Empathy cannot be simply turned on and off

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 dilatation and curettage. 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.

MomTFH is a medical student and blogs at
Mom’s Tinfoil Hat and Mothers in Medicine.

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  • http://www.TheHealthCulture.com Jan Henderson

    Thanks for sharing your thoughts. I hope you get the career you aspire do, since it sounds like you will have many appreciative and satisfied patients.

    There was an article on empathy in a recent issue of JAMA. It detailed the activity in the brains of two individuals when there is an exchange of empathy between them. The upshot was that the way to convince doctors to express empathy is to demonstrate the scientific basis of what occurs in the brain.

    It struck me as a sad commentary on the state of medicine and the doctor/patient relationship. Instead of understanding empathy as a natural response of one human being to another, one must now prove the existence of a neurobiological event before acknowledging that there could be any benefit.

  • Somewhere in Florida

    You ultimately will become what you are. Your feelings of empathy will be covered by a cloak of professionalism when necessary. Ultimately you will by judged by your peers for your skills and professionalism and your empathy, bedside manner and your skills by your patients. Your mission is to have a balance between all. Your happiness will depend on it. Always stay true to yourself and your moral convictions, no matter who tells you otherwise. You’ll feel the most rewarded when your patients send you ‘Thank You’ cards and gifts while your selfish, thoughtless peers receive lawsuits and negative commentary. Best of luck. We need more thoughtful, caring people like you in OB-GYN

  • http://www.momstinfoilhat.wordpress.com MomTFH

    Hey, I just found out this was reproduced here. Cool!

    Thanks for the thoughtful comments. I hope I hold on to the empathy, along with the professionalism.

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