By Gary Evans, Medical Writer

Rana Awdish, MD, a young, pregnant critical care physician, became a patient spiraling toward death in her own hospital in the course of a single day that began with her shopping for shoes.

She was hit with a sudden devastating illness in 2008, hemorrhaging and experiencing organ failure that resulted in the loss of her unborn child, and very nearly her life. A benign liver tumor had ruptured, causing severe bleeding that led to hemorrhagic shock. She required 26 units of blood, multiple surgeries, and physical therapy to recover and return to work. But her transformative experience as a patient irrevocably changed her view of medicine, which she saw for the first time as too callous, distant, and dysfunctional.

In subsequent speaking engagements, articles, and a 2017 book,1 Awdish emphasizes a compassionate, patient-centered approach to care, which occurred to her as a great need both personally and within her profession when she was near death.

“When I overhead a physician describe me as ‘trying to die on us,’ I was horrified,” she wrote in an article in the New England Journal of Medicine.2 “I was not trying to die on anyone. The description angered me. Then I cringed. I had said the same thing, often and thoughtlessly, in my training.”

Awdish is a specialist in pulmonary medicine and critical care in the same hospital where she was a patient, Henry Ford Medical Center in Detroit. Hospital Employee Health recently spoke to her for the following interview, which has been edited for length and clarity.

‘I Did Not Know My Value if I Could Not Fix Things’

HEH: You wrote that in the transformation from provider to patient, you saw in caregivers an inability to acknowledge patient loss and suffering.

Awdish: For me, as a critical care physician specifically, I had been acculturated to believe that the way we relieve suffering was to treat the disease. Any time that we spent where we were just holding space with emotion was less valuable than doing the work of retrieving someone from the brink of death. As a patient, what I really felt acutely was the need to feel that my suffering was seen.

“Suffering” is a word that we are not comfortable with in medicine. I think part of that is that we feel very impotent in the face of emotional suffering. We know that we can’t fix it — we can’t “un-sad” anyone. Physicians are very goal-oriented and driven to fix things. In many ways, that is how we measure our value. I, for one, did not know what my value was if I could not fix things. I didn’t necessarily think that sitting with someone through an emotional trauma was valuable.

HEH: How did your own illness change your view of this?

Awdish: Going through the years of my own illness, what I really saw was that there was an incredible amount of healing from just being present and available to hold that space. It wasn’t just the people around me who showed me that. It was also my patients when I went back to work, and I was approaching things from a different perspective. I made myself available for those difficult conversations, where I didn’t have any answer and I couldn’t fix it. I would just be available for the pain. What was reflected back to me was how meaningful that was and how it was healing — even though I couldn’t heal. I learned that from both my caregivers and my patients.

HEH: Does dropping that guard, becoming empathetic, run the risk of making you more vulnerable to burnout or negative aspects of patient suffering?

Awdish: I think it’s quite the opposite. We were taught not to do that to protect ourselves out of a fear that we would deplete ourselves. What we now know is that medicine without connection doesn’t actually nurture the provider. It doesn’t provide for longevity; it doesn’t let you see [the patient and the system] in a way that creates joy in work.

While I think our predecessors touted this idea of “clinical distance,” it was at a time when, really, the system itself wasn’t resilient. There wasn’t space for them to debrief; there were not venues to recuperate after a trauma. It was very sterile, clinical, and male, frankly. I think as more women enter medicine, we can drop that façade a little bit and allow these traditionally feminine attributes of nurturing and caring.

We are seeing now how much value is there. It really is bidirectional — if you open yourself, it doesn’t deplete you. It actually nurtures you and helps you find joy in work.

HEH: How do nurses fit into this view?

Awdish: I think nursing has been ahead of us as physicians for a long time in terms of integrating the whole person into their education, integrating compassion and the presence of suffering. They are a group we can really learn from because we did not have that in our medical education.

HEH: How did you bring these new insights into your clinical practice after you recovered from your illness?

Awdish: One of the first things I did when I went back to work was to really look for resources and find out how to have these conversations effectively. I looked to Vital Talk, a national organization that trains physicians in difficult conversations.

I went and trained because it was not something that we learned in medical school, in residency, or fellowship. I went as an attending [physician], and we role-played difficult conversations. I learned how to have those conversations in a way that didn’t deplete me. I knew they would be healing for the patient, and, therefore, I wasn’t as afraid of them.

I think having that kind of training is necessary. This isn’t something where we are asking clinicians to open their hearts and bleed, because that is not sustainable. It’s finding ways to be compassionate that are actionable, to show that you will support someone through a difficult time, but feel supported yourself as well.

We can’t do this in a dysfunctional system. It requires the system to really support clinicians and ensure that they have the resources that they need. That is why I brought the training back to Henry Ford Hospital along with other physicians who trained with me. We knew that we needed it in order to do this work. (Editor’s note: Vital Talk, which offers training to help clinicians engage in difficult conversations with patients and families, is available at: https://www.vitaltalk.org/.)

HEH: You point out that it is a misconception that this approach will require more physician time.

Awdish: The myth is that it takes more time. The truth is that it doesn’t. There are good studies to show that physicians that are compassionate in any specialty actually have shorter clinical encounters. That makes sense intuitively, because if the patient feels heard, they can let go of needing to retell their story or describe their symptoms again. They feel “seen.” I think a lot of what we are avoiding is actually the answer.

HEH: Based on the success of your book, your message seems to be resonating in the healthcare community.

Awdish: Yes, and I have to say that was not my expectation. I honestly believed that what I wrote was more subversive than it turned out to be. I thought it was more counter to the culture. As is often the case with a story, when we are vulnerable we tell our truth. A lot of people can identify and see themselves in it, so it has been picked up as either required or suggested reading at over 50 medical schools now. It is part of the curriculum in hospital business administration, nursing curriculums, and ethics curriculums as far away as Ireland and Australia. I think it struck a nerve. That’s wonderful that it is part of the larger conversation about how we can heal. I’m grateful for that, but I think it is really just the beginning. There is so much we can do to really operationalize compassion and make the system work for physicians so that they can apply these things if they want to. It’s very rewarding.

HEH: Speaking of telling your story, you wrote of “narrative medicine” and the clinical value of the patient story.

Awdish: All roads lead back to the patient story. Whatever road I’ve gone down, I keep coming back to narrative medicine because there is something so visceral about really hearing the patient story and receiving it — not extracting it in data points that are relevant to physicians, but letting the patient story really have primacy. I think we can do that, even with our stories.

As clinicians, sometimes we need to tell our story of trauma that comes from a death, or an error, or a really bad night on call. By doing that, we can create affiliation through representation. We can see each other in these stories. At its basic core, narrative medicine reduces us to our humanity. I think it is there that we can really see that we are all the same — physicians and patients. We are interchangeable depending on the moment. What we all want is to be seen and known, and stories can help us do that.

HEH: What do you mean when you say you found that “the wound is the gift?”

Awdish: There are so many hurts and injuries that we all sustain in our training. There are wounds that we sustain as patients. If we can sit with that suffering, that’s where the lessons reveal themselves. My book, for me, was a meta lesson in that. If I could sit with this suffering, there was such a gift within it of wisdom, clarity, purpose, and direction that I wouldn’t have had otherwise. It was part of my upbringing to believe that good can come out of anything. “The wound is the gift” is really just a different way of saying that.

REFERENCES

  1. Awdish RLA. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. New York: St. Martin’s Press; 2017.
  2. Awdish, RLA. A View from the Edge — Creating a Culture of Caring. N Engl J Med 2017;376:7-9.