Being Catholic In Medical School
This talk was given at Franciscan University of Steubenville on October 7th, 2011.
Good morning to all of you. It is a real honor to be able to return and speak before you. It was not too long ago that I sat in those very seats, contemplating my future and all that lay before me. At that time, I never imagined the journey the Lord would take me on, particularly in regards to medical school and the like. My journey since I graduated in 2007 has been filled with many joys and some sorrows. I have felt lifted up and torn down. But through it all the Lord has guided me, and as I stand before you and reflect on that journey, I feel that I am a stronger man for it, and without a doubt, it has drawn me closer to the Lord. Today I wanted to take the time to talk to you a little bit about this journey. Namely, I will outline some of the challenges I have personally faced being Catholic in medical school, as well as other issues my Catholic colleagues have faced. But being Catholic in med school is more than just about being on the defensive, and so I want to also spend some time on how being a Catholic medical student has brought me greater skill and joy when caring for my patients. Throughout the talk, I will touch upon a subject I feel is extremely important for all of us, and that is the need for every Catholic professional to seek to be both technically and spiritually competent in their field, and I will explain more of this at that time. I will also discuss the ways that you can both find support in medicine as well as work to make a difference.
Being Catholic surely does not make medical school or any other healthcare related job any easier. In fact, it makes it harder. The easy way is to go with the flow, and simply accept what mainstream medicine and our culture says is “okay” and the “appropriate thing to do for our patients.” But of course, all of you probably realize this and recognize that what the culture tells us does not make it the right thing to do. Going back to healthcare, those challenges and difficulties begin the moment you leave this campus and enter any job dealing with the care of the sick. For the sake of time, I will focus on medical school in this talk, but the ideas and challenges can be applied to any healthcare worker, especially nurses and pharmacists.
So Let us begin with the process of getting into medical school.
Dr. Kuebler just recently publish an excellent article in the National Catholic Register. I hope all of you have had the opportunity read it, because it is the truth. This article is entitled “The Case Against Pro-Life Physicians: Bias Begins at Med School Interview.”
Here are two short paragraphs I wish to quote:
“It is routine for medical-school admission interviews to include open-ended questions on ethical issues. Primarily, these questions are included in the process to see if students can articulate clearly and defend adequately their thoughts on complex issues. If this were the sole reason for their inclusion, questions about abortion and abortion access could play a legitimate role in the interview process. But that is often not the intent of such questions.
The reality is that many schools are using abortion-related questions to screen out pro-life candidates. This is despite the fact that federal law prohibits medical schools that receive federal funding from discriminating against candidates based upon their views on abortion. While the law prohibits explicit discrimination against pro-life candidates, it does not prohibit schools from inquiring about abortion during the interviewing process. Unfortunately, this situation creates a loophole big enough to drive a truck through.”
Getting into medical school is not easy for pro-life students. And this becomes even more difficult for faithful Catholics because not only can questions of abortion arise, but a pernicious interviewer could easily raise questions concerning contraception, sterilization, and end-of-life care.
How do we face these types of situations? I think this is particularly pertinent for those of you who will be in this situation sooner than later. First of all, and this will be repeated in other situations, you must be knowledgeable. Why do you believe what you do? Know it. And not just what the Church teaches us. Of course this is extremely important for us to know, and to know well. But I am going to tell you a little secret about the people who do not want you to succeed: They do not care what the Catholic Church teaches. If your main argument against abortion, contraception, sterilization, etc is because it is against my faith, then I am telling you now, you will lose the fight. The best overall strategy I can offer you is two part: 1) Stay calm and maintain a respectful attitude. Losing your cool will only help the other person succeed in preventing you from entering medical school. 2) Be able to explain your position using only medical and ethical, NOT religious, reasoning. I will tell you now that I try to never bring in the fact that I am Catholic as a reason for not participating in a procedure or action. The problem is that once you use that argument, the other party, even if they are Christian, will typically zone out and not listen to any subsequent defenses. I can expostulate eloquently on the medical risks and complications of abortion or contraception, but if I had first said that “it is because I am Catholic”, all of that will not be heard. In many cases, simply the fact that people know I am a faithful Catholic has hindered me. I don’t even say a word about it in these situations, but they already have preconceived misconceptions about why I will not prescribe contraception or perform/assist in abortions. In those cases my work is twice as hard. Now, I want to clarify that I do not mean that we hide our faith, but rather that we don’t hide BEHIND our faith. The wonderful thing about our Faith is that all that Holy Mother Church teaches on these medical issues is confirmed in the natural world.
