In Shock Read online

  Ask, and ask again: Physician

  Don’t assume everything is on the table when the patient stops speaking. The most pressing concerns are often the last to be stated. When there is a pause, ask for more—“Is there anything else?”—to ensure you’ve got a complete picture. This will allow you to prioritize. “It sounds like your knee pain is really limiting your ability to get out of the house, and that concerns me, so I’d like to be sure we address that today. But I also want to talk a bit about your annual health maintenance. Would that be okay?” Always check in to allow the patient to feel they have agency and choice in their care.

  Agenda setting: Patient

  It’s time to pull out the list. READ the list to the doctor. Don’t censor yourself; simply read those top issues that you had identified prior to the encounter.

  Possible starter sentences:

  •  “What I hope to accomplish today is to gain a better understanding of my recent diagnosis.”

  •  “I am hoping to learn from you what steps I can take at home to reduce the impact of this disease.”

  •  “Can you explain how you will know that the treatment we decided to try is working?”

  Understand that the physician may have a different priority. Something that the doctor has identified as a “red flag” symptom may redirect the entire encounter, but know that this is being done for your own safety and well-being. But, even in situations when your health is stable, it’s important to know where the doctor feels the focus should be. If the doctor doesn’t provide his or her own agenda for the visit, try asking questions like “What about my current health concerns you the most?” Or “If I were to focus on changing one thing in order to positively impact my health, what do you think it should be?”

  DURING THE ENCOUNTER: PHYSICIAN

  Empathy

  Emotions can be difficult to decode. Even benign symptoms can trigger intense anxiety. I don’t know of a single physician who, when stricken with a terrible headache, hasn’t for at least a moment thought, “I wonder if this is a brain tumor or an aneurysm that’s ruptured?”

  Explore: It helps to ask the patient what they are worried about. For example: “I have some ideas based on what you’re telling me, but what do you think is going on here?”

  Check in: Consider whether news you thought was relatively minor seemed to overwhelm the patient: “I want to make sure I hear what you’re thinking. How do things look from your point of view?”

  Name the emotion: When you do see emotion, try naming it: “It seems as if you are feeling anxious.” Find out what feels authentic to you; everyone’s communication style is different.

  Provide support: A gateway, if you are less comfortable expressing emotion, is to offer genuine statements of support and reassurance. “It must be overwhelming to think about. I want you to know I’ll be here with you to figure out our next steps.”

  Assess understanding

  Opportunities for misunderstanding can occur on both sides of the exam table. To avoid this, take the following steps:

  Restate and reframe: An easy way to ensure that your message has been understood is to ask, “Could you tell me how you might explain what I’ve just told you to your family when you get home?” This will allow you to gauge both what content has been absorbed and how the patient may be framing it to themselves.

  Check in: How is their perspective? Is it accurate? What meaning has the patient attributed to a diagnosis, test or treatment plan?

  If, for example, you are discussing the need for a procedure—say, an ultrasound examination of the heart to better characterize chest pain—and you ask the patient for their thoughts on having the procedure and the patient says, “It sounds like I’d better get my affairs in order,” there is a clear disconnect. On the other hand, if the patient replies, “I think it is time to be proactive; I’ve been putting off finding out the cause of the chest pain for too long,” you are better aligned.

  Respect: Regardless of what is said, respect the patient’s viewpoint, and add to it if necessary. “That’s a really good restatement of the issue. Can I add one detail that I think is important?”

  Expectations

  When setting treatment goals, know that the desired endpoint might look very different from the patient’s perspective. Ask the patient “What would you most like to achieve?” To us, heart failure management may simply mean a certain number of pounds of water weight lost to offload pressure on the heart. To a patient, it may mean being able to go back to church because the swelling has decreased and she can get her shoes on again. That is a shared goal, just articulated differently. Use it to effect change.

  DURING THE ENCOUNTER: PATIENT

  State your fears

  If you are concerned about something and feel it isn’t coming across or that your concerns are being minimized, be deliberate and direct. For example, tell the doctor, “I am worried that this pain represents something serious, like a tumor.” Fears left silent will fester and feed on themselves. Fears expressed can be calmed.

  Restate for clarity

  If you are unsure of something, ask about it. If the physician lapses into medical jargon, try saying, “Can I try this in my own words so I make sure I understand?” Or rephrase what you hear: “What I hear you saying is … is that right?” This allows the doctor to understand how effective their communication has been and where gaps remain.

