We are generally taught to treat the patient as a whole person without engaging emotionally, with little specific advice on how to accomplish that. Behaviors modeled by each generation of physicians are passed to the next by some sort of diffusion. The rationale is that engaging emotionally might decrease objectivity and cloud one’s judgment. William Osler in his book ‘Aequanimitas’ urges us to maintain equanimity through distance, coolness and presence of mind.
Rana Awdish insists that this thinking does not serve us well, saying “medicine cannot heal in a vacuum; it requires connection.” Her book ‘In Shock’ is particularly impressive because she describes her own emotions as a patient in intensive care and operating room when things can get extremely intense during life versus death moments. One of my best friends who is an accomplished doctor herself and battling a serious illness gifted me this book, saying it resonated deeply with her. When doctors are at the receiving end of care, they get to experience what it is like for a patient. As a critical care physician-in-training herself, going through the ‘hybrid physician-patient’ situation was a particularly painful yet beautiful, life-transforming experience for her. In her book, she ‘paints’ the intensity of the experience in multiple dimensions. She assumes a ‘double role’ in her story – as someone who experiences everything that is happening to her body and the medical care she is receiving, and as someone who is hovering over her own story to gain a fresh new perspective on modern day medicine that might help her and others become better physicians. In medicine, we study diseases, not people. However, emotions are an integral part of human existence and emotions respond to emotions, not medical data. I can vouch for that from my own experiences as a doctor-patient and from talking to other friends and colleagues.
She urges doctors to make a conscious choice to be present for the patients’ suffering. She describes how disheartening and depersonalizing it was for to hear words like “she is circling the drain” when she was in the operating room for an emergency cesarean section. Even as she was processing loss of her seventh month pregnancy and processing her own intense fear that she may die any moment, she wanted to receive and feel hope from the treating teams that there is hope she would survive and be there for her husband, mom and everyone else. The human instinct to survive is particularly strong and unassailable.
Her own journey as a patient lasts a few years, and she does survive to live a full life, with a husband, a child, and a fulfilling career. However, as physicians, we know that such a successful outcome is not as common, given the complex medical conditions she lived through. She has multiple stays in intensive care, general ward, rehab, and even in an obstetric ward for complete bedrest to prevent uterine rupture during her second pregnancy. She has multiple surgeries and the repeated visits to the operating room, doctors’ offices and emergency room take a toll on her. Her husband and mother support her throughout this journey. Not everyone of our patients has the kind of social support she has. In addition to losing her first pregnancy at seven months and nearly dying in the operating room, she experiences a wrong diagnosis not because of incompetence but because the diagnosis is genuinely complicated. She receives an incorrect medication because the resident orders it while knowing it is incorrect but does not speak up to his attending. She was unwittingly asked by a radiology resident to describe the ultrasound image of her own dead baby in the belly, who in that moment was focused on his learning and was impervious to her feelings about losing her baby. We need to recognize that these are otherwise good well-meaning human beings who worked hard to work through medical school and got into top residency programs. She fires a doctor because she did not feel safe in his care. She also describes experiencing ‘onion bagel breath’ and numerous instances of cavalier talk, and one sentence presentation of radical therapies when a cohesive narrative was warranted. She describes weaning trials that were not communicated to her as cyclic episodes of panic and darkness. Her chosen way to grieve is not respected by the nurse who talks to her about how to grieve her stillborn baby. She even receives a bill for the stillborn baby because they didn’t enroll the baby in health insurance!
She urges all her fellow physicians and other clinicians to make place for a patient’s uninterrupted narrative and not make assumptions or tag onto words of association. She describes the role of hope during her critical illness and prolonged hospitalization. “Hope was an orientation, a way of being in the face of reality that was not of their choosing.” “Standing outside the unit, I silently hoped for the strength and clarity of thought to write my experiences as a patient and a physician into a cohesive whole, in a way that would honor all that I have been through.” She also calls attention to the omnipresent shame, guilt, and feelings of vulnerability, and how she and her colleagues were able to successfully support each other through reflective conversations. This was during a time she is on forced bedrest during her second pregnancy and was hospitalized in the same hospital where she works. She reminds us that we can do this. “It is entirely possible to feel someone’s pain, acknowledge their suffering, hold it in our hands and support them with our presence, without clouding our judgment.”