Now going back to the interview. What I just said is extremely important to remember. Now, as Dr. Kuebler talked about in his article, it isn’t as much about religion as the position of pro-life versus pro-abortion. However, as it stands, there is little we can do until our rights are better enshrined in law. What we CAN do is to speak eloquently and with love. Even if the interviewer disagrees with you and seems to be out to get you, it is extremely important that you stay calm. I know of several individuals who antagonized the interviewer as much as they were antagonized, and let’s just say that it did not end well. We must be different than our aggressors. When we show we are willing to hold our temper, to continue to be respectful, and still intelligently defend our position, we are more likely to succeed in softening their hearts, and possibly convincing them that we would ‘not be a threat’ or could ‘have our mind changed’. Now is this always going to work? No, but it has a much better of success than allowing yourself to become enraged at their provocations.
Once in medical school, the challenges you face become different. Life in medical school can be a bit challenging when faced with the variety of ethical and moral issues that come up.
During the first two years, you really are not in true clinical scenarios. This does not mean, however that you do not have challenges to face. Many schools now have lectures or even classes on medical ethics or related topics, in which you may find yourself in a bit of a pickle. Or you may be in lectures where abortion or contraception or even euthanasia is being touted as something good. So the question becomes, what do you do? You could simply keep your head down, telling yourself that once you are through med school, you can practice how you want to practice. This is one way. But there is another. I can remember a couple of different scenarios that came up. One was during my first year of medical school, during the behavioral science block. The lecture was on adulthood, and the instructor had touched up the progression of adult relationships, and had made the comment on how cohabitation was healthy step in a relationship, and that some couples may or may not progress to marriage, and then on to divorce (almost as if it were a given). Now, I took issue with this a bit, and so I raised my hand to ask if the instructor was familiar with the research that indicated that those who cohabitate prior to marriage have a higher incidence of divorce. The instructor basically brushed me off and ridiculed me saying he knew of no studies showing such a thing. Having my laptop handy, I did a quick lit search on pub med (an extremely important skill!) and found dozens of articles on this topic, and not just about the correlation of cohabitation and divorce, but of cohabitation and poverty, abuse, murder, and other issues. At the break, I went and talked to the instructor about this and when the class returned, he put me on the spot to share what I told him. I told the class that a simple lit search did in fact show cohabitation to be unhealthy for the relationship. Now, this was a very difficult thing to do. It exposed me to all of my classmates, and in fact upset several of them because, lo and behold, they were cohabitating with their significant other and felt ‘attacked and judged’ by me. This was an unfortunate consequence, this straining of the relationship with some of my classmates. But it was important to do. This instructor was spreading false information to future physicians who would then influence multitudes of others. Another situation I encountered was during my second year, during the reproductive physiology lecture. Now, being a Natural Family Planning instructor, I was quite curious to see how the topic of contraception and NFP would be approached. I had access to the previous year’s PowerPoint presentation and was able to scout things out. To my expectation, natural family planning was treated rather poorly, using the typical (and false) statistic of a 25% failure rate. Since I had a heads up this time, I actually emailed the individual giving the lecture to ask him about this in light of several articles I cited to him, which showed the success rate of 99%. After discussing this issue and the efficacy of lacational amenorrhea (and providing him with solid sources) he actually changed his presentation to be more NFP friendly.
These are just a couple of the times that I had to stand up and say “This is not right.” But when I did rise up, I tried to do it in the most respectful way possible. Did I get angry and upset at times? Absolutely! But I knew I needed to cool off before responding. And then I made sure that I knew what I was talking about. One of the worst things we can do, other than losing our cool, is to be caught with a bad or defenseless argument. So before you respond, if you are able, take the time to do a little reading, now what you want to say and have the sources to back it up.