  Next steps

  Make sure you are clear about next steps. This may require direct a question, such as: “What symptom changes would warrant a follow-up visit?” If you are having testing, ask how the results will be communicated: “How will I learn about the results of the testing? Will a letter be sent or will someone call? When can I expect to hear?” Not doing so may mean unnecessary anxiety. This is true of either a clinic visit or an inpatient hospital stay. One of the most anxiety-producing aspects of being an inpatient is the loss of control, the unknown. Ideally your care team will anticipate this and inform you of what lies ahead, but if they don’t, ask. “What tests are planned for today? What are you hoping to learn from the results?”

  Have an action plan

  If you have a condition that flares up or is subject to exacerbation, you have the advantage of being able to plan ahead. By developing an action plan with your physician, you will be able to better self-manage certain recurring issues. For example, some patients with heart failure who weigh themselves daily are instructed to take an additional dose of their water pill if they have gained two pounds of fluid weight. Some asthmatic patients know that if they are using their rescue inhaler more frequently, they made need to start an oral steroid pill. To the extent that plans can be worked out in advance, you can stay ahead of problems that may arise while still having the comfort of knowing that each step you are taking is supported by your physician and care team.

  USE ALL AVAILABLE RESOURCES: PHYSICIANS AND PATIENTS

  Technology

  Take advantage of whatever communication resources are provided to you. Many electronic medical records have a patient portal through which you can directly communicate. Use it to ask the question you forgot to ask during a visit or follow up on test results. Your physician may be happy to e-mail responses to questions. The knowledge that communication channels remain open after the encounter can alleviate some of the pressure of the visit and allow for a trusting relationship to develop over time.

  Human Resources

  Some clinics have care teams staffed with nurses, social workers or even pharmacists. Patients, learn what services your clinic offers and who best to direct your questions to both during and after office hours. Find your community. This may mean joining a local patient support group or (if you suffer from a rare disease) an online forum that is supported by a national organization. Physicians, find out about the support system your patient relies upon for help. Is it a family member or a neighbor who drops in to check on your patient? Are there community services in the area that you could eng
age to fill the spaces between visits? It is only by building a community that is engaged and active that we can hope to effect true change.

  Acknowledgments

  I’ve written a book that is about the darkness, the shadows, and the times when we failed. Implicit in the fact that I was even able to write this is the truth that my life was saved on more than one occasion by teams of people who are experts in their field. I will forever be indebted to each of them, and I hope that my efforts to change our profession for the better are seen as what they are—an effort to honor your life’s work, the passion you bring to it, and our shared commitment that we can always be better.

  To Tony—You are the hero of this story.

  To Marwan—You are everything I aspire to be. Resilient and wise and humble and generous. You are ALL OF THE THINGS.

  To Maria Z.—You truly showed me another way. It is so clear that medicine is your calling, and you exemplify compassion. You know I adore you.

  To Dave—You showed me what bravery looked like. What showing up every day for your patients looks like. And how to know when it was time to blow everything up and start over.

  To Jacqueline—I have no idea how you knew I could write a book, but thank you for finding me. Your e-mail changed my life.

  To Karen—Thank you for believing in this project, for being its tireless, passionate advocate, and for getting half the world on board! And above all, thank you for making me believe I was a writer, when I was quite insistent I was not.

  To Father George—Thank you for your endless support. During every crisis, you were a tremendous comfort to us. And for enthusiastically sharing our joys as well.

  To the Pulmonary and Critical Care Department (especially Geneva, Razaq, Mike E., Paul, Bruno, Jenn, Lisa, Ron, Joey)—Thank you for your support during this time; the coverage you provided when I was endlessly sick; the leadership, mentorship and friendship; the sideline consults, the guidance and the treatment. You’re like family.

  To Hector—You taught me everything I know. And I entertain you by eating bananas with a knife. So I’m pretty sure we’re even.

  To Rose and Vanessa and Kelley and Vicki and Michelle (and the whole CE team)—Thank you for partnering with me in the actual, tangible, hard work of improving patient care. I’m so proud of what we are doing together.

  To Kristen, Erin, CLEAR facilitators and actors—What you do is MAGIC. Kristen, thank you for bringing the VitalTalk format to our institution. It has been a game-changer.

  Tricia and Jillian and Erin and Kelsey and April and Susan and Debbie and Barbara and truly all of the nurses—Your presence through those days meant more to us than you’ll ever know. I learned more about how to be there for my patients from watching you than I can ever hope to explain.

