Monthly Archives: August 2010

The empathy toggle switch

In our clinical years, our medical school has instituted a program in which we do learning modules along with our in hospital experience and didactics. I was happy to see a module on empathy for my second month of surgery. The last question to be answered in this module was: “Although the studies on empathy are very consistent other authors have indicated that medical students are really not losing cognitive empathy, rather they are learning to engage in a “toggle switch” approach to patients where one side of the switch is “associated with the patient” and the other is “disassociated from the patient” which is necessary in order to perform medical procedures. Please discuss this and use example which you have seen or in which you have been involved.”

Here is my answer:

I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.

I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.

I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.

After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.

I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.

Edited to add: RH+, a contributor on Mothers in Medicine, where this was cross posted, pointed out that a pelvic exam would be necessary in the D & C to determine the position of the uterus. She was right, and the physician did do a pelvic exam when he came in, and explained to me why he was doing it. In that scenario, if he asked me to perform one and tell him what I thought the position of the uterus was, with instruction, I would have thought it was ethical. He did not ask me to perform one. When the OR nurse (who is not part of our teaching faculty) offered the opportunity to me, it was more as an opportunity to perform one on an anesthetized patient just because the opportunity was there, not as a specific learning experience. I guess it is a fine line, but it’s there.

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More prenatal humor

It’s a good day for prenatal humor. Yes, I know this is over the top and sarcastic, but it is also hysterical. (Yes, pun intended again)

The “Emergency” C-Section

(I can’t get it to embed. Boo.)

This was written by a local midwife. A doula isn’t a rash. It’s a person. But it’s just as annoying. LOL!

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Funny, funny fetuses (feti?)

This has to be the funniest and most deft synthesis of pregnancy, current events and humor I have ever seen. Dare I call it hysterical?

From Tom the Dancing Bug on boingboing.net:

Beware the plotting fetuses

Click to embiggen, or follow the original link.

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Rethinking residency

I haven’t been posting that much. I am really busy. I am not busy with pregnancy / women’s health stuff for the most part, so I haven’t really been inspired to post on my passionate topics. And, I can’t really vent too much about my life drama on here. My ex is apparently reading my blog, and will take random statements out of context and bring them up at really strange times, and throw me off. For example, he read this post, and got out of it that I apparently want to drop out of medical school. Talk about missing the point.

I’m not going to lie. My future medical career is not looking as rosy to me as it once was. I remember feeling on top of the world when I found out I got accepted to medical school. It is not often that one gets to fulfill their wildest dreams. I went from being a single mom who was waitlisted for medical school and had unsure career options to a remarried mom with a new baby and an acceptance to medical school within the span of about three years. It was an amazing turnaround. Yes, I should have seen the red flags in our relationship already (like his refusal to move with me if I got into a school out of the area, then turning that around on me as my threatening to leave him…huh?, and the rages I had already suffered), but I thought I could reason with him, or that therapy and love would fix him.

I am reluctantly letting go of my ideal residency dreams. I met the program director from OHSU at ACOG’s ACM residency fair earlier this year, and she said I would be a good match for the program. Unfortunately, it is about as far as I could get from my two baby daddies while still staying in the continental United States. While it is rumored to be a family friendly program, and I have a substantial support network there of numerous friends, it will still be legally, emotionally, and logistically difficult to justify moving the kids that far away. It is breaking my heart.

I am not sure what is going to happen, now. I can’t imagine doing any other specialty rather than ob/gyn. Ob/gyn has become an increasingly competitive specialty recently, and I can’t consider myself as a shoe-in for any program I apply to, especially as an osteopathic candidate in the allopathic match. There is one, count it, one residency in the immediate area. According to APGO, they have an average of 600 applicants for 9 slots. There are a handful of other programs in the state, but the closest is more than a four hour drive away. I guess that’s better than being a four hour flight away, but…sigh.

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Another music post

Time for another music post. I have been putting it off, but I got triggered by the blogiversary at The Unnecesarean. Whenever I say “Happy anniversary”, I always think of “I Think I Need a New Heart” by the Magnetic Fields, which isn’t really a cheerful song and wouldn’t be appropriate for a blogiversary comment. But, it fits in with my life right now pretty well.

So, since I felt like posting that, I am going to post a few more songs that have been bopping around in my head:

I love her voice, and her melodies are so catchy. Nothing in particular about that song that made me want to post it.

I’ve decided what the next song will be whenever I get to do karaoke:

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I’m in print!! *link fixed*

I have an article published in the Journal of Perinatal Education:

Social Media, Power, and the Future of VBAC

Squee!!!!

Special thanks to Amy Romano, who was the lead author and did almost all of the final version of the piece, and to Desirre Andrews, who was the other co-author.

Edited to add: I fixed the link, but now they are asking for pay-per-view. I think if you register for a free trial of Ingenta you can read it for free. If not, let me know.

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Reply turned post, IUDs as EC style

Sungold has a great post up at Kittywampus about the little known use of the copper IUD as emergency contraception. I wrote a reply, and figured I would share it here:

No one seems familiar with this whenever I bring it up, and that includes ob/gyn clinicians. In the US, IUDs are supposed to be just as acceptable to insert in nulliparous (never had a baby) women as parous (has had a baby) women. As Sungold pointed out, that is not the reality for all women. I was actually told by my ob/gyn that I wasn’t a good candidate, even though I had already had a baby, because I was divorced. (!!)

According to a midwife who taught me about birth control, the reason why IUDs were not recommended for nulliarous women were because so many of them successfully sued over the Dalkon shield. The company had to pay a much higher settlement to women who never got to have children due to their injuries than they did to those who already had children. The indications for the newer IUDs, including the copper T, originally said the ideal candidates were parous women, but that is no longer the case. New recommendations say that pretty much any woman who does not have active pelvic inflammatory disease is a good candidate.

The Dalkon shield was a completely untested, unresearched, unregulated piece of scrap metal. The copper IUD is a much more carefully created and substantiated device. It has a higher rate of continuance of use than any other form of birth control. Not only do I have an IUD, but the IUD is an incredibly popular form of birth control among female ob/gyns I have very unscientifically surveyed.

The main issue I can see with using IUDs as emergency contraception is that the standard of care is to screen for and treat STDs, particularly gonorrhea and chlamydia, before insertion. With conventional screening, time for results, and then treatment if necessary, you are probably running over the 5 day window. So, even if USian practitioners were comfortable with using the IUD as emergency birth control theoretically, this protocol may be a barrier.

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