EP. 25: A DOCTOR’S JOURNEY FROM THE EDGE OF DEATH
WITH RANA AWDISH, MD
An intensivist and author shares lessons on hope and human connection learned from her time as a patient in her own ICU.
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Episode Summary
Dr. Rana Awdish was on the last day of her critical care medicine training when her life changed forever. Seven months pregnant at the time, Dr. Awdish abruptly found herself in a life threatening crisis when a previously undiagnosed liver tumor suddenly ruptured. She was rushed to the ICU of her own hospital, where she came unimaginably close to death multiple times. Despite this tragic event, she survived thanks to the incredible work of her medical team. Today, Dr. Awdish is the author of the acclaimed memoir In Shock, which recounts her time as an ICU patient. She's also the Medical Director of the Pulmonary Hypertension Program at Henry Ford Hospital in Detroit, Michigan, and Medical Director of Care Experience for the Henry Ford Health System. In this episode, she shares what she has learned from her experiences about compassion, hope, and improving empathetic communication in health care.
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Rana Awdish, MD, FCCP is the author of In Shock, a critically-acclaimed, bestselling memoir based on her own illness. A critical care physician and faculty member of Wayne State University School of Medicine in Detroit, Michigan, she completed her medical degree at Wayne State in 2002 where she was inducted into the Alpha Omega Alpha national medical honor society, her residency at Mount Sinai Beth Israel in New York, and her fellowship training at Henry Ford Hospital where she serves as the current Director of the Pulmonary Hypertension Program. She also serves as Medical Director of Care Experience for the entire Health System. Dr. Awdish’s mandate as well as her passion is to improve the patient experience across the system and speak on patient advocacy at health care venues nationally.
After receiving his undergraduate and master's degrees in Electrical Engineering and Computer Science from MIT, he completed his MD and internal Medicine training at Tufts University School of Medicine and Tufts Medical Center. He came to Stanford to serve as a Research Fellow in Cardiac Electrophysiology and Biodesign Fellow where he learned to identify unmet human-centered needs. After completing his post-graduate training, he stayed at Stanford as clinical faculty in Primary Care and Population Health in the Department of Medicine and started the Consultative Medicine Clinic, which evaluates patients with medical mysteries. He currently directs Medicine and the Muse, Stanford’s medical humanities program. Finally, he co-founded and co-directs, with Dr. Latha Palaniappan, the Center for Asian Health Research and Education (CARE) which aims to improve the health of Asians everywhere.
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In this episode, you will hear about:
• How a family ailment inspired Dr. Awdish to pursue a medical career - 2:10
• An riveting personal account of the catastrophic medical event that befell Dr. Awdish - 4:17
• A discussion of the learning curve in medicine and the need to create safe spaces for physicians to admit ignorance - 12:13
• The fascinating and unsettling experience of being a highly-trained physician and a critically-ill patient at the same time, and how this experience showed her the way our current medical culture disempowers patients - 15:17
• Dr. Awdish’s reflections on the antagonistic environment of her prolonged hospital stay - 20:19
• A discussion of hope, concept often misunderstood by physicians as running counter to realistic expectations - 27:37
• The intense and unexpected role of spirituality in Dr. Awdish’s critical care experience - 32:14
• Navigating the medical profession while confronting suffering and not burning out - 34:37
• A discussion of Dr. Awdish’s profound essay The Shape of the Shore about the first year of the COVID-19 pandemic in Detroit - 37:36
• Dr. Awdish’s advice to new physicians and students to help them stay connected to their work and to see the humanity in their patients - 44:33
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Henry Bair: [00:00:01] Hi. I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Dr. Rana Awdish was on the last day of her critical care medicine training when her life changed forever. Seven months pregnant at the time, Dr. Awdish abruptly found herself in a life threatening crisis when a previously undiagnosed liver tumor suddenly ruptured. She was rushed to the ICU of her own hospital where she lost her entire blood volume multiple times over. Experienced organ failure was put on a ventilator, suffered a stroke, and eventually miscarried. Despite this tragic turn of events, she survived thanks to the incredible support of her medical team. Today Dr. Awdish is the author of the best selling memoir "In Shock", which recounts her time as an ICU patient and what she has learned from the experience about compassion and hope. She's also the director of the Pulmonary Hypertension Program at Henry Ford Hospital in Detroit, Michigan, and medical director of Care Experience for the entire Henry Ford Health System. As a patient advocate, she has devoted her career to improving empathetic communication in health care. In this episode, we explore her story and the ways clinicians can seek to humanize their patients. Reena, thank you very much for joining us in conversation.