Now, you need to take these same steps during your clinical years. Only now, you will find yourself in situations where you are unable to say ‘I will get back to you on that’, but you will need to make a split second decision about how you will act. So the best way to handle this is to know what you will do and why you are doing it ahead of time. Let’s take a few examples.
One of the most commonly encountered issues for Catholic medical students is contraception. Our culture accepts it as a given, and medicine is obviously no different. Many of you probably know that the only organized group of individuals that vocally rejects contraception is the Roman Catholic Church. That being said, you need to know why the Church teaches what she does. Be familiar withHumanae Vitae, read up on the commentaries and instructions given by individuals like Janet Smith (her Contraception Why not?). But you also need to be up to date on the medical reasons why you would not prescribe contraception. This includes the risks associated, the side effects, the long term consequences on a woman’s health like breast cancer and infertility. You also need to know the ethical reasons. My main response is that I am not comfortable with causing a major, healthy, functioning organ to stop working. Basically I am causing a disease state in an otherwise healthy woman. This, too me, goes against the basic tenets of medicine.
I have found myself in these situations on several occasions. Most of the time I was able to avoid having to deal with it, but when I was unable to avoid a visit that was specifically about obtaining birth control, I had to calmly tell the physician I was working with that I was going to not go in on the visit because I was not comfortable with prescribing birth control. Most of the time the physician looked a bit confused, but would shrug his shoulders and go into the room without me. Other times I would see the eyes narrow, and the lips purse, and the physician ask, in a bit of a menacing way, “Why not?” And so I would have to explain myself, mainly with the reason I stated above. Sometimes this would turn into a more in depth discussion and I could venture into natural family planning as an alternative, and other times it ended there. I praise the Lord that I was never put in situation where I felt my grade was in jeopardy, but I know it has happened to others. Surprisingly, the people from whom I received the most flak about my stance on contraception were my fellow classmates. They were more cruel and intolerable than many of the physicians I have worked with, and some of the harder ones to respond to. And yet you do what you can in the way I have already outlined.
One of my strengths in this area is the fact that I am a Natural Family Planning instructor. This was something I was able to offer as an alternative, if not to my patients in the clinic, then at least to the physician who questioned why I would not prescribe. Having a skill like this can be invaluable, not only because it is a tool to offer but because of the knowledge that you have because you took the time to learn about NFP.
Another issue, related to the contraception issue is sterilization. There are two forms of sterilization you will encounter in medicine, tubal ligation and vasectomy. Sterilization is one of the most common forms of birth control used in the United States. As such, you will undoubtedly find yourself having to make a moral choice about your participation in the sterilization of a patient. I have been faced with both tubals and vasectomies. I had an interesting experience in dealing with the vasectomy issue.
Early in my third year I was on my surgery rotation. It was a Friday afternoon of the first week with this particular surgeon, Dr. B. I had already rotated with the trauma service and the neurosurgeon at the University Hospital, and now I was assigned to small, community hospital. The week had gone great, with a variety of general surgery cases and now we were wrapping up the week with a few hours seeing patients in the office. As I reviewed the list of patients for the afternoon, I saw something that made my heart sink. The last patient of the day was scheduled to have a vasectomy performed. I had not anticipated this being a problem on surgery. In retrospect, I should not be too surprised, since a vasectomy is a surgical procedure. I suppose that since the male reproductive issues do not come up as often, I simply wasn’t thinking about it. However, that quickly changed. After all of this came to my attention, I mentioned to my preceptor that I saw the last patient of the day was a vasectomy. I started to say “I hope you don’t mind, but-“, then I was interrupted by my preceptor saying “You would like to sit this one out? Not a problem.” I said thank you, and we went on to see the next patient. When we returned to his office, he related to me that since coming to this hospital about 15 years ago he has done the majority of the vasectomies because the urologist in the hospital was a Catholic and would not do vasectomies. I again gave him my gratitude for understanding, and we left it at that.
Now I tell you this story, because I want you to realize the importance of standing up for your beliefs. Thanks to this urologist, I did not have to “deal” with that issue in this case. I have in other times, but in this situation, because someone had come before me and set the example, my life was a bit easier and my beliefs were already accepted. This is why I am here today, to encourage you and show you that a path has been laid out. It is not necessarily easy, but with each passing student, and each success we make a little headway in regaining our freedom to practice as Catholic physicians. We will come back to this later.
