Further Thoughts on Women's Health

Sunshine in Lynch Park

     I started my June post remarking how surprising it felt that yet another month was over and that I was already in another rotation, and I could repeat those exact same thoughts now as July ends. Even though graduation next May still seems years away, the days have flown by ever since I started my clinical rotations. Since my last post I've completed my time in women's health, and I'm already done with two weeks in primary care. Leaving women's health was even more difficult than leaving my psych rotation, so before I move into full general medicine mode, I have some reflections from my time there. 

This has nothing to do with WH, I'm just
proud of my first batch of cold brew
that I made with my coffee sock.

     The first is that you learn to get over awkwardness in women's health. I'd say you get over it quickly, but that's not 100% true. There were still days toward the end of the rotation when it felt odd to ask a woman about her bathroom habits or if she had any discharge, not to mention all the times I said, "you're going to feel me touching you" or "do you have any irritation in the vagina?" Asking about a woman's sexual habits was pretty awkward at the beginning as well, especially if you started realizing those women were the same ages as some of your female relatives. That being said, my classmate and I needed to get over the awkwardness quickly. All these questions weren't asked just for kicks and giggles. They were necessary to get to the bottom of a diagnosis, determine if treatment was working, and figure out how a patient's issues were affecting their life. Plus, I quickly realized that the answers were not ones I could just guess or assume, especially when it came to sexual activity. A 50-year-old might look at me as if it was was crazy to imagine she might still be interested in sex, whereas a 79-year-old might answer "yes" so emphatically that it would seem crazy that I could think a woman might ever lose interest. There were a few women who asked why I needed to know, and at the beginning I might have wondered myself, but it was amazing how asking such simple questions could lead to important diagnostic information. I think of the women who'd given up sex because it had become painful or uncomfortable, but who had never mentioned it to a clinician because they were too embarrassed or because they thought nothing could be done, and then how elated they were when we could tell them that there was in fact a treatment for their interstitial cystitis, or vaginal atrophy, or pelvic organ prolapse, or whatever their particular problem was. It was pretty rewarding to be able to give someone back a part of their life. 

     The second reflection is a bit of a long one. It began with how we joked frequently during my rotation that being a woman sucks. Sometimes it was the playful joking of saying that women go through the awfulness of periods just so we can go through the agonizing pain of childbirth, or that once you hit menopause everything starts falling out (at least one kind of prolapse was found in 14-34% of women in the WHI study, and some studies think this is closer to 50%). At times though it was a rather dark sort of joking, especially when you looked at statistics. For example, 1 in 8 U.S. women will develop breast cancer in their lifetime. That sucks. Cancer of reproductive organs in general has the potential to be more deadly for women than for men because the reproductive organs of men are more easily examined, whereas the reproductive organs of females are primarily hidden inside the body. To often this means that symptoms of a cancer are not detected until the cancer has progressed and spread, a primary reason why ovarian cancer is the fifth leading cause of cancer death in women, even though only 1-3% of women will ever get ovarian cancer. Looking at younger females, 1 in 15 sexually active young women (ages 14-19) will have chlamydia at some point. This is can be quite tragic since chlamydia is most commonly asymptomatic in females (possibly as few as 5% have symptoms) so it's not treated, but left untreated chlamydia can lead to pelvic inflammatory disease (PID) in at least 10-15% of women. PID in turn can have drastic effects on a women's fertility: 1 in 8 women with a history of PID will have a hard time becoming pregnant, and the rates of infertility increase dramatically with each incidence of PID. For any woman who does become pregnant, she then faces the possible heartbreak of a miscarriage. Depending on which study you look at, miscarriages happen in 31% to 70% of pregnancies, though most of these occur early in a pregnancy, often before the woman even knows she's pregnant. Still, 15-20% of confirmed pregnancies end in a miscarriage, a rate much higher than many people realize, which can lead many women who miscarry to believe that the miscarriage was their fault or that they must suffer alone because they think no one else knows their pain. 

