#36 Review: The Doctor as Patient
Yes, medical memoirs have been written before, but Rana Awdish, MD, raises the genre to a whole new level in her book In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope (St. Martin’s Press, 2017, 272 pp.). The first edition of the book had the subtitle: How Nearly Dying Made Me a Better Intensive Care Doctor. That succinctly sums up her memoir, but it is so much more. To heighten the implications of her unique experience, she was hospitalized and treated in the very intensive care unit where she worked as a pulmonary and critical care attending physician.
Her experience opened her eyes to the impersonal and dismissive treatment patients sometimes receive in the emergency department, operating room and the intensive care unit. From the very start of her illness, she was triaged to the labor and delivery unit, where the focus was entirely on the status of her unborn child and not on the rapidly deteriorating health of Dr. Awdish, the mother.
Even when Dr. Awdish alerted the nurses and physicians to her own level of pain and disability, she was summarily dismissed. At one point, when the ICU nurse leaves her lying flat while she has to leave the room, Dr. Awdish starts having respiratory distress and must pull the code blue cord on herself! If this story doesn’t shake one to the core, nothing will.
Disrespectful dialogue
On numerous occasions she overheard the house staff and attending talking about her in the most unflattering way. As she was rushed into surgery while internal bleeding caused very low blood pressure, she heard the frantic voices of the anesthesiologist and surgeons:
“‘We’re losing her.’
Words echoed, or were they repeated this time?
‘Guys! She’s circling the drain here!’
You know I can hear you, I thought.” (pp. 29)
Dr. Awdish laments later that these might have been the last words she heard on this earth. She particularly came to loathe the very common dialogue that the medical staff uses towards their patients that portrays them as adversaries.
In the ICU, she overheard her case being discussed by the surgical resident during morning rounds. "She's been trying to die on us," (pp. 40) he said.
She becomes very angry.
“No, I was not actually trying to die on anyone. Though perhaps not manifest by outward appearances, I was trying desperately not to die. And though I might not have had a lucid enough mind to articulate it, by blaming me, I felt he was positing me as an adversary. If my care team didn’t believe in me, what possible hope did I have? I felt the ice I was balancing on detach and begin to float me away.” (pp. 40)
The incident highlights what Dr. Awdish calls the “subconscious construction of a narrative in which the doctor-patient relationship is somehow antagonistic.” The house staff would regularly frame their shift as the battles they waged against patients working against them as if they wanted to die.
When Dr. Awdish ultimately returned to work as an attending and educator, she reminded her residents and students about the importance of their words.
Obedience vs. the honest exchange of information
During another memorable incident while Dr. Awdish was hospitalized, the resident on rounds was told to order more of the diuretic Lasix for her low urine volume and early kidney failure. Dr. Awdish knew this was the wrong treatment but was unable to communicate at the time.
Later, when she questioned the resident about ordering the medication, which caused her to have even worse kidney failure, he responded that he wrote the order that his attending told him to write even though he knew it was a bad idea and he didn’t want to do it. He said, “it wasn’t my call” (pp. 46). He was outranked by the attending and he didn’t want to question the person who would write the evaluation at the end of his rotation.
Dr. Awdish writes, “I wondered about the reliability of a system that was set up to insure obedience rather than an honest exchange of information. Was it possible we’d been socialized to allow medical error rather than prevent it? Had we somehow inadvertently set up a system that obstructed good communication and allowed errors to occur unchecked?
I knew in that moment my kidneys had been set up to fail.”
A call for a culture change
Fortunately, Dr. Awdish survives both her illness and the often incorrect or inadequate care that she received from her doctors and nurses. She vividly recounts her recollections of her difficult course and serial setbacks. Her honest telling of what it really feels like to withdraw from opioid pain relievers must be read by those of us who treat people with opioid use issues and have no personal experience to draw from.
In the book, Dr. Awdish advocates for a move away from “The House of God” culture, where we were trained to detach and depersonalize, to one that needs to be centered around empathy and caring, not just for the sake of our patients, but for our own humanity.
Dr. Awdish, who clearly thrives in the practice of critical care medicine and in the mentoring of medical trainees, manages to look at the practice of her colleagues and the medical system with a combination of affection and outrage.
She discloses the secret, shameful feelings many doctors feel they have to hide regarding their interactions with some of their patients. She shows us how we might do better. She has rededicated her career to improving communication in the doctor-patient relationship.
How can young trainees and physicians who have largely been healthy, not yet parents, and rarely experienced the loss of a loved one, really understand the devastating illness or loss their patients are going through? One can imagine what it must feel like to lose a baby or receive a cancer diagnosis, but how can one know what one does not know? The answer: Read this book.
This review appeared in The DO magazine June 2022.