Though I dodged this bullet, I did not dodge the bullet on tubal ligations. One night on labor and delivery, there was a tubal ligation scheduled for after the C-section I was assisting on. So I told the physician I would be stepping out of the room after the baby was born because I could not assist in the tubal. The physician turned to me with a bit of an antagonistic look and said “What do you mean by stepping out? Out of the room? Off the floor? Out of the hospital? Off the world?” I calmly replied that I would be stepping out of the room. He said “Fine”. So that is what I did, and despite the hard time he gave me, later in the evening he let me deliver the baby of one of his other patients and we had a fairly decent conversation. But that was a hard trial, because I was forced to go up against a well established OB/GYN. Here was a man who could make my life miserable, but I needed to follow my conscience and my beliefs. If I was willing to violate it now, how could I live with myself and know that in the future I would continue to do what is right by my patients? This is the challenge each of us faces in these situations.
I have spoken of contraception and sterilization first because it has been my experience that these will be two areas in which you will be most challenged in clinical practice. As I said before, Catholics are the only unified voice that still speaks out against these practices, and so you will even find yourself unpopular on these topics with your protestant, pro-life colleagues. So you need to be well versed in why these actions are attacks on the human person and attacks on love.
Next let me turn to the issue of abortion. A recent Guttmacher Institute study showed that 54% of abortions occur because another form of birth control failed. You will not learn this in medical school. No, you don’t learn a lot of things about abortion in medical school. Like the fact that women have greater risk of mental health issues after an abortion, or that it leads to increased rates of pre-term labor and other neonatal complications. Not to mention the surgical risk associated with the procedure. What you do learn is that this is a “Safe, healthy procedure that is legal in the United States and that it carries less risk than bringing a pregnancy to term.” For those of you active in the prolife movement, you may have heard some of these lies about how safe abortion is. Well, I am sad to say they are perpetuated at the highest level in medical school. So you may find yourself coming up against classmates and instructors on this issue. Again, know your stats, know your studies, know why the pro-abortion people are wrong in their science. When it comes to Ob/Gyn and embryology, you may need to do some extra reading in order to get a real education in this area, in order to get beyond the lies and falsities. I know I had to. Now, in regards to participation in abortion during your clinical years. This, praise the Lord, I have not been faced with, and I believe it is safe to say most medical schools are not going to put you into that position. If you go into OB/GYN and do a residency, the situation changes, but as of now, most schools will not force medical students to participate in abortions in any way. Now, that doesn’t mean there are not opportunities and you may here of classmates who do special electives or work with certain doctors who train them to do abortions. So, for now, you have some safeguards, but there is an area you need to consider, and that is the treatment of ectopic pregnancies. Ectopic pregnancies are rare, and difficult cases. Some treatments are morally acceptable and others are not. It is your responsibility as a medical student or nurse to know what the treatment is going to be on a given case. You do not want to be unwittingly assisting in a direct abortion.
Unfortunately, the pro-abortion, pro-death ideology is alive and well in medical school. I think you would be hard pressed to find a place where abortion, contraception, sterilization are not accepted as every day, good things. You will be taught in such a way to try and justify these procedures and drugs, and you will be taught that what the patient wants you should give. This is the tyranny of autonomy, the idea that whatever the patient wants, as long as it is legal, the patient should have access to. And this is why we end up fighting so many of our battles. Our medical education system continues to try to destroy any philosophical basis for our ethics, and replace it with an ethics based upon the legal system. As such, when we are faced with a situation where a patient is requesting something that is legal, but against our moral code, we are viewed by our colleagues as withholding a reasonable medical treatment from our patient, and thus violating the rights of our patients. Obviously we are not violating the rights of our patients in respecting our consciences, but this is what our culture is trying to paint us as doing. And so, even if you are never faced with an actual abortion, you will be challenged by those around you on why you would withhold a legal service from a patient. So be prepared to have these conversations, and to find yourself quite frustrated in them. But know that it is important to remain strong.
A few other areas that you may encounter, mostly on the theoretical level unless you pursue certain fields of practice, are IVF and other reproductive technologies. I mention them to you because the conversations will arise, and you will be on the unpopular side if you stand with the Church, and so it is again important that you be well studied on these issues.
