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.

12 Comments

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12 responses to “The empathy toggle switch

  1. Emily CNM

    Even though I’m aware of the phenomenon of residents “practicing” pelvic exams on unconscious patients, I’m still horrified every time I hear about it. I’m glad that you said no. I know I certainly wouldn’t want anyone practicing *anything* on me when I was unconscious. The patient signed up for a necessary procedure and no more than that.

    I hope you carry this with you – I have called many a resident/house officer into the room to help with something and have been constantly amazed at how not ONE of them introduces themselves to the patient before touching them (often in a very intimate and painful way). It’s as if she is just a vagina or just a baby and there is not a woman attached to that vagina and/or baby. It sickens me every time I see it and I try to make it a point to introduce my patient to the physician.

  2. This is such a wonderful post and topic I was hoping – just checked, to see if you put it up at MiM (are you still doing MiM?).

    I am glad that I got through medical school without ever witnessing or hearing about (or offered the opportunity to do) a “practice pelvic” on an anesthetized patient. I agree – that needs to be consented along with the procedure.

    I don’t come across patients that often, but I can’t imagine shutting off completely to do procedures. I am constantly aware of my patient’s facial expressions and body posturing to see how far I can go and what sort of pain level they are at. Last week I stopped and took 10 minutes to let a nauseous patient eat crackers and drink water before I went on (he hadn’t had lunch). I guess surgery might be different, with an anesthetized patient.

    This post also brought to mind the thought that as a pathologist, I am so far removed that I sometimes feel guilty for getting excited about a cool case when I don’t even know the patient or will ever experience the impact that the diagnosis will have on their life. That is a journey I didn’t sign up for. This is good and bad, I guess.

    • MomTFH

      Thanks! I was thinking of posting on MiM. I am glad you suggested it. I still do post on there, I am just wary of which of my posts are appropriate.

      I can see how it can be weird to be the pathologist. On the one hand, you don’t get to experience what the diagnosis will do to their life. But, on the other, you make these key diagnoses all the time, which have can have such a significant impact on these patients’ lives, whether it’s ruling out something serious or confirming something serious.

      As for the pelvic exam issue – I am happy that I had examined the ethics of performing pelvics on anesthetized patients before I was offered the opportunity.

  3. Suzy

    That the OR nurse offered you an opportunity to violate that woman with an unauthorized pelvic exam makes me ill. Penetrating an unconscious woman for your own purposes is called rape, whether or not you are a medical student. I am glad you had the sense to say no, but I do hope you report the OR nurse to the ethics board. She should NOT be offering unconscious women for the taking.

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  8. Gary

    Just what makes any OR nurse feel they have the right to offer another persons intimate areas ? What void of basic morality allows the medical community to feel they have this dominion at all ? This practice should be investigated, exposed and any person who has taken part should be subject to civil suit and criminal prosecution .

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