Healing with intention: Emotional connection key to transforming care

Key takeaways:

• Vital Talk training is a communication program that helps physicians learn how to have difficult conversations in and out of the ICU.
• The CLEAR program uses improvisational actors who act out tough health care scenarios for medical staff to learn from.

CHICAGO — Physicians should treat the patient experience the same as medical procedures — with intention, according to a speaker at the Women in Medicine Summit.

Rana L. Awdish, MD, FCCP, FACP, medical director of care experience at Henry Ford Hospital in Detroit, said the current state of medicine can be transformed, but the only way to do that is by doing it together.

“The boat that got us across the river cannot get us to the next place,” Awdish said during the opening keynote address. “We need different tools from what got us here. We need community and we need to support each other differently.”

‘Circling the drain’

Awdish’s career has been anything but linear.

“The way that I have evolved in my career has been a reaction to the way that things have gone for me in my life,” she said. “I completed my pulmonary critical care fellowship training at Henry Ford Hospital in Detroit. At the very end of my training, I really thought I knew medicine and how to take care of patients.”

That all changed when on the last day of her training, Awdish became critically ill.

“I tried to time a pregnancy as a woman in medicine, so that it wouldn't interfere with my training,” she said. “I was 7 months pregnant at the time, out for a celebratory dinner with my best friend when I suddenly experienced the onset of the most excruciating abdominal pain that I could imagine. It was so severe that the word pain doesn’t describe it. The pain was so severe that if it continued, I knew it would kill me.”

By the time she got to the hospital, she knew she had an intra-abdominal catastrophe and needed emergency surgery, she said.

“I was met by a hospital security guard at the entrance to the ER who asked me how pregnant I was and he said that anyone over 24 weeks gestation has to go to labor and delivery,” Awdish continued. “I listened. I lost agency in that moment, which was an awakening to how quickly our patients lose agency — something that I hadn’t been aware of previously. It wasn’t that I thought I wouldn’t receive good care in labor and delivery, but that the focus would be on the baby. For me, knowing that I was dying, that didn’t seem like the best plan.”

The medical team didn’t know it at the time, but Awdish had a ruptured hepatic adenoma — an arterial bleed that filled her liver capsule that caused her to lose blood volume in a matter of hours.

“When a resident came [to my bedside] to check on the baby, there wasn’t a heartbeat,” she said. “[The team] then rushed me into the OR and that’s when things really went bad.”

The bleeding had crushed her liver, according to Awdish, and she became coagulopathic.

“I had what is known in trauma as ‘the triad of death.’ I heard the anesthesiologist say ‘we are losing her. She’s circling the drain.’ That caught my attention and I tried to orient myself to my surroundings, and I could see the anesthesiologist trying to place IV access, but he was struggling,” she said. “I could see the obstetrical team ready with instruments to extract the baby and I could see myself on the table and I remembered thinking that if I can see myself that I am probably already [dead].”

Different side of medicine

Awdish recalled feeling completely at peace in that moment, but she also recalled experiencing a side of medicine that she didn’t like.

“There were disturbing deficits in communication. There were words said around me, such as ‘she’s circling the drain,’ that I remember myself saying about patients,” she said. “I have been in OR rooms where we are trying our hardest to get everyone to realize how important it is to move quickly and to act, but I never realized what it would feel like if a patient had to have those words land on them and what it would do to their own sense of ability to recover.”

Her next memory was when she woke up after that night in the OR to her childhood priest motioning the sign of the cross on her body and immediately thinking she was dying.

“I hadn’t seen him since my wedding. As an intensivist, I would have rather woken up on ECMO because we put people on ECMO when we think they’ll survive, but we bring the priest when we don’t think they’ll survive,” she continued. “All I wanted to know was whether I was dying. I remember gesturing with my restrained hand for a pen, but they wouldn’t give me a pen because my mentor, the attending and my division head — all men — had agreed that I shouldn’t be told that the baby had died. That they would decide when I was ready to hear it and they were afraid I was going to ask about the baby.”

That is when Awdish said she realized that information about women’s bodies does not truly belong to them, but exists outside of them and is doled out in a way that has been deemed appropriate for what others think that someone can handle.

“The next memory that I had was hearing the rounding team in the hallway,” she said. “I had just rounded with that same team the month prior and so I recognized one resident’s voice. He was saying that I was post-op c-section for fetal demise, with intraoperative observation of a large subcapsular hematoma. I was following along like I was part of the team, but then he said, ‘she’s been trying to die on us.’ That made me mad. I know I looked affright, but I was not trying to die on anyone, and by attributing that intention to me, he was declaring that we were on opposite sides.”

Awdish then remembered saying that exact phrase 2 weeks prior in the ICU — a common way of attributing responsibility to the patient and deflecting it away from the medical team.

“I realized that this is our culture, all of the things that I was hearing is who we are as physicians and that was enough to start to light a path before me of what needed to be different,” she said. “Circumstances will absolutely tear us apart and we will have to put ourselves back together again — and we can choose the way that we put ourselves back together again. My experience as a critically ill patient showed me the aspects of our training that I was blinded to.”

Emotion > data

Those in the medical field are trained that all questions are a request for data, according to Awdish.