Rana Awdish: [00:02:14] I'm happy to be here with you. Thank you for the invitation.
Henry Bair: [00:02:18] To set the stage for our listeners. Can you take us all the way to the start and tell us what first drew you to a medical career and to intensive care medicine in the first place?
Rana Awdish: [00:02:30] You know, when I was very young, we had a relatively dramatic experience with my brother as an infant. He had acute respiratory difficulty at the time. All we knew was he was sort of drooling and looked like he was struggling and he had epiglottis, which of course is now a vaccine preventable disease. But I remember watching my mother on the phone with our pediatrician, just describing how he looked and sort of imagining the pediatrician aggregating that data into a diagnosis through all of his medical knowledge and being able to heal him. You know, we we had to rush him to the hospital. And my mom actually put his head outside the window for positive pressure. He was quite sick. And that really, to me, that idea that just through listening and transforming what you heard through a filter of scientific knowledge could heal. And comfort felt like the most beautiful description of a job I could imagine. And really, from that point on, that was all I wanted to do. I came to critical care the way many people do. I think those were the people in my residency who were the most engaged, the most interesting to me, the most interested in their patients. And it was contagious. It felt like the place where everything happened and you could really be there at critical junctures in people's lives. That felt very meaningful to me.
Henry Bair: [00:04:17] So you work your way through your training and arrive at the very final days of your fellowship, which is the last stage of your training, and that's when your life takes a hard left turn. Something happens that forms the inciting event of your book in shock. Can you tell us more about what happened?
Rana Awdish: [00:04:44] The timing was, as you said, just almost unbelievable. It was the very last day of the culmination of all of my medical training, the last day of my pulmonary and Critical Care Fellowship. And I was seven months pregnant at the time. I had tried to time a pregnancy so that it wouldn't interfere with my medical training. I was out for a celebratory dinner with my best friend, and I had this acute onset of abdominal pain that was honestly so immediately severe and debilitating. I didn't even think the word pain described it. It the only thing I knew about it was that if pain of that magnitude continued, it was going to kill me and it was going to happen fast. And so I was rushed downtown to our Level one trauma center. My husband drove about 100 miles an hour and got there, presented at the door of our ER really feeling like I had done my part. I was clear that I had an intra abdominal catastrophe. It was peritoneal the whole way down.
Henry Bair: [00:06:00] To clarify for our listeners, when Rana talks about being peritoneal, she is referring to the group of symptoms that indicate inflammation of the peritoneum, which is the inner lining of the abdominal cavity and abdominal organs. This usually indicates that something very bad is happening, like the rupture of an internal organ or the leakage of body fluids into the abdominal cavity.
Rana Awdish: [00:06:27] And we were met by a hospital security guard who saw that I was visibly pregnant and said, How many weeks are you? And when I answered that, I was 27 weeks, he redirected us away from the level one trauma center to OB triage, which I remember looking at my husband with an expression that was intended to convey, "just so you know for later, that's the decision that killed me" because I was 100% certain I needed emergency surgery and I was 100% certain that it would be delayed in favor of the baby if we went to OB. And ironically, even though I was a graduating, fully formed physician at that institution, I didn't argue. I respected the authority of the hospital security guard over my own agency. And that was really the first clue to me of how quickly, as patients, we lose a sense of agency over our own care.
Henry Bair: [00:07:37] So you are rushed to the obstetrics department, even though, as you would later find out, that was really not the the main issue. So so then then what happens in the OB department?
