Friday, April 29, 2016

Memorial Mass for the Dead at St. Patrick Manor

I celebrated the memorial Mass for those residents who died at St. Patrick Manor during the month of March.  The Gospel was the beatitudes from the Gospel of Matthew.  

One of the great consolations of the Catholic Church is her formalized structure of prayer surrounding death: Masses for the dead,  prayerful care for the dying, and prayer for those who survive.  The prayers in the Mass for the Dead are meant, in part, to comfort us.  Some of the most consoling words of the Mass for the Dead, are found in the preface leading to the consecration, prayers you will hear shortly: "For your faithful Lord, life is changed not ended."

"For your faithful Lord, life is changed not ended." 

The Easter-season Gospel readings have described that change. They reiterate the promise of eternal life, the promise that was fulfilled through Jesus'
incarnation, birth, passion, death, resurrection and ascension.

"For your faithful Lord, life is changed not ended." 

This is true for the one who has died.  It is also true for those who survive.  Life is changed for those who survive.  It is a dramatic change.  Mourning takes time.  It is time measured in months and years not days or weeks.  Grieving demands physical, mental and spiritual energy. Oftentimes it demands more energy than we have at a particular moment.

"Blessed are they who mourn for they will be comforted."

They will be comforted.  We hear these words and scream:  How?  When?  By whom?  We also scream the angry question.  Why?

The biggest lie fed to those of us who mourn, a lie perpetrated by journalists, social workers, clueless psychologists, inane TV talk-show hosts, the lady at the post-office, the guy down the street, and just about everyone else, is the word "Closure."

Closure.  Does.  Not.  Exist. 

It is a false concept meant to make those who invoke it feel better. "Oh wow, I've like said something like really significant . . . like."  The illusion of this so-called closure does nothing to comfort us who mourn.  Mourning eases with time.  The sharp edges of grief become more rounded.  We no longer mourn with the intensity that marked the first few days following the death.  With time we adapt to the changes that death has forced on our lives. 

Things never return to the way they were before.  But, with time we arrive at a new baseline. We learn a new definition of normal.  We forge a new way of being.  However, we don't forget.  There is no quote closure unquote.  Forgetting.  Ending.  These are what the word closure suggests, indeed closure seems to demand erasing the memory of the one whom we loved.  Closure only exists in the minds of those who have no idea what they are talking about.  Closure is only possible for those who have never endured the death of someone they loved.  Eventually, however, they learn. 

While I was preparing the funeral homily for Jesuit Father Ned Cassem, former Chief of Psychiatry at the Mass General, his former administrative assistant gave me a copy of some of his writing. He titled one of the essays "Creed."  It reads in part, "Death is not depressing.  It's inspiring.  It makes one sad, but being sad is different from being depressed.  If there is a lot of sadness it is a measure of how much the person was loved." 

"Blessed are they who mourn, they will be comforted."

Neither mourning nor grieving is synonymous with depression.  Mourning cannot be treated with a few anti-depressants.  Grief doesn't resolve with a few anti-anxiety pills. Both require a great deal of what physicians a generation ago referred to as tincture of time.

The comfort promised those who mourn comes from those who listen as we, the bereaved, the grief stricken, the sorrowing, as we . . . are given the opportunity to talk. We need listeners as we talk about our loss.  We need listeners as we reminisce, weep, and yes, laugh.  Those who mourn need time and companionship  . . . not Prozac. 

The comfort promised those who mourn comes from prayer, contemplation on the promise of eternal life, and from frequent reception of the sacraments.  Those who mourn need the quiet time of prayer . . . not Valium.

The comfort promised those who mourn comes from sitting alone with the memories of a husband, wife, mother, father, sibling, grandparent, friend.  Even the memories of the last days or weeks of life may be consoling.

As Father Cassem wrote in Creed: "If you confront death with somebody you love who is dying, out of that will come learning, learning that transforms your life.  It leaves you stronger, braver, and calmer."

Life is changed not ended.  Not only for the one who died but also for us who loved, and continue to love albeit in a different way.  With time we do become stronger, braver, and calmer.  Perhaps we also become less anxious at the prospect of our own deaths. 

Requiem aeternam dona eis, Domine,
et lux perpetua luceat eis.
Requiescant in pace.

Eternal rest grant unto them, O Lord,
and let perpetual light shine upon them.
May they rest in peace.


Cemeteries of religious orders are uniform and quite remarkable.  There is a palpable sense of peace. Two of the cemeteries are Jesuit, one is Trappist and one is Benedictine.   Cemeteries seem to photograph a lot better in black and white than color.  Less distraction.  Only the last one here is in color.

