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In Shock in Her Own ICU

Rana Awdish, MD, FCCP is an intensive care physician and director of the pulmonary hypertension program at Henry Ford Hospital in Detroit, and is the author of the book In Shock, a memoir based on her own experience with critical illness that landed her in her own Intensive Care Unit (ICU). She is now a champion for empathy through connection and communication in medicine, and was named National Compassionate Caregiver of the Year by The Schwartz Center in 2017 and Physician of the Year by Press Ganey in 2017.

Here is an excerpt from Dr. Awdish’s 2017 piece in the New England Journal of Medicine about her medical experience and her mission to change the culture of medicine:

When I overheard a physician describe me as “trying to die on us,” I was horrified. 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. “He was trying to die on me.” As critical care fellows, we had all said it. Inherent in that accusation was our common attribution of intention to patients: we subconsciously constructed a narrative in which the doctor–patient relationship was antagonistic. It was one of many revelatory moments for me.

When I read Dr. Awdish’s piece in NEJM I knew I had to read her memoir, and it was every bit as compelling and resonant as her piece was. I was able to chat with her over the phone about her path to medicine, and how her experience with critical illness led her to rekindle her art, empathy, and desire to share her story.

Vidya: What drew you to medicine in the first place? Were you also writing at an early age?

Dr. Awdish: I only ever remember wanting to be a doctor. It always spoke to me. I saw how our family viewed our pediatrician as a hero after he saved my brother’s life (the story is in the book’s introduction). I really admired how much knowledge he had and how he was able to apply it in this really human way. I also really liked art, but I had this sense that I could always use art in my life. I felt that if I had a talent in science, then I should pursue it because I could do more good with both art and science than I could do with only one.

Vidya: When you were in college and medical school, did you continue painting and expressing yourself in that form?

Dr. Awdish: Not at all. I remember in medical school, I was completely into the science. I was so focused on learning the craft that I didn’t feel like I had room for other things. There was an 8-year period where I didn’t really watch TV, so I have a vacuum of current events knowledge. When I met my husband, I think every joke he made was about Seinfeld, and I didn’t know what it was. I think I seemed like an alien to him. I had left art behind: I didn’t write, I didn’t paint, I wasn’t doing anything creative. Looking back on it, I wish I had left more space for it. I always enjoyed art museums, so I would still make time for that, but I wasn’t creating.

Vidya: When did you start creating again?

Dr. Awdish: When I got sick in 2008, and was so physically limited, there was this period where I just could barely leave a chair or my bed, much less the house. I have an active mind and personality, and I felt like I needed to be able to do something, but I hadn’t really gotten all of my language back from the hypoperfusion and shock. I still felt cognitively slow and inarticulate, so reading and writing wasn’t really available to me yet. I could lose myself in painting.  I had all these thoughts and emotions that were bubbling up that I didn’t know what to do with, and putting visual imagery to it really helped. I wasn’t very good at it, but I enjoyed it so much. It was a very important part of my life at that time.

Vidya: I know in the book you share some anecdotes about how moments of empathy were seen as weakness in medical school.. How do you think your illness influenced your thinking about those moments and medical culture?

Dr. Awdish: I felt like I wanted to fit in during medical school. Medical students are young, and there is this club you’ve wanted to join your whole life. If someone tells you implicitly or explicitly, “This is how we talk in this club, and this is how we act,” you start to adopt those behaviors if you want to fit in. What I can say is that it never felt comfortable to me. It never felt good or like we were advancing the care of the patient when we distanced ourselves from the emotional impact of patient suffering and patient care. I think part of what we don’t talk about in medicine, especially as women, is that we’re representing a traditional male archetype in medicine, a sort of stoic, unfeeling, distant father figure.

I did an interview with a journalist who asked me, “Is there anything you wish you had put in the book that you didn’t?” What that caused me to reflect on was that I took subconscious effort not to over-identify as a woman in the book. I didn’t want to be perceived as a female doctor; I wanted to be perceived as a doctor. I thought it would discredit my voice, and I’m sort of mad that I bought into that.

Vidya: I think it’s fascinating and amazing that you were able to write this book about your own experience in your own hospital. When did you first think of writing about your experience, and what was it like taking that to the form of a book?

Dr. Awdish: It’s been a process. I first wrote a short article about it a few years ago in an academic journal, and that was really my first brush with writing about it. I started speaking about my experience at the Sepsis Day lecture that I mention at the end of the book. The video of that circulated on the internet and a literary agent reached out to me and said “You’ve got a great story here, and I can see by how you talk about it that you really love words, and I think you should write a book.” And I was like “Haha that’s funny.” But eventually I spoke to my husband, and he suggested that I could offer this as a resource to students and residents. So that was how I approached it. I had two rules for myself: one, it was going to be the truth. If people looked bad, they should have acted better at the time, because I was just writing what happened. And two, after writing it, no one has to see it. I think that uninhibited me in a way that was liberating. I wasn’t thinking about an audience, I was just thinking about me. I didn’t show anyone my writing at the hospital until it was in bound galley [the pre-publication version], which meant it couldn’t be changed, not a word of it. It was done.

Vidya: And did they know about it, at that time?

Dr. Awdish: They knew. I showed it to them when I was done and I remember expecting to be fired. It was a risk I knew I had to take. I was speaking my truth and I knew I could stand behind it. And when they read it, it was amazing. It was the complete opposite of what I expected. Everyone was like, “Yeah, this is who we are. Now we can talk about it.” Anyone who works in healthcare knows this is all true and it all happens everywhere all the time. They bought 4,000 copies for all the leadership, passed them out, started book clubs, and put me on every stage they could in order to share my story.

: If you could go back to when you were a medical student or a resident, what would you do differently?

Dr. Awdish: I think I would tell myself what I tell medical students today: “Don’t believe the lie.” Don’t believe that you have to change yourself to fit the culture of medicine. Be yourself and let medicine move to fit you, because you are healthier and more whole than medicine is right now. Model good behavior, because a lot of what you see in the hospital is dysfunctional. And people know it’s dysfunctional, they just don’t know another way. So if you can care and be present, let people see that. That’s how culture change has to happen.