Rana Awdish: [00:07:52] So predictably, the focus was on the baby. It was clear by then that I was in shock. We didn't know what type of shock yet until my labs returned. But I was approached almost immediately by a resident with an ultrasound machine who wanted to check on the health of the baby. I couldn't bear to keep the fetal monitor around my abdomen because I was very peritoneal. And, you know, he was very apologetic. He said, I'm not really great at reading this yet. And in my head I thought, "That's okay. I'm trained in ultrasound. I can I can see what we see." And from the first images, it was clear that there was no heartbeat. And I said that. And he said, "Can you show me where you see that?" Which in that moment was so alarming and distressing to me because I really had an awareness that for him to ask that meant that he wasn't seeing me as a woman who had just lost a pregnancy, who was nearly dying herself. He was viewing the entire situation through the lens of his own education. He was centering the experience on himself, and that terrified me, mostly because I knew what it was going to take for me to survive. That night my labs had started to come in. My hemoglobin was three, my platelets were 15, my ASD and Alt were in the tens of thousands.
Rana Awdish: [00:09:29] The presumptive diagnosis was help syndrome and I could picture my trajectory. I knew the calls to the blood bank. I knew what it would look like to keep me alive, and I didn't think he would do it if he didn't care enough about me. So with those values and the lack of fetal heartbeat, I was transported into the operating room and that was where things really started to deteriorate. I went into multisystem organ failure, my kidneys failed. I had a stroke from lack of blood to my brain. I was already in liver failure at that point. And I remember hearing the anesthesiologist say, "We're losing her." And. Wanting to know if that was true, you know, wanting to orient myself to the room. And recognizing that I could see the obstetrical team. They were readying with instruments to extract the baby. I could see the anesthesiologist who seemed very frustrated trying to get access, I had gone in with only one peripheral I.V. and I could see myself on the table. And I remember thinking, Oh, if I can see myself, I'm probably already lost. And there was no pain in that moment. It was honestly a very freeing, very peaceful moment. I felt small and weightless. And by all records, that was when I coded.
Henry Bair: [00:11:01] Wow.
Tyler Johnson: [00:11:02] I just want to back up for one second just because some of our listeners are early medical students or other people who may not have the lingo down yet. So just to clarify a couple of the things. So when Rana was first brought into the obstetrics room and had her labs back, basically her labs showed that she had almost no circulating red blood cells, almost no platelets, which are cells to help with healing if you get cut or if you're bleeding. And then her labs also showed that she was very quickly going into liver failure. And basically, when you have all of those things together in a person who's pregnant, they usually indicate, as she said, that you have developed this thing called help syndrome, which is basically just the constellation of all of the things that we just said. So it's having really low blood counts, liver failure and all of that in the setting of a pregnancy. But all of that is to say that even I mean, I can only imagine, Rana, from your point of view, right? I mean, I know as a resident or as a now as an attending, previously, as a resident, that was the kind of thing that if I had a patient who came into the emergency department and I asked to go see the patient, and I'm assessing the patient, and then I get those labs back, right? My heart rate goes up by like 25 beats per minute or something.
Tyler Johnson: [00:12:13] Just when someone hands you the labs. Right. Because those are I mean, you can't get very much more abnormal than what some of those lab values are. So which is just to say, I can only imagine what's going on in your head, in your heart. You get those labs back, and now finally they're taking you to the operating room where you wanted to go in the first place. Right. But got sort of redirected and only got there in this very roundabout way. I guess I'm curious, this is sort of a side point, but there's a really interesting Atul Gawande essay from a long time ago talking about the learning curve in medicine. And one of the things that he admits is that so he goes through this whole thing about how obviously doctors, just like everybody else, have to learn how to do things right like that. Doctor who is taking care of you in the word has to learn how to do ultrasound and that. Right? I mean, all of those things have to be learned. But then it's so interesting because after pages and pages and pages of exploring this, then he comes back at the very end and talks about how when his child was born and his child was going to need some kind of like a surgery to fix their fetal heart defect, even though Dr. Gawande sort of knew in his heart that he should just tell them that he would be happy with whomever wanted to do the surgery. Doing the surgery. When it came time to choose, he found the best, most renowned, most experienced surgeon that he could to do his baby surgery. Right. Which who wouldn't? Right. And I know that I've talked to surgeons here about this same thing, that it's just true that if you know somebody or you have some influence in the hospital or you're one of the doctors or whatever, like you get access to at least the people who are perceived to be the best. I'm just curious. I mean, you're just barely you hadn't even quite finished your training, right? You're right on the cusp of finish your finish your training. So I guess I'm curious sort of how that mental and emotional back and forth went. How were you thinking about that or how were you processing that in the moment?