     The hardest statistics to look at are the ones where a woman's suffering is not related to purely medical causes, but to what other people do to her. For example, there's the disturbing statistic that the rate of abuse of women INCREASES during pregnancy. In the UK it's estimated that 30% of domestic abuses begins when a woman becomes pregnant, and in the US almost 1 in 6 pregnant women have been abused by their partner. The fact is that I need to be more concerned about screening pregnant patients for abuse than for preeclampsia or gestational diabetes because the rate of abuse for pregnant women is higher than the rate of both those conditions combined. That's absurd. Even if a woman is not abused during pregnancy, chances are she has already been abused in her life because studies show that 1 in 4 women in the US were sexually abused as children. While I may not have statistics for it, there also seems to be an alarming number of women being sterilized against their will. I saw 3 such patients over the course of 4 weeks. Three! That's a lot in such a short time frame. These weren't old women either; all three had been sterilized by force or without their knowledge within the last 5-20 years, so this is a current problem. While all 3 were from countries other than the U.S., this is not solely a foreign problem. California didn't pass a ban on forced sterilization of prisoners until last September, and that only after an investigation had revealed over 140 females patients were coercively sterilized between 2006 and 2010, at least 39 of those without legal consent. This doesn't just suck; it's horrifying. 

Shout-out to the woman who first introduced me to the
beauty and strength of being a woman: my mom

     I could leave this post right here. I could end with the conclusion that women have horrible lives due to their own anatomy and the injustices of society. I could do that, but I won't, mostly because I disagree with that as a universal statement, and also because that's just not the conclusion I got from my rotation in women's health. Over and over again I was presented with the sheer strength of women. Sometimes it was the forceful strength of the woman in labor, pushing with all her might. Sometimes it was the quiet strength of the woman who'd suffered in silence, simply plugging away with her life despite lasting discomfort. Sometimes it was the plucky strength of the older woman who'd wink while reminding me and my classmate that "it's a terrible thing to grow old." Sometimes it was the resilient strength of the woman who'd faced injustice after injustice and hadn't let it break her. I've never really used the term "girl power" (at least not seriously), but there was something about working with women every day that grew in you the feeling of sisterhood and camaraderie. Yes, sometimes my patients convinced me that women were completely crazy (especially during my first week), but they also convinced me that I could work in women's health and really enjoy it, even the parts that aren't all pregnancy and babies (though there is something simply magical about locating a fetal heartbeat on your own for the first time... and every time after). Is women's health where I'll end up? I don't know yet, but I'm so very grateful that I was able to spend 5 weeks there.
     And now as I close, some last few bullet point thoughts*:

1. KEGELS! No matter your age, women, you should be doing these. They might not be the most effective treatment once a problem like prolapse develops, but starting them early might help prevent some problems from developing in the first place.
2. Uteruses are overrated. They're good for growing babies but after that they're more of a nuisance.
3. If you are menopausal or postmenopausal, a local estrogen (either a ring or a cream) is something you might want to talk to your gynecologist about. 
4. Coconut oil has a surprising number of uses. 
5. If you're being abused, or you think someone you know might be, do not keep quiet. There are always ways out and always ways to help. Obviously this post was focused on women, but this point applies to anyone, male or female. Oh, and while we're at it, instead of just helping someone who is being abused, let's work on creating the kind of society where abuse is neither tolerated nor encouraged.
6. Don't rule out a male gynecologist. My preceptor was a man and he was one of the best doctors I've ever seen. My classmate and I both talked about how we want to be clinicians like him one day, and you could tell his patients loved him. Sure, some women admitted being nervous about seeing a male gynecologist, but it was well worth it for such excellent care.
7. On a similar note to the last point: Ladies, be nice to the male students. It's always going to be awkward to have a student in the room for these kind of examinations (and a few patients did turn away me and my female classmate), and it can seem even worse if the student is some young, attractive fellow, but if your clinician asks if you mind having a student in the room, please consider saying yes. The practical experience is invaluable and many of my male classmates have left their women's health rotations frustrated because no patients would let them see them. Just think about it.

Turtles know the proper way to enjoy sunshine.