  To Rosemary—I will forever be grateful that a chance encounter in a grocery store brought you into my life. You made this book better. You led me to an introduction that was so elusive, for so long. You are a gifted and generous teacher.

  To Maria—You are my Guru. Your wisdom and compassion are boundless. You have made me into a smarter, braver version of myself through your friendship and coaching. I wish everyone had an opportunity to learn from you.

  To Cara—Thank you for teaching me to trust the reader. You were a Godsend. And I don’t know which aspect of you I adore more: Talented editor, with amazing insight? Or late-night dance partner and karaoke singer? I hope our yearly trips together continue for-EVAH!

  To Jim—You can say things to me that no one else can. And you are ALWAYS right. I don’t think I’m overstating it when I say this book would have been unreadable without your insights. Thank you for reading the horrid early drafts.

  To Mechelle—Thank you for insisting Jim re-befriend me. And your endless encouragement.

  To friends that I trusted with the awful early drafts (Bryan, Lisa, Sara, Lynn, Kelly)—Thank you for your guidance and encouragement to keep going. You helped me to find my voice.

  To Sara—Thank you for being my partner. Your dedication to our work has allowed me to do more than I ever could have alone.

  To Dana—Thank you for being there for ALL OF IT, the pain and the healing and the work that followed. Thank you for asking the hard questions and for always prefacing them with, “OK, so … loaded question, but…” For wearing the Spanx, for the -erfect wedding toast (even though everyone kept talking), and for telling me I am your favorite human. And I totally forgive you for making me walk up the hill.

  To our families and friends who visited, fed EVERYONE and provided comfort (esp. the Awdish/Ayoub/Kouza/Chammout/Sharrak/Shaya families)—Thank you. Though I couldn’t participate at the time, knowing you were there was a great comfort.

  To Kamal—Thank you for dropping everything and driving to get to me. You have always been there for me when I needed you. And I’m so glad we share so many memories that no one else understands.

  To Nellie—Thank you for teaching me to look for the light, in every situation, to be grateful always, and that GIRLS CAN DO ANYTHING BOYS CAN DO. Everything I am is because of you and Dad.

  To Randy—Just like everything else in our lives … this book is proof of your love and your willingness to sacrifice for us. And yes, you can use this as a testimonial if you ever have to date again. But I hope you never have to use it. Because nothing would make me happier than living our -erfect life together forever.

  About the Author

  DR. RANA AWDISH is a critical care physician and Medical Director of Care Experience for Henry Ford Health System. She was inducted into the Alpha Omega Alpha Honor Society while attending Wayne State Medical School in Detroit and was awarded the Speak Up Hero award for her work establishing the innovative program CLEAR, which focuses on improving communication skills in medicine. She was named Critical Care Teacher of the Year in 2016 and is board certified in Internal Medicine, Pulmonary and Critical Care Medicine. In 2017 she was named a finalist for the Schwartz Center’s National Compassionate Caregiver of the Year Award. Her essays have appeared in the New England Journal of Medicine and Academic Medicine. She lives in Northville, Michigan, with her husband, her son and a very old tabby cat. You can sign up for email updates here.

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  Contents

  Title Page

  Copyright Notice

  Dedication

  Introduction A Chance to Die

  One   Bled White

  Two   A Hollowness

  Three   Waiting to Fail

  Four   Sequestered Words

  Five   Increments and Impediments

  Six   Shifting Frames

  Seven   Vulnerable Masses

  Eight   Censors of Light

  Nine   Revolutions

  Ten   Deliverance

  Eleven   Relapse

  Twelve   Broken Vessels

  We Can Do Better—Communication Tips

  Acknowledgments

  About the Author

  Copyright

  IN SHOCK. Copyright © 2017 by Rana Awdish. All rights reserved. For information, address St. Martin’s Press, 175 Fifth Avenue, New York, N.Y. 10010.

  The names of some individuals depicted in this book have been omitted and identifying characteristics changed. A select few portrayals are composites.

  www.stmartins.com

  Cover photograph of hospital © Aping Vision / STS / Getty Images

  The Library of Congress Cataloging-in-Publication Data is available upon request.

  ISBN 978-1-250-11921-6 (hardcover)

  ISBN 978-1-250-11922-3 (e-book)

  Our e-book
s may be purchased in bulk for promotional, educational, or business use. Please contact the Macmillan Corporate and Premium Sales Department at 1-800-221-7945, extension 5442, or by e-mail at [email protected].

  First Edition: October 2017