Title: In Shock: a book about compassion in the emergency department
Abstract: On a spring evening about 10 years ago, Rana Awdish experienced intense abdominal pain while dining with a friend. Soon she was rushed to The Henry Ford Hospital in Detroit, MI, USA, the very institution where she was doing a fellowship in critical care. She was 7 months pregnant at the time. “I was certain something inside of me had burst”, writes Awdish in her memoir In Shock: How Nearly Dying Made Me a Better Intensive Care Doctor. It turned out to be a benign vascular tumour in her liver that had ruptured. She lost her baby and almost bled to death. She spent the next 3 months in hospital recovering from a stroke and multiple organ failure. It took several surgeries and rounds of rehabilitation to relearn to speak and walk before she could return home that summer. In this poignant and riveting book, Awdish recounts her near-death experience in an attempt to educate doctors and nurses who could also end up being patients, like herself. Writhing with pain on the stretcher on that fateful night and enduring agony later in the hospital bed, she yearned for her colleagues to see her as a person with emotions rather than a clinical case of pregnant woman with “abdominal pain and foetal demise”, she writes. She recounts several incidents in which she felt that her colleagues did not empathise with her as a human being, instead reverting to their medical training that taught them to treat people as problems to be solved. For instance, on the evening she was admitted to the emergency department, Awdish could not help but self-diagnose—a typical habit of doctors. A resident performed a scan to check her baby's heartbeat, but Awdish was the first to recognise the fate of her unborn child. “There's no heartbeat”, she said. In response, the resident asked, “Can you show me where you see that?” Awdish recounts how she shuddered in emotional pain. On another occasion, she heard a resident telling a colleague, “She's been trying to die on us”. In fact, she was trying not to, but her colleague's off-hand comment made her cringe with an uncomfortable memory; she had said that herself in the past. “We all said it all the time”, she writes. The problem, according to Awdish, is that doctors are trained to separate feelings of empathy from their professional personas in order to present themselves as strong and confident. She also asserts that they generally lack skills to communicate well among themselves and with their patients. “To listen to our patients with a generous ear does require a willingness to relinquish control of the narrative”, she writes. Awdish suggests that ring theory, a concept that she first encountered in a Los Angeles Times article on helping people in crisis, might help clinicians to better empathise with their patients. The theory states that, in a metaphorical concentric ring of circles, at the centre is the one who suffers. In Awdish's case, the inner circle comprised her immediate family, who were also affected by her crisis; the secondary circle represents less close family, then friends, and so on, with distant acquaintances occupying the outer ring. The theory states that the person in crisis is allowed to complain to the people in the outer rings, but the people in the outer rings cannot complain to the person about how their crisis affects them. As per that article, the rule is “comfort IN and dump OUT,” meaning comfort in and complaint out. “[But] everyone in those [hospitalised] days seemed intent on dumping in”, Awdish writes—that is, people were complaining to and about her, except her loved ones. In Shock is not a book bemoaning the standard of hospital care in the USA; rather, it is a book of hope for both patients and doctors alike. Awdish views the traumatic episode she endured as a life experience. She went on to train her fellow caregivers to improve their empathy and communication skills through a programme that she and her colleagues set up called Clear Conversations. In the USA and certain other countries, doctors tend to be trained to be impartial, clinically detached, and intellectually curious, and Awdish argues that this deprives them of an opportunity to be the instruments of healing that their patients actually need. “We mustn't fear connection”, she told The Lancet Respiratory Medicine. “We need to unlearn the old model and embrace a model that teaches us that relationships with our patients are not a toll we must pay in order to provide medical care, but that healing itself exists in that space.” Within two years of her admission to hospital and the loss of her baby, Awdish was once again hospitalised when 7 months pregnant. Luckily, her baby son survived but was delivered prematurely and kept on a ventilator in the neonatal intensive care unit. Naturally, her colleagues remembered her previous experience. But this time, they did not pass any upsetting comments about her or her past experience. She suggests in her book that the Clear Conversations training has helped the caregivers to be more empathic towards her. For her work setting up the Clear Conversations programme, the Schwartz Center for Compassionate Healthcare at the Harvard Medical School, Boston, MA, USA, rewarded Awdish with the National Compassionate Caregiver of the Year Award 2017. Beth Lown, director of the Schwartz Center, is all praise for Awdish's work and book. “By speaking about her own experiences, she exposes aspects of medicine that are uncomfortable and need to be addressed; she models a willingness to be fearless about expressing her truth; she shows that one can emerge from the darkness of illness reconstituted, and as she says, reconstructed, in new ways we may not have foreseen”, Lown told The Lancet Respiratory Medicine. “In this way she inspires hope.”