The Jesuit Cemetery at the former novitiate and now retreat house in Chang-hua.  Ignatius and I generally get to the retreat house at least once when I am in the country.  Generally we stop there on the way to Sun Moon Lake, one of the most beautiful places on earth.    I had been raining that morning.   The dark squares on the tombstones to the left have plaques.  The white tombs are waiting to be filled.  

The cemetery at St. Vincent Archabbey in Latrobe, PA.  I made a few retreats there when I lived in D.C.  Would like to go back but it is a much longer drive, one that I don't particularly want to make. 
The archabbey has been in place for about 200 years.  Huge cemetery. 

The cemetery at St. Joseph Abbey.  A Trappist house in Spencer, MA it was the location of my final vow retreat.  The cemetery is in the center of the cloister garth.  The men see it on a daily basis.  It is a silent reminder of our mortality. 

The cemetery at Campion center in the winter.  

This freshly dug grave received the coffin of Fr. Ignatius Ikunza, SJ, a close friend who died at a tragically young age.  

+Fr. Jack, SJ, MD

Sunday, April 24, 2016

5th Sunday of Easter

Acts 14:21-27
Ps 145
Rev 21:1-5a
Jn 13:31a, 34-35

The reading from Acts sounds as if Paul and Barnabas could have benefited from a GPS unit or at least Map Quest.  They certainly covered some ground.  At times Acts has the sense of a travelogue, describing the difficult work involved in spreading the message of Jesus crucified, risen from the dead, and ascended to the Father.  Much was happening as the community began to cohere.   Acts gives us some of that history.  On Tuesday we heard “and it was in Antioch that the disciples were first called Christians.”   As Paul, Barnabas and the others spread out the Church was gaining an identity, and the believers gained a name which would serve to give a concise description of them, a name that would accrue more and more associations—positive and negative—over the ensuing millennia. These associations to the word Christian emerged, and continue to emerge, from observations of how Christians conducted themselves in the public arena.  

This phenomenon was well illustrated in a fine book by Rodney Stark titled, The Rise of Christianity: A Sociologist Reconsiders History in which he studied the period covered by Acts and into the first two or three centuries.  It is important to note that even then abortion was absolutely forbidden.

The first reading from Acts gives us history.  It is anchored in a specific time and location.  In contrast, the reading from Revelation indicates a point well-beyond the horizon.  It tells us of what is to come.  The images are strange. They are strange because that is the only way to describe that which we cannot know in this life.  The reading does not tell us the how or the when.  But it assures us that we will be transformed. We will be transformed in that instant--and it is only an instant--when we pass from life into eternal life.  We can take great comfort knowing “there shall be no more death or mourning, wailing or pain for the old order has passed away.”    What greater consolation is there?  What greater consolation can there be?  Pain.  Suffering.  Sorrow.  All will come to an end. 

Our identity as Christians, our identity as Catholics, is anchored in Jesus’ command at the end of the Gospel.  “I give you a new commandment: love one another.  As I have loved you, so you also should love one another.”  That identity should be apparent if we follow Jesus’ command.  That is the problem.  Living that command.  Living it on a day to day basis.

Back in the seventies, an unhappy liturgical era when some truly awful songs were foisted upon us under the guise of hymns, one of the most annoying and wrongheaded ones featured a thumping marching chorus with the stunningly self-aggrandizing lyric:  “They will know we are Christians by our love,  by our love. They will knoow woooo we are Christians by our love.”  Sung too vigorously that last know wo sounded like the communal passing of a kidney stone. 

Musical value:  none
Narcissism index:  off the chart. 

While nothing will ever help the melody, if the verse went, they SHOULD know we are Christians IF they see our love, the sentiment would be less narcissistic and more descriptive of a goal that this gospel places before us.  There is nothing wrong with the conditional sense rather than a definitive statement. Rather than assuming that we manifest our love so perfectly that others will immediately see us as different, it is more realistic—and a more humble stance—to admit that we have to work at it.  Just because we proclaim ourselves Christians it doesn’t mean that the love part follows automatically. 

The psalm assures us:

“The Lord is gracious and merciful,
slow to anger and of great kindness.
The Lord is good to all
and compassionate toward all his works.”

This describes the Lord only.  We have to work very hard at it. 
In Boston parlance it was a wicked busy week.  Tomorrow is the first day in about 28 that I am not celebrating Mass somewhere outside of Campion.  Definite sleep in plans.  That means about 8 at the latest and more than likely earlier than that. 

Some photos from Maribor, Slovenia.  All of these were taken early in the AM.  Most mornings I had the option after Mass to have breakfast or to go out with the camera.  It was an easy decision.  The bread would still be there when I returned but the warm morning light would have changed had I eaten first.  

