In Shock
Author: Rana Awdish

Synopsis

This book is a very powerful commentary on the parlous state of compassion and empathy in the medical profession. It is the story of a critical care physician who fell catastrophically ill, and experienced an alarming odyssey through an incident-ridden healthcare system. She describes how her role as a hybrid ‘physician-patient‘ provided her with an eye-opening perspective of the shortcomings of clinical practice, from uncomplimentary attitudes such as simple discourtesy, to harrowing exposures to life-threatening conduct (page 21). The author used her personal experience to recommend solutions to the paradoxical situation whereby otherwise proficient practitioners of a caring profession struggle ‘clumsily‘ when it comes to empathy (page 9). The book’s consistent message was to affirm the overriding importance of compassion across the range of medical practice, from medical education to patient safety. 

The foundation of the book is the chronological account of the critical internal haemorrhage the author suffered in the seventh month of her first pregnancy. She described this as an ordeal ‘that took me apart, piece by piece, and put me back together in a conformation so different I questioned if I still existed at all’ (page 2). Her compelling story-telling graphically portrays her sudden onset of ‘excruciating and unsustainable pain‘, the shock that ensued from massive blood loss; how she survived stroke and ‘the triad of death‘ on the operating table; and her slow recovery interspersed with euphoric small victories and depressing relapses (pages 11-25, 30-34, 81-85, and 144-146). More profound is the turmoil she endured from soul-wracking emotions ranging from fear of complications, to anxiety over medical errors that may arise from decisions ‘made without looking at the whole picture’. She graphically describes the regret she felt for the loss of her sense of self as ‘a strong, capable, independent person, and the ‘overwhelming self-pity and anger that overcame her when she saw the ‘ravages of illness‘ on her reflected image in the mirror (pages 43 and 84-89).

The running theme through the book is the author’s experience of lack of empathy, and the emotional impact this had on her. Many of these encounters manifested as relatively minor infractions, for example when physicians spoke to her flippantly, or with a detached insensitivity, or with a refusal to meet her gaze (pages 24-27). She however also encountered disturbing transgressions from fellow doctors who made treatment decisions about her care with casual negligence, and those who allowed an authoritarian medical hierarchy to stop them from challenging the such decisions (pages 40-47). Such experiences made her question the ‘reliability of a system that was set up to ensure obedience rather than an honest exchange of information’ (page 47). Equally distressing were the arrogant, patronising or defensive physicians who addressed her concerns in accusatory and condescending ways, leaving her feeling unimaginably powerless and vulnerable (pages 156-157, 194 and 220). She however also acknowledged many examples of good practice, such as the neonatal ICU where ‘the very transparent discussions, the follow-through, the constant communication and disclosure created a cocoon of safety‘ (pages 47 and 201). 

Why do many physicians treat their patients without the requisite empathy and compassion? One of the key answers the author proffered to this agitating question is that physicians are trained to see pathology rather than patients. She traced this phenomenon to the tendency of medical schools to emphasise the study of diseases over the understanding of people, asserting that ‘the true relationship is forged between the doctor and disease’ (pages 26 and 123). She suggested that this explains why doctors have difficulty listening to their patients, especially when ‘the story the patient relays can be circuitous, or filled with content we believe to be extraneous‘, or when ‘we might feel pressed for time and wish our patients could somehow just tell us what we need to know’ (page 217). She was also critical of the paradigm of medicine which teaches that reserve, distance and coolness are essential for clear judgment, and that connecting with patients will lead to loss, disillusionment and burnout. This is the reason, the author maintains, why doctors learn to conceal their emotions, and to overlook the emotions of others (pages 10 and 165-166). On the contrary, she argued that ‘it is entirely possible to feel someone’s pain, acknowledge their suffering,…and support them with our presence without depleting ourselves, without clouding our judgment‘ (page 239). 

Perhaps the most practical aspect of the book relates to the helpful recommendations the author made to physicians. Many of these are communication tips, such as to listen to patients ‘with a generous ear…by not dominating the flow of information‘. She argued that a ‘patient-centred narrative‘, whereby the physician relinquishes control of the encounter, enables the ‘actual history to emerge’, and has ‘the potential to heal everyone involved’ (pages 52-53). The book also encouraged doctors to trust their patients more, to understand their difficult circumstances, to recognise their emotions, and to address their fears and anxieties with empathy rather than with more ‘data, facts, and explanations‘ (pages 126- 137). She advocated the ‘Ring Theory‘ etiquette which empowers the patient ‘to say anything she wants at anytime to anyone‘, and which protects the patient from the complaints of others (page 55). 

An elevating quality of the book are the reflections on illness and pain which the author interspersed in her narrative. Most insightful is her contemplation of the value of illness, a state she viewed as an avenue to ‘wisdom that is normally hidden, except in times of utter darkness‘ (pages 3-4 and 9). She noted that her illness experience enabled her to better appreciate suffering, and this manifested in her subsequent heightened sensitivity to the ‘small indignities‘ being inflicted on patients all around her (pages 122-124 and 178). She also thought deeply about the nature of pain, a constant feature of her illness; she came to understand that ‘my experience of the pain depended upon what I agreed to attend to’, and her adopted strategy to cope was ‘to look at the pain honestly…to sit beside it, acknowledge it and be whole in its presence’ (pages 106-107). 

 

Opinion

This autobiographical account, infused with breathtaking prose, is striking as much for its detailed illness narrative, as for its philosophical reflections on the impact of illness and suffering. The author revealed many egregious examples of poor conduct by healthcare practitioners which raised serious empathy and safety concerns. The book provides invaluable learning points for physicians to remodel their attitude to patients; it specifically puts emphasis on appreciating the perspective of the sick, understanding their concerns, and alleviating their fears and anxieties. The author also highlighted the need to address the non-technical inadequacies of medical practice, and to re-balance the curriculum of medical training.

Overall assessment

This is a remarkable perspective of a physician as patient, and the author’s passionate advocacy shines through on every page. Facing an existential illness, she masterfully captured the physical and emotional turmoil she endured, not just from her illness, but also from the attitudes of those charged with her care. She boldly pointed out the glaring inadequacies at the heart of healthcare, both at the individual and the organisational levels. This is a sad indictment of medical training and practice, and a clarion call for reform. It is an essential read, and I recommend it to all doctors

Book details

Publisher, Place, Year: Transworld Publishers, London, 2007
Number of chapters: 12
Number of pages: 266
ISBN: 978-0-5930-7949-2
Star rating: 5
Price: £14.99