In Shock, by Dr. Rana Awdish, A Book Review

It’s 5pm on a Monday and I’m sitting in a conference room with attending physicians and residents, listening to a mandated “Faculty Development” lecture on how to give proper feedback. I hear words thrown around, such as “timely feedback,” the “feedback sandwich,” “adult learners,” “professionalism,” “communication,” and “learning goals.” We are asked to role play, give and receive feedback. I look around and see a few nodding heads, in a room filled with blank stares, fidgety movements, and many blatant “this is a waste of my time” looks. As I am listening and trying very hard not to give off any impression of annoyance, I can’t help but appreciate the timeliness of this lecture and the most recent book we read for our Lady Docs book club. We, in medicine, need these robotic and forced sessions regarding appropriate feedback, because we receive no formal training in how to communicate with empathy. In fact, our training often gives us so much knowledge and expertise in our craft in exchange for stoicism and isolation.

In Shock is a book written brilliantly by Dr. Rana Awdish about her journey from physician to patient, back to physician but as patient advocate as well. The book starts with the day she was seven months pregnant as a Pulmonary Critical Care fellow at Henry Ford Health Care center and fell into hemorrhagic shock due to a ruptured adenoma, a tumor, in her liver. As a result of this rare (and misdiagnosed at the time) occurrence, she spent weeks in intensive care, lost her baby, suffered a cerebellar stroke, and had to face her identity as a physician. Through it all, she had the support of her husband, mother and countless friends. Slowly, she managed to return to work and started as an attending physician in the same hospital where she was trained and had just been hospitalized.

However, her medical ordeal was not over. She had to deal with multiple complications from her original surgery. She required additional surgery to remove part of her liver and suffered significant complications. In one part of the book, she jokes that she is the only person she knows who has survived every kind of “shock”: hemorrhagic, neurogenic, cardiac, and septic. Her resilience, through all of these incidents, is awe inspiring. If that was not enough, she decides to get pregnant again, and delivers a premature baby boy, whom she and her husband eventually bring home after a stay in the neonatal intensive care unit. This story in itself is a page turner and would attract many readers, but while there are many such stories of physician-patients and the journeys others going through humbling and life changing illnesses, Dr. Awdish shares in a manner that makes her book brilliant and necessary.

Dr. Awdish has a remarkable writing style in making the reader become one with her words and feelings. As we read her words, we are transported into her head at the time of each occurrence, and with that, we feel what she feels. We also feel what others may have felt around her. Finally, we judge her as she honestly and eloquently paints a picture of her circumstances, thoughts, and actions. She writes about the circle of influence with the patient being the center of the circle. She points out the insensitivity of the obstetrics resident who tells her how hard the night of her near death event was for him. On one hand, the reader feels what she is writing and understands her. On the other hand, the physician reader may judge her for her failure to appreciate, that the reason the resident was so clueless at that moment was due to the culture of medical training.

We expect her to understand the actions and words of the physicians treating her, because she herself is a physician. That’s exactly how medical training has failed most of us. It has programed us to ignore our own feelings and emotions because they are thought to be less important than the patient and treating the disease. We ignore our own feelings, and we encourage and expect our colleagues to do the same. Perhaps, if we had been given some sort of coping mechanism or outlet, it would have been better. Unfortunately, without many healthy outlets for emotional release, most physicians are left feeling isolated and lacking the skills needed to cope with the strenuous years of training and demanding careers. It is no surprise that we have some of the highest rates of divorce, alcohol abuse, and suicide among all professionals. 

Dr. Awdish talks about all these issues as she recounts her own medical problems and setbacks. Her accurate critique of the medical training system, shortfalls in empathy and communication, are interwoven in her story of betrayal and shortfalls of her own body and health. The reader is moved by her beautiful words, awed by her resilience, and inspired by her spirit. The physician reader empathizes, but also feels conflicted whenever she criticizes the unthoughtful words and actions of her caregivers. These conflicting feelings slowly fade away by Chapter 10. It is during this section that she recounts her time on bedrest with her second pregnancy. She describes the impromptu creation of a safe space in her labor and delivery hospital room where friends and colleagues came to drink tea and share the thoughts and feelings that they were programmed to repress and/or ignore for decades. It is in this place that the author gained empathy for her patients and physicians in the same way that she wished her physicians would empathize with her as a patient. She believes this is the important lesson of truly listening. Genuine and nonjudgmental listening. 

Bringing change is not easy. Bringing change into the institution that provides medical training may seem insurmountable. However, for our patients and our own survival, we must take this on. It is not that all physicians need to be taught empathy. By default, many of us who are attracted to medicine have some of the highest levels of empathy. What we need to change is the idea that, in order for us to be good clinicians and physicians, we must suppress our own feelings and emotions. On the contrary, we need to be encouraged to practice self awareness and insight. Our feelings need to be acknowledged, accepted, and when needed, worked through. Perhaps not during the patient interaction, but at a later time. Solitary or with a trusted group, we all need to have a safe space, one where physicians can truly heal ourselves.