At the other end of the spectrum on ethical issues is death and dying. Euthanasia is legal in three states, and appears to be gaining ground in other states. But euthanasia occurs more often than we think. Consider the issue of artificial nutrition and hydration. This is where a person receives food through a feeding tube and water through an IV line. Now, mainstream medicine has said that this is extraordinary care for an individual and so can be withdrawn at any time at the discretion of the physician and family. Yet the Church has emphatically stated that ANH is NOT extraordinary, but ordinary means of care and should never be withdrawn unless it is burdensome or harmful to the patient. I have encountered some situations where the very fine line on this has been very, very gray. So it is important for you to have a firm grasp of the Church’s understanding on the caveats surrounding ANH.
So I have spoken for quite awhile on the challenges of being Catholic in medical school. But there are many, many joys that come too. I look back at the past three years in awe at the way the Lord has lead me, and helped me grow stronger and closer to Him. I have found that my faith has been transformative in my understanding and practice of medicine. From the beginning of medicine, my views on suffering have been very different than my colleagues. Because of this, I am able to approach my patients not by viewing them as a disease process to be fixed, but rather an individual who has been given the gift of suffering, and it is my role to either alleviate that suffering and in doing so show the power of God, or to help the patient better understand their suffering so that they can grow in virtue and holiness because of it. Now I do not necessarily do this with overt words, but rather through my actions. If I take the idea that my suffering neighbor is Christ, and I love them in that way, so much good can come from that relationship, both for the patient and for myself. Another great joy comes from the struggles I talked of earlier. I am not speaking of joy begotten from strife with others, but of knowledge of the Truth. While your classmates may struggle with ethical issues, there is joy and peace that comes from have drawn your line in the sand and standing by it. That joy comes from trusting in the Lord and in the Church. You of course do your part to gain the knowledge necessary, but you can take solace in the Authority of the Magisterium, unlike many of your classmates, who in their relativism, are lost in these ethical conundrums.
Another great joy comes from finding fellow Catholics. This is not always an easy task, but now there are a growing number of Catholic groups on medical school campuses. And there is now a national group for Catholic medical students called the Catholic Medical Association Student Section. This is the group I have helped to start and been a part of the past two years. Even if you feel you are the only Catholic medical student who remains faithful to Catholic teaching at your school, this is a group where you can be in contact with other faithful Catholics from around the country. We also work to connect students with Catholic physicians who are members of the Catholic Medical Association, a national group of faithful Catholic physicians.
Other joys come to. Maybe they are better known as solaces, like I mentioned earlier. But many of us go into medicine, not because of the money, but because it is our calling, our vocation. And when you have an understanding and commitment to that idea, your whole outlook changes. The way you approach your studies, your exams, your patients, the long hours in the hospital, all of this has a new meaning because you know that what you are doing is in the service of the Lord.
This brings me to my next point I want to discuss: The need for excellence. As we move forward as Catholics, the pressure upon us to conform to the culture is only increasing. When I look around, I recognize that the easier way is to conform, to give in and do what my professors and colleagues, and the culture want me to do. But I know this is not what I must do. I know that the Lord is calling me to remain faithful to Him. But you know, it is not enough to just get by, to quietly keep my head down and ‘wait until I am established in practice to be a Catholic doctor.’ I talked a little bit about an experience of having the way made easier because another Catholic had set the example. Imagine if all the Catholics out there made their voices heard and set the example? Perhaps we could shift the tide in medical ethics, and we would no longer have to fight these battles. But it isn’t that easy. Consider yourselves for a moment. Would you listen to someone who didn’t know what they were talking about? Would you have much respect for them if you knew that half the things they said were wrong? Probably not. The same goes for you and me. Do you think the world is going to listen to you on issues of faith and morals or good medical practice if you play the fool? Even if you have the most theologically sound mind and the tongue of Chrysostom, if you don’t have the technical knowledge in medicine, you will not have the respect, and no one will listen. We must have competence, both theologically/morally and technically (in our respective fields of medicine). We must rise up as the top students in our class, as the best residents in our program, and the best doctors in our communities. When you have technical authority, your voice gains greater strength, and the respect for you grows. It makes sense doesn’t it? If you are an incompetent physician who tends to lose the trust of your patients medically, how will people trust you when you speak on things like NFP, contraception, sterilization, abortion? So, your job begins now.