Rana Awdish: [00:14:04] It's interesting that, you know, there was another resident, a surgical resident who was called to see me, and she very quickly assessed the situation and called her staff and said, I don't know what's wrong, but she's really sick and you know her and I just need you to come to the bedside. That felt very familiar to me, that recognition of I don't know enough to be standing here right now and have you be entirely in my care. And making health systems psychologically safe spaces so that people can say that, I think is truly the work of our generation. It's not who we were when I trained. And it's, I think, who we're trying to become with just culture and safety, culture and and reporting of errors. But it takes a lot of humility and it takes a supportive network that doesn't criticize when we admit what we don't know.
Henry Bair: [00:15:17] I'd love to explore another aspect of your experience, having gone through it from the perspective of of a health care practitioner when you're describing this horrifying situation in your book. There's also this commentary that you talk about going on in your head. And sometimes it's commentary slips out when you're addressing the people who are taking care of you. And that's, you know, you're able to comment on all the medical things that are happening. You're able to at some point even correct people who are trying to give you care. So I'm just curious to to hear in your mind, what was that like? Was that a reassuring thing? Was that did that make the situation more scary? Like to know that in your head you're making all these calculations, you're thinking through all the pathways of like what's going on in your body?
Rana Awdish: [00:16:05] Yeah. You know, it was all of those things. So that first moment when I was presenting in hemorrhagic shock and I stood up and I recognized the sensation of shock. I love medicine so much that I was still fascinated by my own death. It was it was remarkable that I. I was still so enamored by the body that I was watching it, interested and somewhat detached in a way. When I heard the surgical ICU routing team going through my case and sort of tallying my different organ failures and recognizing that, gosh, if I had five organ systems down, I was probably at 100% mortality, that it was less reassuring. I had more information than I would have wanted in moments. And another sort of unanticipated side effect of that is that people depended on me to explain what was happening to my family. Because they knew that I understood and so they could speak to me and then would leave me with the difficult conversations. And that was a burden that I think I've learned not to place on patients when they happen to be physicians or nurses.
Tyler Johnson: [00:17:32] So if we if we can bring the conversation back now, so you've told this really harrowing story about you're on the operating table and you can sort of feel in real time that things are getting worse and getting worse. And you hear the signs of panic from the doctors and other health care professionals in the room. And then you coded, which again, for those who are early in your training, coded means that you some version of that you don't have vital signs anymore. Your heart stops or you can't breathe or you have no pulse or whatever. Basically, it's a person usually in need of CPR. So what would the doctors at the table tell us happen next and what did you experience next?
Rana Awdish: [00:18:16] The doctors in the operating room would tell you that they spent the next 6 hours resuscitating me. They got access. They flooded blood through a warmer because I was developing the triad of death, hypothermia and acidosis and coagulopathy. I got 26 units of packed cells, additional cryo and platelets and FFP. I was sent to the surgical ICU and ongoing resuscitative measures happen there. From my perspective at that point, I was unaware. The next thing I remember is waking up to the voice of my childhood priest who was making the sign of the cross on my body, which, as an intensivist I found like the worst prognostic sign possible, worse than the lab value was my priest praying on my body. So I immediately thought, I must be dying. My last memory is I'm dying. And then my priest is praying. It was interesting because I, I was restrained because I had an ET tube, and so I was on the ventilator so that I wouldn't pull it out. My hands were restrained, and I wanted to just write, "Am I dying?" Because that was the only thing I cared about in that moment. And they wouldn't give me a pen because they were afraid I would ask about the baby and this sort of group of men had decided that they weren't ready to tell me that it wasn't the right time. So that was another moment of awakening to the fact that we don't even really believe that our patients are the owners of their own medical information. We think it's ours to sort of dole out as we think is appropriate in a very paternalistic way.
Henry Bair: [00:20:19] So after you were admitted into the ICU, you were thankfully able to be stabilized and thus began your prolonged hospital stay in your book. You note that it was during this stay when you started picking up all the little things that the care team would say to each other or do that felt alienating to you as the patient, whether that's the use of dehumanizing language or being dismissive of your concerns. In fact, at one point you characterized some of the interactions you had with members of your care team as antagonistic, which might strike some as very surprising. So I'm hoping you can tell us more about what you mean by this antagonism and what you observed in the hospital.