     If you've made it all the way to the end of the post, congrats! It was a bit longer than my usual posts, and somewhat lacking in photos or catchy songs (I was unable to find a song that adequately conveyed the idea of "if you're a girl there's a good chance you'll face societal injustice, multiple forms of abuse, the pain of your own body working against you, and when you' go through menopause everything will go to pot and/or fall out, but it's ok because girls are awe-inspiring and amazing," so if anyone knows of one, let me know), but I had a lot to say after this rotation. Who knows what I'll have to say after my time in primary care. For now though, it's back to the books to review all the intricacies of diabetes, coronary artery disease, hypothyroidism, and basically everything else in medicine. Hopefully I'll emerge from my study cave to get at least a little vitamin D this weekend. :)

*I'm not a licensed or certified PA yet, so any medical advice is simply a suggestion. Talk to your own healthcare provider further if you have questions.

PSA: CPR (20/30)

     Two summers ago I did a short PSA on drowning because many people don't know how to recognize the signs, which are often subtle (not the thrashing and yelling that Hollywood teaches us to expect). Today I present another PSA on a topic that has the potential to save even more lives: CPR. 

     First, I have some quick background info. CPR is used to treat cardiac arrest (also called sudden cardiac arrest or SCA). While a heart attack can lead to SCA, the two are not the same. In a heart attack, a blockage in the heart's blood vessels deprives areas of the heart of oxygen, which causes the affected cells to die, resulting in pain. The heart will usually continue to beat though. In a SCA it's the electricity of the heart that is affected. The normal electrical systems of the heart that control heart rate and rhythm stop working, and thus the heart stops beating completely, often without warning. There are many possible causes of SCA, everything from coronary artery disease to inherited heart defects (e.g. hypertrophic cardiomyopathy, valve diseases, Brugada syndrome) to stress to drowning to simply being hit in the chest by a baseball at the exact moment that the heart's electrical system is vulnerable (i.e. commotio cordis). If a heart attack is left untreated, it can also lead to a SCA once enough cells die or enough scar tissue forms. Because it is the electrical system of the heart that is failing, victims of SCAs require immediate defibrillation to "jump start" (so to speak) the heart and get it to beat properly again. If the heart is not beating, oxygen is not being delivered to the rest of the body, including the brain, and permanent brain damage can occur within 4 minutes, and death typically follows by 8 or 10 minutes. This is especially concerning because, as their name implies, SCAs often happen without any warning (the first sign is typically when a victim loses consciousness) and 88% occur while a victim is at home, away from the immediate help of emergency services.

     About right now you might be asking how all this affects you. If you're not a healthcare professional, you might never be trained in how to use a defibrillator, which is what a person suffering from an SCA most needs. However, anyone can be trained to perform cardiopulmonary resuscitation (CPR). While CPR typically does not cure an SCA, it buys valuable time. By keeping the heart pumping, CPR ensures that oxygen is still delivered to the rest of the body and thus staves off the death of other cells until defibrillation can be performed and the heart can resume pumping on its own. According to the American Heart Association (AHA), CPR can double or triple a victim's chance of survival, but in the US it is performed in only 32% of cases. So what can you do?

     The simplest answer is to take a CPR class. The AHA and Red Cross regularly offer classes in Basic Life Support (BLS), which includes training in the performance of CPR and the use of a defibrillator, and often includes training in the Heimlich maneuver as well. Classes do not cost much, last a couple hours, and are offered in different versions for laypersons and healthcare professionals. If you don't have the time or money for that, at least learn the basic steps. They've been simplified over the years to encourage more people to learn them and they're rather easy now. As depicted in the graphic to the right, the first step is check a person for responsiveness. You can yell at them or rub their sternum with your knuckles, and then check for breathing. If they don't respond at all and/or they're not breathing, move to the next step. If you're by yourself, call 9-1-1. If someone else is with you have them make the call and send them to find an automatic external defibrillator (AED) as well. Next, begin CPR. The AHA currently recommends that laypeople do what they call "compressions only" CPR, which means that you don't have to stop to give the victim breaths. You simply need to "push hard, push fast" in the center of the victim's chest. Ideally you're pushing at a rate of 100 bpm, and you're allowing for full recoil of the chest, but the fact of the matter is that poorly performed CPR is still going to be better than no CPR at all. Even if you are incredibly nervous (and that's normal), it's far better to start compressions than to sit around wringing your hands waiting for EMS to arrive. If you're scared of hurting the victim the fact is that they are already dead (at least in a cardiopulmonary sense), and your attempts to provide CPR can only help. The bottom line: just try.  Still nervous? Here's a 90-second video explaining how to perform CPR, complete with cheesiness and the Bee Gees. 