In order to even get into medical school, you need to be competitive when it comes to grades, experience, research, and the like. But more than just getting accepted, the classes at FUS will prepare you and make med school easier. So pay attention! Work hard! Get good grades now, so that in med school, the pressure is a little less. I found that I was extremely well prepared for the first year of med school because I had already been through Cell phys, biochem, immuno, developmental, neuro, and the like. And do research! When you have papers published (I have three in scientific journals, and one in bioethics), it increases your clout. And you know what else you need to do? Study theology. This is the best place on the planet to study both theology and biology, so don’t waste that opportunity. You need more than just Intro and Christian moral principles. Take advantage so that you can use your knowledge TO your advantage later on. I have never regretted my theology degree. It has been immensely helpful in my medical decision making, my conversations, and my general spiritual life.
Once in med school, you need to be on top of your game and to do as well as you can. Now I throw in a caveat. I do not recommend you study so hard, and so much, that you do not have time for a life or for the other work the Lord places in your path. Balance is key. It is hard to find, and is very individual, but you must be both competent academically and socially.
For my part, I am married. And this has helped a lot in that regard. My bride is a FUS grad, we met here, courted here, and were married at St. Peter’s. We now have a 2 ½ year old son and another coming in December. As an aside, I encourage anyone in a serious relationship to consider marriage before med school (without rushing things of course). It has its challenges, but all in all, the married ones make better students and better physicians and it is very doable. Let me know at the end of the talk if you have more questions.
Back to competence. So I talked about doing well in your studies, both now and in med school. It requires a lot of reading, but it is well worth it. Now, just to be clear, when I say be competent and top of your class, I do not mean you turn into what we call the “gunner”. That guy who always answers the questions and tries to make others look bad. You also need to have a life. So find the balance. Practice that now, and remember those tricks in med school. Most importantly, take it seriously. This is the rest of your life, it is your calling, your vocation, and you may very well answer before the Lord on how you used your time.
There are things you will not learn in med school that are very pertinent to medicine. Things like natural family planning. You will be questions by your family and friends on things like vaccines, and end of life care. You will need to do extra reading to be able to have some authority in these areas. Moreover, certifications are great. Going through programs like Creighton or the couple to couple league (for those who are married) to become NFP instructors. Just recently I was able to use my certification as a NFP instructor to give a lecture to the family medicine residents at a local, secular hospital on natural family planning.
You also need support. This is not a journey you can make alone, no matter how strong you are or how hard you try. I have witnessed students, good people, break trying to do so. It is important to find community, even if it is outside of the medical school. Look for parishes, look around in your class. See who responds when you say something, or who comes to pro-life events. It is a slow process, but eventually you might find someone who shares your beliefs. I know that over the course of 6 months I found two other men in my class who wanted to know more about their Catholic faith, and they came to me because I spoke out in discussions. Beyond just your med school, which may or may not have a decent Catholic students group, there is the Catholic Medical Association Student Section, which I mentioned earlier. Become an active Catholic. Be active in your school, your parish, and your community. It is amazing the opportunities and gifts the lord will give. I never imagined that during med school I would be here giving this talk, or giving the other talks I have given back in Toledo, or traveling to Rome for medical conferences at the Vatican, or being an advisor on medical ethics to several priests in my diocese. The Lord has opened doors because I responded to His call, and He will do the same for you when you pursue your vocation with prayer and willingness.
I have tried to talk to you all about several different issues. I wanted to first make you aware of what challenges lay in your path, and also what joys you might be able to expect. I want to reemphasize that you need to know your stuff. This means extra studying in areas beyond what you might be tested on, but it will serve you and the Church well. And remember, you are not alone. There are organizations, like the CMA-Student Section where you can find others for support. You can also check out the CMA-SS blog, which has many posts about some of these experiences and ways to become stronger Catholic physicians. Also, reach out to other pro-life students in groups like Med Students For Life. And most of all, do not be afraid to live out your faith. You never know when the battle you fight now may change the life of another person who comes after you.