Rana Awdish: [00:21:16] The first time I remember feeling that I was on the other side of my team was when I was in the surgical ICU, still intubated, and the team was rounding on me in the hallway and presented my case. I was listening because I was intensely curious about what was happening and no one was telling me. So it almost felt like I could be a part of rounds and the surgical resident explained that I was post-op. Day four status Post-crash C-section for fetal demise with intraoperative observation of a large capsular hematoma. And that I was anurick after all of the 26 packed cells resuscitation. I was at 40 pounds and in how he was telling my case, I was sort of starting to develop a problem list. I understood I would probably need dialysis if I was to come off the vent. If I was that volume up and I wasn't producing urine. It was making sense to me that the pain was a sub capsular hematoma, that there was bleeding into the capsule of my liver. And then he said, "She's been trying to die on me." And that really struck me because, first of all, I wasn't trying to die on anyone. I was doing everything I could not to die. I didn't know how to try any harder not to die. But not only attributing that intention to me, but the vectoredness of that statement -"trying to die on ME"- as if it was like I chose violence. Right? Like I decided to ruin his day. And even as I heard it and it made me mad, I recognized that I had used those words right? Like two weeks before, probably when I was in the medical ICU, it was so common for us to describe patients as "trying to" do something that was in opposition to our plan of care. And in retrospect, I think that there's a lot about that that speaks to our fear of failure that we are trying to do this thing and the patient is the barrier. It's not us. It's not our lack of knowledge or our ability. It's the patient. And it's kind of a transference and blame situation. There's a lot of guilt that that alleviates if you frame it that way for yourself. It's not about the care. It's about the patient's unstated, but very obvious intention. It truly is a way of deflecting the sort of fear and guilt that we have when things aren't going well. And the fact that I would say all the same things that my team was saying that bothered me so much is really what gave me permission to write the book, because this was in no way an exercise of blame, because I knew I was a good person and I still said these things. I knew I had good intentions and I still said these things. So it was more about the culture of medicine that sets us up to believe that the patient is our adversary and they're in the way of discharge. They're in the way of the cure. They're in the way of the treatment being efficacious, all of it.
Tyler Johnson: [00:24:55] One of the things that always strikes me everywhere in the hospital, but especially in the ICU, is that there are so many physical elements to being a patient that most people who have not been in that situation can have at best a vague, theoretical, imaginary sense of what it would be like. And and even then, most of them don't even go that far. Right. But things like having a tube down your throat, if you had a feeding tube, having a feeding tube in, if you had a urinary catheter, having a urinary catheter and having probably an arterial line for your blood pressure and another line in your neck for blood transfusions. And I mean, all of those things, not to mention having people poking and prodding you in private, uncomfortable places all the time, having no control over what parts of your body are covered by clothing and I mean all those things. Can you just talk a little bit through what that was like?
Rana Awdish: [00:25:52] Yeah, it was a very surreal experience to wake up in a body that not only did I not recognize. I remember drawing my hands up to feel my face the first time. They weren't restrained and encountering my face like so much further out than I thought it would be because I was just so volume up that I was like a balloon. I had staples going down the length of my abdomen, which was tense from all the bleeding. The blood loss that I had was about the size of a volleyball, and it was right under my ribs. So every time I took a breath, there was extreme pain. I had two large bore trauma lines the size of garden hoses, one in my neck vein and one in my groin. I had an arterial line that was malfunctioning and shooting out blood in rhythmic spurts. Often. I was completely immobile, not only from all of the lines and drains and tubes, but also just from the debility of critical illness. Just shifting slightly in the bed. If the nurses wanted to move, a sheet would put me into respiratory distress. I had no endurance. It felt like, you know, the end of my life. It felt like I was 100 years old dying in an ICU. It was uncomfortable. The lack of dignity that you feel as a patient like that is difficult, both physically and emotionally.
Henry Bair: [00:27:37] I'd love to explore the idea of hope next. Several times in the book you talk about teetering right there at the boundary of life and death and instinctually feeling as if death was fast approaching, and yet you had hope and you held on to that hope. And this has been instrumental to your recovery. Can you share some lessons you've learned about hope in the patients illness experience, where we find it and in what ways it can support us?