Outdoor cafe.  The temp was in the 40's.  Slovenians are very hardy people.  Note the blankets over the backs of the chairs.  Peter wondered about sitting outdoors to drink coffee one day when the temp was in the 50's.   I wondered about his sanity.  We had the coffee indoors.

 The view across the river from the left bank, where our house was, to the right, where the center of the city is.  Note the tiny shrine atop the hill just to the right. 

A pair of swans.  Today I learned that a group of swans is called a bevy.  

Central Square.

The morning commute with the central square reflected in the store windows. 
+Fr  Jack, SJ, MD

Monday, April 11, 2016

Thoughts on Being in Medical School

I've been in contact with two medical students over the past few years.  Recently received a note from one wondering if perhaps the student had made a mistake.  Below is the reply.

Received your e-mail yesterday.  Much to say about your questioning and self-doubt.  

Every medical student on earth has felt what you are feeling at some point during his or her time in school, particularly the latter stages.  The following quote is near the end of the Temple Medical class of 1975 yearbook The Skull.   "Remember feeling depressed with too much work to do and no end in sight to the hassle?  One could always feel better by walking by the Dean's office and seeing the applicants waiting for an admissions interview.  They were trying desperately to be as miserable as we were."  It was funny but also summarized the reality of those four years that were mercifully at an end.  

There is something important to recall during school.  I call them  'The Three F's' of Medical School."  Fatigue.  Frustration.  Fear.  

Fatigue is the most self-evident.  This is particularly true during the final two years when it seems that one is balancing a full-time job and life as a full-time student, reading, researching, and writing in addition to the hours at the hospital.  However, even during the first two years with the demands for study, memorizing, more study, and weekends that were breaks only in the theoretical sense, i.e. not having to go to class, turned life into a grind.  Computers have made life a little easier in that you don't have to go to the library to access the index medicus (a lot of students have no idea what that is) to research a topic.  You can research from home or just about any place else at any time of day.  However, there is so much to learn and so little time to learn it that intellectual, emotional, spiritual, and physical fatigue are more or less constants.  It is almost impossible to describe the life change that happens upon beginning medical school.  Friends get real jobs, marry, have kids, buy cars, and other perks (if they find a job) while we are grinding away at the books  every night and most weekends.  Oftentimes we lose touch with those friends because our lives have no common points any longer.  The change in one's self-understanding will have to be the topic of another e-mail.

Once night call enters the equation you learn a whole new meaning of fatigue.  You also learn that it can be overcome at least temporarily.  Alas, even when that adrenaline surge hits during an emergency there is a price of physical exhaustion to pay afterwards.  It may be difficult to feel rested.  Sometimes it seems that from the standpoint of feeling rested medical school is a mild case of the flu that lasts for four years.  

Frustration.  This one is tough.  It gets a lot better during internship, residency and the rest of life.  A medical student has no job description.  The student is expected to do what needs to be done, when told to do it, and in the way it is supposed to be done.  The problem, particularly in junior year, is that rarely does the student know what needs to be done, is often times told to do it without a lot of instruction, and has no clue, for the most part, how it is to be done.  I think that is one of the reasons I hated surgery.  I could sort of figure out internal medicine but surgery meant that my ignorance was exposed in the OR.  I never had a clue. 

The frustration is compounded by the instability of rotations.   Just as you are figuring out what needs to be done and how to do it four weeks into a six week rotation, you get ready move to another rotation.  The six basic rotations we had (I am assuming they are the same) of medicine (twice), surgery, OB-Gyn, peds, psychiatry might as well be different solar systems from the med student's point of view.  It becomes an completely different game with each move from one to the other: new attendings, nurses, hospitals, rules, regulations and expectations on everyone's part, including yours.   Having to figure out a new parking lot, new route to the hospital and so on does not help the situation.  On one memorable away rotation at the beginning of senior year I had a 9 x 9 room over the morgue.  It was very quiet. 

You can't really appreciate how off-balance you are/were during med school until you have the chance to look back from a point of relative stability.  I don't think I fully realized this until I became a Jesuit novice.  The same sense of being off-balance and geographic mobility--we were never in Boston for more than four months at a time--reemerged.  That sense of being off balance as a novice wasn't pleasant until I figured out what it was.  Then I realized that after med school the Society of Jesus could not throw one curve in my direction that I couldn't hit out of the park

The questions of making a difference and helping others bears attention.  You do make a difference.   You make a difference though neither you, nor the patient, nor the people with whom you work are aware of that difference.  Most of the time, even when others and perhaps you yourself, are aware, there is no formal thanks or feedback or dissection of how you helped the other (or how the other helped you, something you must never forget).  Being calm at the bedside while an attending was giving bad news, a reassuring hand on the shoulder, and visit after rounds, may make a world of difference that goes unappreciated at the time.  As you progress through training you will become more secure in the kind of difference you make be it resuscitating someone during a cardiac arrest outside of hospital, putting the fears of a concerned parent to rest, or intervening in a way that relieves the pain or cures the illness.  But it is too early for that.  You are not allowed to do anything independently (a change from my day when we would make decisions to catheterize bladders and other things without supervision or discussion) or without guidance.  At times you know the answer to a patient's question but prudence dictates that you not act on what you know. 

