grave silence or a nonchalant silence or a hurt silence or a panicked silence or...?

"Lacey," I said, "I want to hear your side of the story."


"What your mom told me...does that match what happened?"

Nothing. I tried one or two more times. Still nothing.

"Well," I said, taking a new tack, "pardon me while I fill out some paperwork." And so I sat there, across the table from her, checking boxes on the mental status exam. I wanted to show her I wasn't afraid of silence. Several minutes passed.

"You know," I said at last, trying to speak like one seventh-grader to another (or one medical student to another), "I can't make you stay. Finally, you decide whether we can help you or not. Do you think you need help? Do you want to stay?"

A few more seconds of nothing, then Lacey's eyes moved from the window to his lap. Then she nodded. My heart soared, partially with elation at successfully communicating and partially because I thought she really could use the help.

"Okay," I said softly. I didn't follow Lacey after this, but I won't forget this interview soon. Pray for her if you read this.

Saturday, October 5, 2013

Pediatrics: An Inspiring Rotation

This post conforms to the blog rules.
Although pediatrics has not felt as relevant as other rotations, I've certainly had a lot of chances to be humbled and amazed by the parents I meet.

In the outpatient clinic I worked in, my preceptor had me shadow for well child visits. One afternoon, I followed him into a well child check, only to see no child in the room...only a middle-aged woman sitting in the corner chair. She and the pediatrician began to speak and I slowly began to understand what was going on.

This woman was adopting a distant relative's child, "Lupita" after discovering that Lupita and her siblings were being neglected. Raised in a small town in south Texas, the children were left alone often and had to choose which children ate at meals. Lupita didn't speak English very well and didn't know what grade she was in. The woman said that at home, Lupita talked nonstop to whoever was around her and ate voraciously, almost choking on a sandwich in her haste to eat it. Drug use and deportation played a role in her mother's absence.

Lupita came in after the pediatrician had received all this news. She was a grave child, obeying the doctor in everything she could understand without smiling or showing any embarrassment that a girl her age would typically show. She spoke freely but only when spoken to. In her hand, she held a little charm, and when I asked her what it was, she opened her hand and showed me a plastic star the size of a die. "Mi estrella," she said simply.

I was very amazed by Lupita's new adoptive mother. This woman was also planning to adopt Lupita's baby brother, who was still in Mexico. And when my preceptor asked, "how do your twins feel about all this?" I was completely amazed. Pray for them!

In the same outpatient office, with a different preceptor, I saw a follow-up with eighteen-year-old "Aaron" on a stress fracture. Aaron was a young adult with autism and a lot of sensory overload. He was in a post-high school program designed to teach adults to ride public transport, interview for a job, and use a basic skill set in an employment setting. He had come in with his mother, who I learned (and could see by difference in race) was his adoptive mom.

As the doctor conducted the history from his mother, Aaron would constantly interrupt: "what's going on? I don't understand," or "I have something to say. I'm going to explode. I still don't understand," and his mother would quietly redirect him or ask him for input. She was very skillful at letting Aaron talk as much and as constructively as possible, while also advancing the discussion of his painful foot.

During the physical exam, however, the doctor had to palpate for swelling and tenderness to palpation (an X-ray was inconclusive), and the pain began to be more than Aaron could communicate. Unable to say "stop it" fast enough, he screamed loudly, then began to cry. The doctor stopped and we stepped out of the room for a time, while Aaron and his mother re-grouped.

After a few minutes, we came back in. "Aaron wants you to know he's embarrassed," his mother said gently, "but he wasn't prepared for you doing that today." The doctor nodded, apologized to Aaron, and the interview went on. It reminded me of a video I'd seen about a nonverbal girl with autism (at right and also online: Carly's Cafe). It was as if Aaron's world was too overwhelming, and processing it took so much time that he couldn't ask the doctor to stop pressing, and the pain and the inability to stop it became very distressing.

Throughout, the mom was a calm and loving help to this young man who she was barely helping to function. At one point in the interview, she became tearful when she talked about Aaron "falling through the cracks." Where would Aaron be without this woman? This is another story of someone I'll not forget easily, someone whose generosity was humbling.

I just finished the week of newborn nursery time that's sandwiched between the other weeks of pediatrics. I rotated through the NICU and saw some very incredible moms there, too. I spent some time talking with one in particular, "Helen," who had delivered two preemies. Her first child was born at 28 weeks and she spent months in the NICU fighting lung problems and sepsis. While her baby used IVs and NG tubes, Helen pumped breastmilk from the day he was born, hoping that when he was mature enough he could take it. It was a nightmare, she said, something "I wouldn't wish on anyone." Fortunately, her son is now caught up in growth and milestones, and has no residual CNS effects except some possible learning disability.

During her second pregnancy, Helen received weekly progesterone injections (thick, oily, slow gluteal IM shots) and underwent cerclage, but still went into labor at 28 weeks. After trying every drug her MFM had to offer, she started a terbutaline drip at home and stayed on bedrest for six weeks. Helen told me she has a propensity to contact dermatitis and the indwelling needle for the terbutaline drip was a constant irritant in her leg during that month and a half. And at some point every week, she would go into labor again and the terbutaline dose would have to be increased in the emergency room.

"Was it worth it?" I asked.

"Oh, absolutely," Helen said emphatically. "My daughter was born at 36 weeks, and it was so worth it to have her that much farther along. Oh, absolutely." This woman has her priorities in beautiful order. The generosity of soul of these mothers astounds and humbles me!

Thursday, October 3, 2013

How to Discern whether You should Become a Doctor

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

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

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

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

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

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

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