Rana Awdish: [00:28:13] Hope has become something that I have for sure a new appreciation of after this illness. There were so many times as a critical care physician that I feel like I was working towards getting the family or the patient to give up hope. Like that felt like the goal was, if they can just see how hopeless this is, then we'll be able to plan for a peaceful, natural death. And when I was a patient in that same situation with multisystem organ failure and a high likelihood of death. I started to realize that hope isn't this sort of unfettered optimism that is just blind to the facts. Hope is what you have left when you've seen all of the facts and you have absolutely no belief that something good will happen. Hope is what's left, and that recognition has really allowed me not to ever take that away. We can hope for different things. We can hope for a pain free death. We can hope to have our family and the people who are meaningful to us around us. When we're ill, we can hope for a recovery that might look different than what we would normally hope for. But we can't let go of hope because really the thing that keeps the trajectory moving forward.
Tyler Johnson: [00:29:54] I'm curious because I know that I have certainly had times as a doctor, especially taking care of I'm not an intensivist, but as an oncologist. We have a lot of patients in the ICU. And and that is a real tension. Right. I know that especially Intensivists, who by definition are taking care of patients who are nearing the end of their lives, even though some of them get better. But everybody is close, that's why they're in the intensive care unit. I know that there is it feels like a weighty and real burden of being a doctor, trying to help people, to have a candid understanding of what's going on with their own bodies. Right. And so I guess now, as someone who was an intensivist and a patient and again an intensivist, how do you talk to patients about hope or how do you balance the recognition that you had many different parts of your body that were completely failing? And yet here you are having an interview with us. How do you balance the you know, I mean, that's tattooed in your cells somewhere, right? That's just part of you. Now, how do you balance that versus the fact that there really are a lot of people who just have no sense that their body really is failing and that they really probably are going to die soon.
Rana Awdish: [00:31:10] For me, recognizing that they are not mutually exclusive. Things that I can hope alongside someone, that things will change, that they will be healed while also planning for what we will do if that miracle doesn't happen so that I can honor the process that I see before me, while also being willing to be wrong to say I want nothing more than for your vision of complete healing to be true. I'm obligated, though, to attend to this patient's comfort in what I see as a dying body. Can we plan for both? And that kind of alignment, I think, builds a trust that we we don't have the benefit of when we bypass the hope, when we focus too much on getting them to let go of it and be realistic. I'm okay with realistic. Also leaving room for hope.
Tyler Johnson: [00:32:14] Can you talk a little bit about you mentioned that the first. experience or sensation that you had once you woke up after they had finally saved your life and gotten you somewhat stabilized in the ICU? Was the priest there? I don't know if actually giving last rites, but something like that. What element did spirituality or religion or metaphysics or whatever play in your recovery process?
Rana Awdish: [00:32:42] It evolve truly over time. I wouldn't say I went into the operating room an intensely religious person. The physical experience of the peacefulness that I felt at the time of my arrest or death was a really profound experience for me. So much so that I. I remember the first thing I wanted to tell my husband when I came off the ventilator was that there wasn't anything to be afraid of. I had such an intense experience of peace and calm and being part of everything all at once that it felt truly transcendent. And it was immediate and pressing to me that I communicate that to people and somehow having that early experience of death. Made my recovery less scary. Because I sort of knew what the alternative was. And in my head somewhere and my muscle memory was like, it's not that bad. If that's what happens, that's okay too. The bizarre coincidence is the synchronicities that happened during my hospitalization also felt like a kind of love from the universe that just sort of kept me safe. The trauma surgeon who was there the night that I got sick has literally been on call every time I've needed surgery in the last ten years, which is, you know, countless times it's become a little bit of a joke that his call schedule just aligns with my body's decompensation, but it feels like a form of love. And I've been more willing to accept uncertainty about these things and just try to carry forward that sense of protection and peace through all of it.