Of course a source of frustration related to the above is that you don't know much and may be uncertain about the things you do know.  It takes time to feel secure in one's knowledge.  I can now joke, though at the time  it wasn't a joke, that the first time I sent a patient home from the ER with the diagnosis of non-cardiac chest pain (my first day as an intern 24 June 1975), the patient slept better than the intern.  It is the nature of the beast.  The learning curve in medicine is steep.  But any med student worth his or her salt is capable of traveling that curve.

Fear.  Walking into a patient's room the first time with bad news.  Being asked "Doc, am I dying?" Starting your first IV or drawing your first blood gas.  Fear in its purest form.  You may not be able to define specifically what it is that you fear.  That is not a surprise as it is a fear that is not univocal.  Living in a constant state of the Three F's while in med school is exhausting.  

Once school and residency are over much of the fatigue (well, perhaps less than the other two) frustration and fear abate, though it is a slow process.  The transition from book knowledge and boards to the bedside is a tough one.  It is also prolonged.  The first two to three years out of training are difficult in their own way but eventually things settle into a rhythm.  

You wrote a bit ago about your frustration with routine.  Some of us are happy with routine, not just in medicine, but in life. I remember a column written by a man who was considering becoming a Trappist monk.  He lost that desire when he was working with a monk who had been at the monastery for over 35 years.  They were packing eggs.  The aspirant was getting bored.  The Trappist noted that he had been doing this same job daily for 25 years and loved it.   He saw it as the best job in the monastery.

The 'Dig and diuretics' (do you even use digitalis anymore?) of the primary care internist was a drag.  How many times do I want to educate an old lady about regularity?  How many times do I want to assure a man that his prostate is fine.  But then there is the day that the hypochondriac comes in and you realize her voice is much deeper.  And it isn't a cold.  And after a few more questions you realize that her thyroid has become profoundly hypoactive since you last saw her two months ago.  WHAT THE HELL?  Yes, that did happen to me with one of the my most demanding and my favorite hypochondriacs ever, a total of forty-one years and counting. 

The difference between you and all the others, nurse clinicians, practitioners, assistants and so on is that you are preparing to become a physician. You will notice the little things that the others may miss or, worse, be unable to explain.  You know the physiology better, you are much more familiar with the anatomy underlying things, and you know a whole lot more about pharmacology than anyone except a pharmacist.  That is a gift.  Alas, you can't quite use that gift to its greatest extent because you are still a student.  

There is the question of being an example to others, particularly kids who may be thinking of going to med school.  Sometimes it is the encounter with a young physician that sends them in the same direction.  You wrote of the physicians who influenced you while you were still discerning med school.  We rarely, if ever, know how our example influences a younger man or woman to follow into the same career.  Yes, it is wonderful to be told but it is rare.  But these things have to wait.  At the moment you are getting hammered with the realities of medical school.  

On the matter of satisfaction.  The daily examen is important.  Ask yourself, when did I cooperate with God's grace in my daily work?  Where did I resist that grace?  What gave me the most satisfaction?  What was too frustrating to tolerate?  What do I need for tomorrow?   And yes, making the examen while in bed (we called it the examen supine) is OK.

I am going to include a prayer here as a sign off.  It was written by Pierre Teilhard de Chardin, SJ.  He did not write it as a prayer but rather in a letter to a female cousin with whom he was very close, more akin to a sibling than a cousin.  She was struggling with her vocational discernment. She did not feel as if she was making any progress with her life.  Read this often.  

Patient Trust

Above all, trust in the slow work of God
We are quite naturally impatient in everything
   to reach the end without delay.
We should like to skip the intermediate stages. 
We are impatient of being on the way to something
   unknown, something new. 
And yet it is the law of all progress
   that it is made by passing through
   some stages of instability—
   and that it may take a very long time. 

And so I think it is with you. 
   your ideas mature gradually—let them grow,
   let them shape themselves, without undue haste. 
Don't try to force them on, 
   as though you could be today what time
   (that is to say, grace and circumstances
   acting on your own good will)
   will make of you tomorrow. 

Only God could say what this new spirit
   gradually forming within you will be. 
Give Our Lord the benefit of believing
   that his hand is leading you, 
and accept the anxiety of feeling yourself 

   in suspense and incomplete. 

Some black and white photos from Ljubljana.  Eager to go back.  

+ Fr. Jack, SJ, MD