    Lastly, I'll conclude this PSA with some encouraging news about CPR from Sweden. Almost one third of Sweden's population of 9.6 million is trained in CPR. That fact in and of itself is pretty amazing and worth celebrating, but the Swedes continue to go above and beyond to find ways to help their citizens survive a cardiac arrest. In The New England Journal of Medicine published June 11, 2015 Swedish researchers published two articles back-to-back that explored the effects of early CPR (before EMS services arrived) and on how to dispatch laypersons to the scene of an out-of-hospital cardiac arrest. The first study showed that when CPR was initiated before EMS services arrived, a victim's chances of surviving increased from 4.0% to 10.5%, a significant increase. The second study looked at the use of a new app for people trained in CPR. When a call is made that someone has just suffered a cardiac arrest, the app will notify any users within 500 m of the incident and dispatch them to perform CPR until EMS arrives. This study found that the app resulted in bystander-initiated CPR in 62% of the incidents, as opposed to 46% in the control group (still better than the US average of 32%) when the app was not used. Already some cities and counties across the US are trying to create their own similar apps. Who knows? In a few years or a decade, maybe bystander-initiated CPR will occur in 75% or 80% of cardiac arrest cases, and maybe we can bring the survival rate higher than the dismal 4% or 10.5%. 

Man! I Feel Like a Woman (19/30)

Greenlawn Cemetery, a great place to relax if I get home early

      Yet another month has come and gone, and with it has come the end of my psych rotation. Going into the psych rotation I hadn't expected that I'd be sad to leave it, but I was. I had a great preceptor who taught me so much and who helped me grow as a practitioner, and I was surrounded by so many other healthcare practitioners who were just as friendly, encouraging and helpful. It was also such a great thing to see actual differences in the lives of the patients. The best part might have been finally seeing an improvement in one of my patients who was in the ward for my entire rotation, and who didn't respond to treatment for quite some time. When the patient finally said that they were starting to feel better (something we'd been seeing, but the patient hadn't previously admitted), and when the patient's family members mentioned that they thought that my time with the patient had made a difference, my heart felt full to bursting. It's one of the sad things about leaving the rotation that I cannot know how things ended for that patient, but I hope and pray that they continued to improve and were discharged soon after I left.
     Now that I'm done with my psych rotation, as well as my first End Of Rotation Exam (EORE) and PACKRAT (Physician Assistant Clinical Knowledge Rating and Assessment Tool), I've moved on to rotation #2: Women's Health. Although country is one of my least favorite genres of music, I have to admit that I did love some Shania Twain when I was younger and thinking about describing my new rotation kept making me think of her song "Man! I Feel Like a Woman" (plus it seemed a bit more appropriate than "Lovely Ladies" from Les Miserables) so for anyone who wants a bit of mood music while they read this post, here you go: 

     Women's Health has been quite fun so far. As an introvert, it can be a bit difficult for me to adjust to meeting new people every five weeks, and it can take about a week before I really start feeling comfortable, but for this rotation I'm paired with another girl from my class, so it's nice to have a friendly and familiar face with me. Our preceptor for this rotation also likes to pimp us with questions more than my preceptor in the psych rotation, so it's been good to be able to brainstorm with someone else, and somehow not knowing the answer to a question feels less horrible when the other person is just as clueless. Not that we're okay with being clueless. Oh no. My fellow student and I try to spend our time between patients and at home look up any questions, and often try to look at the patient list a day ahead of time so we can study up on pertinent issues ahead of time. We still get stumped frequently, and getting asked questions still makes me nervous, but at least we've started to answer questions correctly, sometimes to our preceptor's surprise. Plus, we've also realized that, as nerve wracking as it can be to not know the answers, our preceptor often cares more that we are thinking through the questions, pushing ourselves to learn more, and to answer with confidence than that we actually know the answers right away.