Henry Bair: [00:34:47] Earlier in this conversation, you described a little bit about the work that ICU doctors have to go through. You talk about, although you try to maintain hope for yourself and for your patients and for the team of doctors you're leading. You know, it doesn't always pan out the way that patients hope for or that you hope for. So I think I can see how a lot of people might hear that description or see the work that you do and think, how can anyone continue in that work without just, I don't know, burning out or just giving up after years of of trying to help patients who. You know, don't have the outcomes that you would like for them. So can you tell us about how you were able to navigate that? How do you how are you able to go in and work in a place where so many of your patients don't have the best of outcomes and yet still continue on with with hope?
Rana Awdish: [00:35:48] The most important frame shift for me has really been redefining my role for myself. When I initially started to practice medicine, I truly believed my only role was to heal. And if I couldn't do that, I really felt pretty useless. Recognizing that I bring value to situations where there is just suffering and all I am doing is holding space for that grief and believing that that matters. Truly integrating into my sense of identity. That part of my role in my patient's life is being a container for their grief and having enough capacity so that I'm not depleted by it, but that I truly feel nourished by that interaction, that I know that the medical course is going to be what it is, and my presence there has a purpose, even when I can't heal. That helped me to value myself differently. I don't think medicine teaches us that. I think medicine teaches us our value is in our ability to treat and heal and cure. Everything else is a failure. And I found that that's not what our patients and families expect. They expect a guide. They expect company on the journey. They expect someone to decode encoded information for them, to be there in difficult moments, to talk them through. But they don't expect perfection. We're the only ones who do.
Tyler Johnson: [00:37:36] I did want to turn our attention to this remarkable essay that you wrote, The Shape of the Shore. For listeners we will link this in the notes. You can find it. It's in Intima, which is a journal of Narrative Medicine. This is a recounting of what it was like to be on the front lines, working in an ICU during the really dark time when the pandemic was cresting. I think you were in Detroit. And so I feel like the experience is strange because 99.9% of citizens of the country, their experience with the beginning of COVID was one of isolation, but almost hermetic protection. Right? We were all sort of sealed in our little bubbles, especially depending on where you lived in the Bay Area, for instance. It was very tightly sealed bubbles in other places, slightly less so, but still, right? No school, no church, no. All of the community that we knew was. Was just gone. And yet. I feel like society and even many health care workers had this kind of vague notion that somewhere there was this terrible place, that the very thing we were trying to avoid was happening. And man, was it ever happening, right? And I mean, there were all of these terrible photos in the newspaper and whatever of the trucks from the morgue that couldn't process the bodies fast enough. And the doctors who were collapsing from exhaustion in the hallway with patients who didn't even have enough rooms to house them and all of those things. And yet what almost nobody has is the on the ground experience of what it was like to actually be there, which is what your what your essay painfully describes. Can you just talk a little bit about what that was like?
Rana Awdish: [00:39:28] Yeah. We were hit really hard in Detroit by the first wave of COVID. And that was, of course, before we knew anything about whether we could bring it home to our children, what our mortality risk was. Even the mechanism of contagion was still opaque at that time, and we very rapidly went from being a 60 medical ICU bed facility to needing to care for 850 critically ill. Wow. One of the roles I took on during that time was just checking on the teams, and that's really what the essay was about. It was about our attempts to process in real time our feelings of futility and harm and isolation and anger and to do it in a way that maybe could nudge us through. Into a kind of post-traumatic growth. I still don't know if I believe that that's possible, but it was what we were trying to do, and it was really through the sharing of stories that we saw. We were all experiencing such similar things. We were all going through the same kinds of grief. And that's really what saved us.
Tyler Johnson: [00:40:58] I'm curious, as a doctor who is on the ground and in particular as a person who was intimately involved in this attempt to try to help. Other health care workers to heal from the wounds that they had taken away from trying to offer care during that time. You know, there's such a an inclination, almost a temptation on the part of society that as soon as the restraints are gone, we want to snap back to, quote unquote, normal and start doing. We want to just go back to where we were two and a half years ago. Right. And I fear sometimes that in our rush to do that, that we may not take time to heal. Right. We may not take time to process the traumatic thing that I think all of us have been through. What does your time both spent there as a doctor yourself and then spent trying to help other doctors to heal from those terrible things? Tell you that you can tell to us and our listeners about what healing looks like and what we need to all address as we try to move forward. From what I think for everybody has been maybe the most difficult 30 months or whatever of our lives. Not in all cases, but in many cases.
