Narrative Medicine Monday: In Shock

Although I’ve never met her, author and critical care physician Rana Awdish on some level feels familiar. Not only are we both part of a supportive online group of physician-writers, but I just finished reading her wrenching memoir, “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” Awdish’s gripping account of her near-death experience, subsequent hospitalization in her own ICU and revelations about the shortcomings in both support for and education of medical providers in the realm of empathy are illuminating. Her book is infused with challenge and hope and a call to transform the way we train physicians and care for patients.

Awdish is thrust from the world of providing medicine into that of receiving it – a patient under her own colleagues’ care. The contrast of these positions of power and vulnerability are striking and Awdish describes the jarring experience and her own enlightenment as she pivots between these two roles. She shares with the reader her revelations regarding how we provide medical care to those in crisis and inspires us to find a better way.

I was particularly convicted by Awdish’s insight into how medical training encourages physicians to suppress many of our emotions. She traces this ideal back to the father of modern medicine, Sir William Osler, who encouraged “‘aequanimitas.’ Osler regarded this trait as the premier quality of a physician. It represented an imperturbability that was described as manifesting in ‘coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.'”

Awdish asserts that as physicians “we aren’t trained to see our patients. We are trained to see pathology. We are taught to forage with scalpels and forceps for an elusive diagnosis buried within obfuscating tissues. We excavate alongside our mentors in delicate, deliberate layers, test by test, attempting to unearth disease. The true relationship is forged between the doctor and the disease.” Do you agree with Awdish’s assessment? Why or why not?

If you’re a physician, if you’re a patient: read this book. Discuss it with your colleagues, mull over it with your book club. The questions Awdish raises, the challenges she poses are vital to improving the way we care for each other in our most acute times of need.

Writing Prompt: If you’re a physician, did you learn to develop “aequanimitas” through your training? Did you feel this trait was a requirement, overtly stated or otherwise, to be a “good physician?” Have you yourself ever been a patient feeling, like Awdish, “powerless in a way that is impossible to imagine, from a privileged position of wholeness and well-being?” Awdish lists biting phrases that were directly said to her or that she overheard when she was a patient. Have you experienced similarly painful words from a medical provider? Have you said such words to a patient before? Try writing from both the patient and the medical provider’s perspectives. Write for 10 minutes.

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Narrative Medicine Monday: Feeding Tube

In “Feeding Tube” author Susan Kelly-DeWitt relays a memory of paper birds that a patient’s family hung over the hospital bed “wild tropical birds, macaws and toucans, parrots and cockatoo.” The visual that Kelly-DeWitt provides is vivid. The reader comes away feeling that humanity reigns over the mechanical devices that tend to dominate the hospital landscape.

I remember very little about the physical details of the critical care hospital room where I participated in my first code as a medical student. I do remember sitting by the resident physician as he wrote his note in the patient’s chart at the nurses’ station just after the man had died. I looked across the desk into the patient’s glass-walled room, my eyes fixed on an elaborate dream catcher hung carefully, just over his bed.

Writing Prompt: The hospital can sometimes feel a like a sterile, mechanical place. Think of a moment or an item, like Kelly-DeWitt’s paper birds, that struck you as out of place or particularly telling about a certain patient, their family and their life. Write for 10 minutes.

 

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Narrative Medicine Monday: A View from the Edge

Dr. Rana Awdish is a critical care physician turned advocate for training in compassionate care following her incredible near death experience in her own hospital. Her essay “A View from the Edge” in the New England Journal of Medicine provides an overview of her 2008 experience as a critically ill patient cared for by her colleagues.

In her book “In Shock,” out this October by St. Martin’s Press, she outlines her harrowing near-death illness and recovery. I’m eager to read Awdish’s book and hear more about how her experience led to advocacy for “compassionate, coordinated care.” In her NEJM essay she describes how “small things would gut me. Receiving a bill for the attempted resuscitation of the baby, for example…. A trivial oversight, by a department ostensibly not involved in patient care, had the potential to bring me to my knees.” After recovering, Awdish channels her grueling patient experience into a drive to transform the way we receive and provide medical care. She contends “we need to reflect on times when our care has deviated from what we intended — when we haven’t been who we hoped to be. We have to be transparent and allow the failure to reshape us, to help us reset our intention and mold our future selves.”

Writing Prompt: Have you noted an erosion of empathy among medical providers? If so, think of a specific example and write about how you felt as the patient. If you’re a medical provider, have you ever been cared for by colleagues at your own hospital? What was it like to be on the “other side,” as a patient? Did you come away from the experience with new knowledge and empathy that you then incorporated into your own practice? Write for 10 minutes. 

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Narrative Medicine Monday: Going Solo

Nurse and writer Amanda Anderson describes the final moments of caring for a patient in the ICU in “Going Solo“.

Anderson opens the piece noting that she decides to scrub the patient’s teeth clean. Why do you think she’s determined to complete this simple act?

The author comments that this passing feels different than others because she doesn’t also have the patient’s family to nurse through the process. Her actions are per protocol, “governed only by a set of instructions:
1.  Administer pain dose once, prior to extubation.
2.  Extubate patient.
3.  Administer pain dose every three minutes for respiratory rate greater than twenty,
or obvious signs of pain, as needed.
4.  Notify house staff at time of asystole.”

How do you feel when you read through the protocol that Anderson follows? How do you think she feels and how does she convey that through her writing?

I appreciate Anderson’s candidness in immersing us in her thought process. She plays jazz for him, then realizes, what if he hates jazz? As medical providers, we only get a snippet of a patient’s life. If you’re a medical provider, have you ever wondered about a specific patient’s life outside of the hospital? How could that information inform their care? As a patient, what do you wish your medical providers knew about who you are?

Writing prompt: As a medical provider, think about a protocol you follow, a procedure or list of instructions you adhere to in a certain situation to provide care. List the steps. Now consider an unwritten protocol, such as a nurse in caring for family members throughout their loved one’s death in an ICU. List the steps. How do they compare? Alternatively, think about an encounter you’ve had in the medical world: a ten minute doctor’s office visit, visiting a friend who is hospitalized, getting or giving an immunization. Imagine the broader life of the person who was giving or getting that medical care. Consider their life narrative. Write for 10 minutes.

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Narrative Medicine Monday: Family Summons

When rotating through the Intensive Care Unit in medical school or residency, one of the most significant skills learned, in addition to adjusting mechanical ventilation settings and how to run a code, is how to conduct a “family conference”. This is where loved ones, preferably including the patient’s designated medical decision proxy, gather to discuss the patient’s status, prognosis and treatment plan. As these patients are severely, sometimes suddenly, ill, these can be very challenging conversations. 

In “Family Summons” Amy Cowan illustrates how she was surprised to have a patient’s family gather in the middle of the night, wanting to speak with her as their family patriarch’s physician. Her piece highlights how important it is to listen and extract the true identity of the patient, the life they lived beyond the ICU. Establishing this portrait can help inform the care team as well as free the family members to make decisions in line with what their loved one would want.

Writing Prompt: Have you ever attended or conducted an important medical family conference? How was it run? If not, can you imagine what questions you might ask to best get to know the patient? Think about if you were the patient in the ICU; who would you want to gather on your behalf and what might they say when asked about you and your life, what’s important to you? Write for ten minutes.

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