This isn't quite related to my rotation, but I found this
girl at the beach to be adorable.

     I think there might have been some people in my program who questioned the necessity of a required rotation in Women's Health, but I am so thankful for it. I'm also not simply thankful because I am a woman and thus the things I'm learning seem particularly relevant to me. The truth is that it has become apparent to me that there is widespread ignorance of women's health issues, even among women. For one example, it seems like most post-menopausal women I've seen thus far have some form of urinary incontinence or prolapse or both, yet these are not issues commonly talked about. Both in this rotation and in my life in general, I've also found that many women, young and old, are fairly ignorant of their own anatomy. I'm not sure if this is simply because male genitalia are talked about more in public, but whatever the reason it does women a disservice as they know neither how to describe their problems, what causes them, or how to prevent or treat them. Even trying to explain how to perform Kegel exercises resulted in at least one woman becoming uncomfortable and deciding to simply have surgery instead, despite the fact that Kegel exercises are simple, non-invasive, and decently effective for her condition. Though I'm a woman who's trained as a healthcare professional and covered women's health in school, I'm still struck by how much I've already learned on this rotation and yet how much I feel I still need to learn. Whether in the office or the operating room, there's something new every day. I'm excited to keep learning for the remaining three weeks I have here, and to be able to share this knowledge. In fact, I wish I could write more about this rotation and some of the things I've already learned and done, but I'm tired and I have to fit in some studying for tomorrow's patients before bed, so I'll have to save those things for my next post. 

I don't often have time to go exploring, but Salem really is quite lovely, even on cloudy days.

We're All Mad Here (18/30)

From Alice's Adventures in Wonderland by Lewis Carroll

     This month I finally began my very first clinical rotation! As you might be able to guess from the quote I chose for this post, I started off in psychiatry of all places. I'll admit that I was a bit nervous when I looked at my rotation results after the Spin and saw that. After all, in school we tried to cover everything we could possibly see in practice, but rather than having a section in clinical medicine that covered psychiatric conditions, we covered everything in primary care psychiatry during our first year, and then hit upon conditions again as they related to our systems or topics (delirium and dementia in neurology, autism spectrum in pediatrics, treatments of anxiety and depression in therapeutics, etc.). It made sense to do things that way since the majority of the cases we'll see in practice will be medical and not psychiatric, but it does mean that I spent the last month of classes reviewing my notes from previous psych lectures and feeling woefully unprepared as my first day loomed closer and closer. And then it was here. 
     I lucked out with my first day of rotation because the morning and afternoon were primarily filled with orientations on different subjects and so I was sort of eased into everything. I didn't know that would be the case ahead of time though, so I'll admit that I was pretty nervous as rotations came closer. I actually texted my boss the night before I started and asked if she'd be willing to "mother" me a bit and give me a hug in the morning if I stopped by to get coffee on my way. She did even better than that and not only gave me a hug and coffee, but she sent me inspirational clips from the Rocky movies and an encouraging message. It was exactly what I needed, and, after another message of "good luck" from a dear friend, I was ready to tackle this first rotation with gusto.
     Because of concerns about HIPAA, I cannot say specifics about my rotation, though after three weeks in psychiatry, there are certainly stories I'd enjoy telling. Instead, I'll just include a few of the lessons I've learned so far.