Rana Awdish: [00:42:20] The most profound learning for me that came from that time where, you know, I heard stories of health care workers, but I also heard the stories of my patients who were refusing to mask and refusing to be vaccinated and weren't being allowed to see their grandchildren. And there were you know, there's so much polarization. It goes without saying that the pandemic was politicized in many ways. What I found to be true was that. Beneath the stories were feelings that we all had in common. So I might have felt isolated for a different reason than my patient who wouldn't be vaccinated felt isolated. I might have felt disposable for a different reason than my patient who was being cut out of her grandchild's life felt disposable. But our grief could vibrate in the same sort of frequency. We were feeling the same thing. And there's something really powerful about admitting to each other that although the material circumstances of our experience might be different, we can still hold the experiences of another person as we hold our own. We can respect and value their experience of the pandemic. And. And really allow our grief to resonate together. And that's helped me. In a lot of difficult situations to say, I don't have to agree, but I can I can recognize your feeling as my own and I can hold it sacred and I can hold space for that that feeling. In that vulnerability of sharing those feelings. I think we can start to develop community again and we can start to break down some of the barriers that have not allowed us to heal. A lot of my healing has come from releasing some of that need to have everyone believe the same things that I believe, but to recognize that everyone's experience is different and honor that.
Henry Bair: [00:44:33] Well. Well, thank you very much for sharing that with us. You know, you've addressed bits and pieces of this question already during this conversation, but to address it more in a head on fashion, what advice do you have for young clinicians and for future doctors about how to humanize the patient experience, how to stay connected with what matters most when things get hectic, when things in the hospital get really tough.
Rana Awdish: [00:45:05] One of the pieces of advice that I give to my new trainees, the new interns who are starting, is really to develop a habit of attunement to your own internal world so that you can recognize the moments in your day that light you up and that make you feel like you're exactly where you're supposed to be doing exactly the work that you want to be doing. Because medicine in many ways is still very achievement oriented. And it will it will dangle goals before you that might not actually bring you joy or happiness. They might seem prestigious. They might seem like something you should want, maybe a fellowship. But if it's not truly what resonates with your soul, it won't bring you fulfillment. And it can't be the shiny thing that your parents want you to want. And it can't be the shiny thing that your mentor wants you to want. It has to come from you. And if we don't attune to our own joy, we're liable to miss it, to miss those moments. And it might surprise you. You know, I dread clinic most days, but my happiest moment is in clinic. And I have to remind myself every clinic that, wow, I was dreading clinic and look how happy I am. It's it's very discordant. And even if at the end of each week, you just look back and you say, these were three moments this week that I really felt a sense of purpose and joy. I think you'll keep coming back to the work that's meaningful because, you know, all the emails, all the pages, all of the paperwork, it's never going to fill your heart. It's not going to create longevity or or joy in work or fulfillment. It those are the tasks that we have to do to get at what's nourishing. And the thing that's nourishing is the relationships with our patients, with our colleagues, with our students. But that's also the thing that's never screaming for our attention. It's always the thing we can forgo most easily. So we have to sort of manually direct ourselves to to spend time there.
Tyler Johnson: [00:47:33] We so much appreciate your time and your writing is so visceral and powerful, and at least in the case of the pandemic, heartbreaking to a point. You almost can't read it because it's just sort of too much, right? There's just too much there. But we really appreciate you spending some time with us. And I'm confident that this will really be a value to many listeners.
Rana Awdish: [00:47:55] Thank you so much. I've enjoyed our conversation.
Henry Bair: [00:47:59] Thank you very much right now for taking the time.
Rana Awdish: [00:48:01] Of course.
Tyler Johnson: [00:48:02] All the best to you.
Henry Bair: [00:48:06] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctors art. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:48:24] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:48:38] I'm Henry Bair.
Tyler Johnson: [00:48:39] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Dr. Rana Awdish is the author of:
In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, a memoir about the harrowing events discussed in this episode and the revelations she attained by going through them.
The Shape of the Shore, an essay published in Intima magazine, about working in the ICU during the first months of the COVID-19 pandemic.
Dr. Johnson mentions the essay The Learning Curve by Dr. Atul Gawande, published in New Yorker Magazine.
Follow Dr. Awdish on Twitter @RanaAwdish.