“[My experience] allowed me to recognize in myself that I was less good at recognizing the emotion behind things,” she said. “The physicians and nurses that I encountered during my hospitalization who were able to come into my room and sit down with me and have conversations — those conversations were healing in a way that I wouldn’t have had access to if it was just the treatment. We can provide perfectly wonderful, technically perfect care and still not be healing if there is no emotional connection.”

The first thing that Awdish sought out when well enough to do so was Vital Talk training out of Pittsburgh — a communication program that helped her to learn how to have difficult conversations, not only in the ICU, but also outside the ICU.

That led Awdish and colleagues to create a program at Henry Ford, dubbed CLEAR, that uses improvisational actors who act out scenarios that residents, trainees and attendings are asked to carry on a conversation about.

“For example, one of our actors performs a case where he’s a dad who has been called by the daycare because something happened to his daughter and he has to go to the ED. The doctor knows that his daughter drowned at daycare and has to share that news,” she said. “For any doctor, that is the worst day ever and we will remember that day until forever. To think that we would have ever tried to do that without practicing, without simulating the encounter, without experiential learning is bananas to me. We have to treat these conversations with the same respect that we treat procedures.”

Art as a form of expression

It was during the time when Awdish was immobilized during her recovery that she found art as a way to express herself.

“I couldn’t remember certain words. I couldn’t remember the word shoes. I love shoes but I didn’t even know the word,” she said. “Everything that I had known myself to be was gone. I didn’t know if I would ever practice medicine again. I had lost myself and I was also confined to a 6-foot space around me because I was so sick. During that time, I found that I could paint. I didn’t have words, but I had figurative images to externalize what I had inside of me that I didn’t have words for.”

This is what led Awdish to incorporate art as the next thing in her medical teaching.

“People bring their different lenses to an art piece, they see things through their own point of view and everyone’s perspective matters. We can learn more when we listen to people who are different from us and we can see more when we see together. If I wanted to teach those things, I couldn’t do it in a lecture, but I could do it in front of a piece of art,” she said. “Consider how we represent pregnancy loss in a chart, the language of disease. Consider instead how a patient may represent it. There’s so much more that is available to us when we look closer and allow ourselves to really see the experience of our patients. The surrogates we have for the experiences of our colleagues and patients may not be their actual experience.”

Next came writing as a form of expression for Awdish.

“Writing a book came later when my words came back. You learn a lot about an organization when you start writing about how it failed you as a physician,” she said. “I’m married to an attorney, and we had a sit down to discuss what I was willing to lose because they might fire me for the things I wrote in the book and I may not have a job in medicine after publishing it, according to my husband. I needed to decide what I was willing to lose. But that fired me up and I decided that no one in the hospital was going to see it until the book was bound.

“To the organization’s credit — they didn’t fire me,” Awdish added, “but instead gave me a bigger stage to talk about it.

“They said that ‘we are a learning organization. Everyone makes mistakes. We make mistakes. You’re giving us a chance to learn from our mistakes and you’re coming up with solutions,’” she said. “It taught me that if I hadn’t been willing to freefall into oblivion, that I wouldn’t have known that I can say what’s true and that people, through that vulnerability, will also say what is true.”

Equanimitas

Recalling the early days of the COVID-19 pandemic, Awdish described one peer processing group session in which a nurse told the story of her experience with a COVID-19 patient who was arresting.

“During the very worst days of the pandemic, we gathered in peer processing groups because it was almost impossible to process alone — we needed to process together. The sessions were led by a clinical therapist or a psychologist and a clinical lead,” she said. “A nurse described being alone in a room [with the arresting patient] and she could see her team outside the room donning their protective gear so carefully. She said she became so mad because they left her alone and she didn’t know whether she should disconnect the patient from the vent and ‘bag’ him, but was concerned that if she did that she would aerosolize the virus and put herself at risk and take the virus home to her children.”

She chose to hold his hand — to recognize his humanity, Awdish continued.

“It was what happened next that was truly extraordinary. The people in the session began reflecting back to the nurse all the values that she demonstrated in that moment,” she said. “They said things like, ‘You brought the best attributes of your profession. You recognized his humanity in that moment. You chose to hold his hand. Do you hear what you rose to become in that moment? You filled a space that would have otherwise been a void.’ We saw her goodness so clearly and we could so clearly describe to her how good her heart was, but we could not see it in ourselves. We all felt like we were failing. But when we saw her goodness, we could believe that maybe we were good too and maybe we were enough. Maybe these impossible choices were always going to be impossible choices but they are what we have and that got us through.”

Awdish said that what she has learned from her experience is that the current structure of medicine will no longer suffice.

“We inherited a structure that was not built for us. A provisional structure that was built by men for men in a time when we were never envisioned to be a part of it. It no longer works. We need to reimagine what it can be,” she said.

According to Awdish, she now has a different understanding of the word equanimitas — the clinical distance that gives those in health care the remove needed to think rationally and not emotionally.

“I now think about it as capacity,” she said. “Having a heart that is big enough to hold it all. Being willing to see the utter reality of our world of medicine — the beauty and the terror — and to love it anyway.”

For more information:

Rana L. Awdish, MD, FCCP, FACP, can be reached on X (Twitter) @RanaAwdish.