• It is so important to get input from multiple disciplines in order to treat a patient. In part, this is something I already knew. I actually chose to be a PA partly because I love that one of the major emphases of the profession has always been to recognize that PAs work as part of a team to provide care. It's one thing to know this in theory though, and another thing to see this in practice. In psychiatry, it's not just the PAs, NPs, MDs, and RNs working together, but there are also the occupational therapists, mental health counselors, and social workers. It's been so helpful to see how many people can work together to provide care for a patient, whether it's a social worker who helps the patient plan for discharge or a nurse who is the first to notice a change in mental status or an OT who can provide insight into a patient's participation in groups. Family members are also key players because they know the patient best and can provide clues that you would have noticed on your own. It's tricky to get the whole picture without everyone contributing their pieces, but when people work together, it's a beautiful thing.
• Sometimes you cannot "fix" the problem. Sometimes the problem is a condition that progressively worsens over time and you might be able to return a patient to their baseline, but not to "normalcy." Sometimes the problem is not a medical one, but a personal or social one, and all you can do is provide the patient with the tools they need to make changes, but those choices remain their own. Sometimes you do everything right, you use treat the patient with the standard of care, and it doesn't help, or it works, but so, so slowly. This last case might be the hardest and most frustrating, both for clinicians and patients, but it doesn't mean we give up or stop looking for other options. 
• I've come to recognize the joy of "normalcy." It's the joy of realizing that the problems being discussed at a family meeting are no longer a patient's psychotic delusions, but rather issues that could be seen at any family counseling meeting. It's the difference between asking a patient, for example*, why they think their parents are spies for the KGB, and asking the patient to explain to their parents why they would like a little more privacy and responsibility when they return home, and to be treated like the young adult that they are, and not like a child. It's the joy of realizing that your patient has improved to a point that you can now identify with their problems. 
• Sometimes you just have to jump right in. I hate talking to people on the phone, but when your preceptor tells you to call another doctor for a consult, or a patient's family member to get more information, you have to do it. You have to swallow your fears and your nerves, pick up the phone, and announce your name and title with pride.
• When passing through locked doors, always make sure no one is following you through who shouldn't be. Just trust me on this one.

We are ridiculous, but great.

     I still have two more weeks left in this rotation, and I can only imagine what more I'll learn in that time. It seems like everyday is filled with lessons about conditions, medications, treatments, what questions to ask, and how to solve tricky diagnoses. I actually might just miss psychiatry when I move on to my next rotation, which is not something I expected I'd ever say. I still don't know if I'd go into psychiatry once I begin practicing, but I will admit that this time has been challenging, but fun. There's never a dull day. Of course, I must admit, there's a very good chance that I enjoy it so much because I'm not that "normal" myself (after all, how many people spend part of their last day at home convincing their parents to join them in dressing up like hobbits?), but I'm okay with that, just as I'm okay with keeping my options open for all the rotations to come so that I can enjoy and learn from each of them in turn. It's an adventure, and I'm enjoying it all.

I love my parents.

*This is not a real patient example.

Crunch Time (17/30)

"Our Lord has written the promise of the resurrection, not in books alone, but in every leaf in springtime." -Martin Luther

     So... If anyone's wondering what happened to my Lent posts, the answer is that school happened. I'm on my first day of my last finals week ever, and two weeks from the start of my first rotation. While last week had only one exam, and the week before that was, mercifully, exam-free, the week before that one featured two big exams: clinical therapeutics and clinical medicine. The medicine one was confined to the topics of pediatrics and geriatrics, but the therapeutics one covered topics ranging from pediatric fevers and pulmonary conditions to psychiatric drugs to every microorganism that lives on your body and how to treat soft tissue infections. It is probably not  so surprising that the therapeutics exam hit people harder than the medicine one, though it was a bit shocking that about 40% of us didn't pass. There were a variety of reasons why so many failed, but the good news is that everyone who failed was given a chance to remediate, and a review session was held for the whole class to make sure we all had those subjects down pat before starting clinicals.

