Sunday, August 29, 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.

Cross posted at Mom's Tinfoil Hat


  1. Excellent post!

    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.

  2. I had an experience last week where I was well aware of my toggle switch. I am a second year med student and a lot of stuff happened in my personal life during first year. My dad had a heart attack which left him on a ventilator in a PVS, which he is still in, fighting infections and bed sores too often. One grandmother was diagnosed with AML and is not doing well. The other grandmother had a stroke, fell on her face, and is mentally a different person. My grandfather died after 10 years of suffering with parkinsons disease. This all happened during my first year of medical school! All last year. When it rains, it freakin pours. Also, my brother ended his own life a few years ago from mental illness.

    So, when I sit with patients and they start to tell me about their medical history, or how their father/mother/brother/sister died there is inevitably a moment where I could say, "I've been through something similar" and tell them about my life. On some level, at some point in my life, I think sharing bits and pieces of information will be good for my patients because they will know that i know their suffering but right now, since the emotions of all of it are new to me, I have not yet put them into the proper words to say. So basically, instead of being too personal and telling my patients too much about me, and risking an awkward situation where they need to comfort me, I instead shut my feelings off. I listen to their pain and I nod, and I try to be empathetic on some level, but I have to shut off my emotion or too much might come out. I am afraid I look cold, or fake - but I am really doing my best.

    It is actually something that I am grappling with immensely - how to process my emotions and be a good medical student. I think by the time I graduate these emotions will be filed neatly away and accessed when needed in an appropriate way, and I will be good to go as a doc - but what do I do now?

  3. @Gizabeth, I think you provide a really interesting service as a pathologist. You may not be personally delivering these diagnoses, but they are so important in the lives of patients. As for the pelvic exam issue, I am really happy I had put some thought into the ethics of it before I was put in the situation.

    @anonymous, I am so, so sorry about your rough year, and your brother a few years back. It sounds like your family has had a lot of bad medical luck lately. It must have been really hard to keep focused while all of that was happening. It is always a difficult decision when choosing whether or not to share a personal experience with a patient - although you may think it may seem empathetic, I think recent research indicates that patients do not respond well to it. So, even though you may be afraid of seeming cold, you may be actually doing what is preferable to patients.

    More than I am wondering about whether you should share your personal experiences with your patients, I am more worried about how it must be affecting you to be triggered by the histories and situations you encounter. I hope in the long run it helps you to be a good physician, but I am sorry that it will probably be a painful aspect of being in this field.

  4. While it is of course inappropriate for a "practice pelvic" to be done by mere observers; but anyone who is actually scrubbing to assist with a gyn procedure needs to do a pelvic in order to know the exact angle of the uterus so when instruments are inserted they do not perforate.

    I appreciate your empathy and kindness in sitting with this patient and appreciating her level of loss.

  5. RH+, the ob/gyn did do a pelvic when he came in, and he explained that it helped him determine the position of the uterus (e.g. antroverted or retroverted), and I would have been willing to do the pelvic with his instruction to determine this in that scenario, but he didn't ask me to. I guess it's a fine line. The OR nurse (who is not part of our teaching team) pretty much just offered it as an opportunity to do a pelvic, not as a specific teaching tool. Does that make sense?

    Anyway, thanks for your commentary. You are right about it being part of the procedure, once the procedure started, and I could have been more specific.

  6. I wanted to add more to my reply, since you brought up such a good point, RH+, and it has made me reassess my post. I went back and edited the original post on my site. This post wasn't as complete as it should have been. It was an answer to a module question that I thought was interesting, and it wasn't a very thorough blog post.

    I didn't scrub in on the procedure. I was invited to observe the procedure by a third party who knew I was interested in pursuing a career in ob/gyn. At the point in time that I was invited to do the pelvic by the OR nurse, I wasn't scrubbed in, and I hadn't met the ob/gyn who was going to be performing the procedure. He wasn't in the OR yet. I was pretty sure I was only going to observe, not assist. The OR nurse was not an obstetrical nurse, but just a general OR nurse who would not be able to instruct me in how to perform a proper pelvic exam, much less how to ascertain the size and positioning of a gravid uterus.

    I highly value being able to perform procedures at a learning facility, and look forward to doing them when the right opportunity presents itself.


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