Dr Rana Awdish writes of the trauma of a life-threatening illness and her return to work in the book "In Shock".
How much do doctors hide? Go to any busy hospital now and pause for a minute in the main corridor. Amidst all the bustle, you will see doctors, young and old, often walking briskly down the corridor. If they are alone, look at their faces. Almost universally, the doctor walking alone in the hospital corridors adapts an expression of detachment, determination even. And as Dr Awdish describes in chapter 8, "Censors of light", those expressions can hide deep wells of unresolved guilt, sadness and unimaginable stress.
“In Shock” is a book that is striking in its portrayal of a doctor who became a patient, nearly died from her severe illness, then recovered and returned to her career as an intensivist. And in this chapter, the experiences of the author are particularly poignant because she returns to work in the same hospital, within the same ICU where she spent several weeks critically ill. Her memories of what she went through are so well crystallised, her words so raw and powerful, this chapter makes you sit down and think. There is an honesty here, born of true experience, so different from the temporary inconveniences some of us have had when we have ourselves been in another doctor's office or waited for a blood test. This author knows what it is to be seriously sick, intubated and totally dependent on the care provided by her nurses and other doctors. That knowledge, when combined with incisive analysis and wonderful, wonderful writing make this one of the books every docotor should read.
Dr Awdish brings to life some of the deepest fears of being a critically unwell patient when she says:
When I was sick, and so desperately vulnerable, I knew I was completely dependent on others to keep me alive. I worried that if they didn’t care enough to do what it took, to do everything perfectly right, that I would die. A death by disconnection and benign neglect.
Being critically unwell changes one's life in many ways. Sometimes, the trauma of a near-death experience is so severe that one never recovers, living constantly in a state of fear, as if waiting for the next big blow to fall. Sometimes, it makes one re-evaluate one's choices in life; perhaps forces reflection on the true value of relationships. But for such a patient to be a doctor who returns to work, caring for patients who are equally critically unwell, adds an unexpectedly personal and desperate edge. The author remembers her trauma and her fear, and there is a new urgency to her work - a need to be absolutely perfect, to care completely, to make sure that her patients do not feel the things that she felt.
Doctors wish for all their patients to get better - but in the critical setting of the ICU, not all patients will improve. And yet, her memories of being a patient, the desperation, and the fear of the unknown all coalesce into driving the author to push herself, physically and psychologically, to do everything she can for each patient. When some of the people she cares for have the same illnesses she suffered, the struggle is even more personal.
One of the most interesting aspects of this book is how the author has been able to capture her internal dialogue and transcribe them onto these pages. The defining characteristic of this book is how Dr Awdish has melded together descriptions of situations and then her thoughts as she considered what to do. This internal dialogue is a constant in the mind of every doctor that has to make a decision that could potentially alter her patients' lives. Dr Awdish captures this constant dialogue and brings it to life with striking, evocative language.To read these words on these pages is, in my opinion, a source of comfort and validation for every doctor that thinks deeply about her patients. Dr Awdish has achieved a rare feat here. She has been able to translate what is a very private, personal experience into language that appeals to every physician. In doing so, she has also helped shine a light on everything that happens behind the façade of the calm, "professional appearing" doctor.
It was the stoic posture you held while your colleagues discussed your error. A structured distance from your own emotions. In today’s language we’d call it centering yourself, but taken several steps further—fully centered and not ever allowing the emotions of others to jostle you from your position.
This chapter also contains some of the most interesting discussions in the book. She quotes William Osler, considered the "father of modern medicine", and describes in detail how doctors are expected to maintain an attitude of professional detachment at all times. She recounts witnessing the death of a child as a young medical student, the emotions that she felt at the time and how she was chastised for showing these emotions. It is sobering to realise that as we instruct young doctors to manage their emotions, we could actually be sending out a message that says, quoting from her book again, ___"… that our sadness could endanger other patients."__ And later in the chapter, as she describes the stories of young doctors who took their own lives because they could not cope with the stress, her powerful writing makes one think again about the actual cost of this sheen of ‘professionalism’ we cultivate.
Many years ago, I decided that I did not have it in me to give off the appearance of a wise and learned physician. I briefly tried growing a beard, speaking slowly and deliberately, in a deep voice, and never smiling, to add all-important gravitas to the professional opinions I gave my patients. But I could not keep this up. Almost unbidden, a joke, a laugh or a touch on the shoulder would escape me. My eyes would fill when I heard a sad story. Sometimes, I too felt the pain and the shock as patients received terrible prognoses. Gravitas was too hard. Over the years, I have learnt to let it be. I now teach my younger colleagues that you can only be the doctor that reflects the person that you are in real life. This chapter in the book reaffirms the view that it is normal - and even therapeutic - to feel emotion when you work as a physician. To paraphrase a quote from Francis Peabody (Peabody, JAMA, 1927)
…the secret to caring for a patient is to care for the patient…
Dr Awdish restores our focus on compassion, on empathy. This book is different because it calls upon all of us to walk not only in the patients’ shoes, but in the doctors’ shoes as well. The relationship and interactions between doctor and patient are among the most intimate and deep connections that one can have outside one's family. This book, and particularly this chapter, reminds us - doctor and patient - to never forget our essentially human nature - the need to be valued, the need for connection and the importance of the emotions we encounter in our everyday workplaces.
Every physician should read this book - it will change the way you think about your patients and your role in their journey.
Summary by Rajesh Raj
Nephrologist , Tasmania, Australia
NSMC Intern, class of 2020