     Today's test on history and physical exam was not too bad, but now I should get back to studying medicine (neurology and miscellaneous topics) and therapeutics (cumulative for the semester, plus CVA and TIA). I still have thoughts I wish to share on Easter, and I have two half-finished Lenten posts (one on justice and one on the unity of the church, which, oddly enough, were the two main topics of the sermon at my church last week), which may appear sometime soon, or may be saved for a more appropriate moment, but in either case they'll have to wait a tad longer. For now I will simply say that N.T. Wright had it right when he said that Christians should celebrate Easter bigger and better than most of us do. Easter is, after all, the most important holiday for Christians, and is certainly a cause for celebration. In honor of this, my roommate and I decided to try something new this year and begin Easter morning with special breakfast, complete with French press coffee, waffles, and mimosas. I think we'll keep this tradition. :) And now, back to the joys of medicine!

Look out, world! These 96 future PAs start seeing patients in 2 weeks!

Being Quiet

     This week has been another busy one, so, once again, I missed my Wednesday post for Lent. I apologize to anyone who was disappointed. I chose two delicious recipes for the post to help make up for it. I'll try to make the rest of my post of few words, as befits the topic I've chosen for this week: quiet times.

     Throughout human history, people far wiser than me have expounded on the benefits of times of silence and solitude, as well as the difficulties of procuring such times. I won't try to top their wisdom today. Rather, I will simply admit that, even for an introvert like me, planning times of quietness, particularly to be used for prayer or meditation, can be a struggle. I can find time on the train to read a chapter of my book, but blocking out the world is not always easy. I find that I often have to take myself out of my normal environment to truly have time alone. Like many others, I prefer to find the quiet places outside, and use those spaces to meditate and pray as I walk or sit in contemplation. However, sometimes the weather works against you (Massachusetts is welcoming the first day of spring with a new snowfall as I type), and you have to improvise. For me this has meant using my walks to the train or to work as times to pray, rather than listen to music or a podcast. This didn't come easily at first. Prayer is something I've struggled with for a while. My mind wanders, or I find it hard to be silent for long enough to actually listen. I've found though that, even if I don't do this every time I walk, the habit of praying is slowly becoming ingrained into my life. 

     I wouldn't say that I "pray without ceasing," not yet at least, but it has become much easier to simply take whatever quiet moments I have throughout the day and use them for prayer. Sometimes the prayers are just small, scattered things like a simple thank you for beauty or a request for a friend, whereas at other times prayer becomes fluid, almost like breathing -breathing out a request or frustration and breathing in God's response. Sometimes my prayers sound a bit like one of David's psalms, the ones where he simply cries out in frustration at God's apparent inaction or at his own failure to perceive what God's purposes are. Like David, I don't always get a specific answer. When I say, "why?!" or repeatedly remind God how much more I'd like to know, God doesn't always explain. Sometimes the answer simply seems to be the reminder that He is God, and I am not, or that He is trustworthy. These aren't always the answer that I want, but they seem to be the answers I need. No matter what shape my prayers take, whether a wrestling with the Creator or a friendly conversation or respectful awe, the key thing I'm learning (ever so slowly) is that you never get better at doing something if you never try. Prayer is hard. Being silent is hard. Giving yourself time for meditation and self-reflection is hard. But they are so worth it. Perhaps this Lenten season you can try to find moments of quietness, even if just once a day or once a week. 

World's Easiest Cinnamon Rolls

I'd been waiting to try out this recipe for a long time and I was so happy that I could yesterday morning because I had it off. These were the first cinnamon rolls I've ever made from scratch entirely by myself and they were delicious. My opinion can be confirmed by the two friends lucky enough to try these rolls. I could have had more expert testimony, but these rolls disappeared to quickly to let anyone else try.

Brownies

I made these last year for one of my vegan friend's birthdays. They are soooo good. I was very happy because I've been, and still sort of am, looking for a great from-scratch brownie recipe and voila! These are both easy and tasty. However, I will caution you that they are also very fudgy, even after baking a bit longer and adding a smidge more flour than the recipe called for. 

A Time for Compassion

     Two Sundays ago, the sermon at my church began with the story of Rev. Everett Swanson, the founder of Compassion International. Swanson traveled to South Korea in 1952 during the Korean War to preach the gospel to the soldiers. When he arrived though, it was the many children orphaned by the war that consumed his thoughts. Their needs were great, and when Swanson told a fellow missionary about the situation, his friend asked him what he was going to do about it, challenging Swanson to action. He returned to the U.S., unclear of his next steps, and was presented with two checks, completely out of the blue. With this money Swanson returned to South Korea and began caring for 35 orphans. Swanson told American Christians of the situation and eventually set up a sponsorship program. Through this program, people anywhere in the world were given the opportunity to sponsor a child, providing them with food, shelter, clothing, medical care, and education until the child became an adult. What began with one man caring for 35 orphans in South Korea is now a program sponsoring 1.5 million children in 26 countries. 

     So why do I retell this story? Is it simply because it's an inspirational tale that might restore some faith in humanity? Or is it just a tale of how one person can make a big difference, or of how God can use us in ways we didn't expect? All of these lessons could apply, but I tell this story now because I think it is appropriate for Lent. While it may have been forgotten in these modern days, or in denominations that don't traditionally celebrate Lent, the Lenten season has long been a time of increased compassion to the poor, above and beyond what should normally be found in a Christian's life. This was once the time when Christians were expected to give alms, if they didn't do so already. It makes sense. After all, if you are giving up certain luxuries (such as meat or sweets) for over a month, you should find yourself with some extra money. Rather than saving it up or spending it on other luxuries, the tradition has been to use this money to give to others who have less. I think it's a beautiful tradition, and one which should be revived and given more attention. Just as a break or relief in a fast on each Sunday during Lent reminds Christians that the hope of Easter, and all that it entails, is coming, so giving of yourself to others during Lent can be a way of joining in the mission of Easter and working to help build God's kingdom in the the here and now. I'd suggest that this is something we should be doing at all times, but the times of reflection, sorrow, and penitence during Lent might be an ideal to truly take a look at the world around you and ask how you can help relieve suffering.
     Here are a few ideas to get you started:

• Sponsor a child -Compassion International and WorldVision are great ministries to help you do this
• Find a ministry to support -whether it be the coffee shop that helps homeless youths, the food kitchen at your local church, the church services that began as an outreach to ex-prisoners, or a ministry dedicated to bringing clean drinking water to all -there is likely already a group you can support to help them serve others. 
• Sign up for Pledgeling -Right now Pledgeling will give you $5 to donate to a charity of choice, just for signing up
• Give -The simplest thing you can do is to simply give money yourself, directly to someone who needs it. In the U.S. right now I think there's a lot of worry that any money you give to someone on the street will be used to buy booze or drugs. It's a valid concern, but I'm not sure that should stop you. You might take a chance, and your fears might be proved correct, or you might make the biggest difference in someone's day. An alternative to cash is always to give gift cards (either to restaurants or grocery stores), or to offer to take the person out for a meal. Who knows? If you try the latter option you might just find that they change your life as much as you change yours. 

Just some happy little vegans, both temporary and permanent

The two recipes for this week come from last Thanksgiving. I decided to stay in Salem, work in the morning/afternoon, and then celebrate "Friendsgiving" with two coworkers and one of my roommates. One of my coworkers is a vegan, and even though they said we didn't have to eat vegan for our feast, the rest of us all decided to do it anyway. The result was a seemingly traditional Thanksgiving feast (complete with stuffing, mashed potatoes, rolls, green beans, and pie) that simply lacked a turkey. If some omnivores could eat an entire vegan feast and be completely satisfied, I figured the recipes were worth sharing.

Garlicky Green Beans with Pine Nuts

Simple and delicious, these were a big hit. I could be biased because I always love anything with garlic, but the green beans were so tasty, and the pine nuts added a little something special. I have yet to try making them myself, but my source tells me that they were quite easy.

Walnut-Apple Stuffing

If you're going full vegan, you should double-check there's no dairy in your bread (you'd be surprised how often milk is an ingredient), but otherwise this is a scrumptious stuffing. My roommate made it and I wanted there to be leftovers so I could enjoy this for days. Sadly, everyone else agreed with me on how good this was and devoured it all.