Lessons from a doctor turned patientDr. Rana Awdish, MD, FCCP, is a critical care physician and faculty member of Wayne State University School of Medicine in Detroit, Michigan, USA. She is Director of the Pulmonary Hypertension Program at Henry Ford Hospital and Medical Director of Care Experience for the health system. Her book In Shock, published in October 2017, is based on her own experience of critical illness.
Dr. Awdish has a special interest in improving empathy through connection and communication. She was awarded the Speak-Up Hero award in 2014 for her work establishing a workshop-based program called CLEAR (Connect, Listen, Emphasize, Align, Respect), which trains faculty and trainees in relationship-based communication skills using improvisational actors. She was named Henry Ford Hospital’s Critical Care Teacher of the Year in 2016, the National Compassionate Caregiver of the Year by The Schwartz Center on 16 November 2017, and the Physician of the Year by Press Ganey on 1 November 2017. Her New England Journal of Medicine Perspectives article, A View from the Edge, went viral garnering over 100,000 views and is ranked in the 99th percentile for reach.
What prompted you to write your memoir In Shock?I realised that as a physician in my own institution I was, at least in theory, an empowered minority. I was someone who had a voice, some measure of authority and personal agency. Yet, as a patient, I didn’t feel at all empowered to be vocal about my needs or fears. I thought about how voiceless you become in many ways just through illness. And, perhaps more importantly, I realised that, if I felt that way, then the experience was far more common than I had understood it to be.
Once I framed it that way for myself, I felt a responsibility to admit the ways in which my own system had in many ways failed me because, if it was failing me, then it was bound to be failing others. What about people who don’t have the medical vocabulary or the foundation of knowledge about what is going on in their body? What about those who don’t know the people in the room or the roles they are meant to play? Medicine is a black box for so many.
We have an obligation to fix this for the people who can’t tell us we need to fix it. Once I felt that responsibility, it led to me writing the piece and, ultimately, to writing a book about my experience.
What training do you provide at Henry Ford to physicians on patient-centered empathic communication?Physician Communication & Peer Support (PCPS) is a resource designed to provide physicians and advance practice providers evidence-based best practices to improve communication as well as augment physician resilience and engagement. The workshops and retreats are customised to meet providers at their learning edge.
Our Values and ProgrammesTo date, PCPS offers a variety of programmes to providers across Henry Ford Health System. Through careful, consistent research, intentional partnerships and practical integration we have built a structure that is both scalable and sustainable. All programmes are built upon the core communication values, which together weave a foundation for culture change.
CLEAR Conversations Programme — the cornerstone of PCPS. CLEAR was started by three physicians, trained in the Vital Talk Method. CLEAR Conversations focuses on toolkits and roadmaps for difficult, often end-of-life conversations. Using improvisational actors from the city of Detroit, the learning is experiential and case-based. Training targets the most fraught conversations in any specialty. CLEAR Conversations is the groundwork for culture change. It is recognised nationally as a standard-bearer for how these skills should be taught
CLEAR Fundamentals — provides education and practice on 5 fundamental communication skills that are validated best practices for communicating with patients in any situation.
CLEAR Provider Shadowing — provides “elbow-level support” to physicians, in a real-time fashion. By observing real clinical encounters from the vantage point of patients, PCPS shadowers are able to provide individualised feedback for each physician. This confidential process allows providers to identify key behaviours they can deploy to enhance the patient’s perception of their quality of care and their care experience.
Learning ApproachThe primary learning approach with PCPS programs incorporates safe, small-group exploration of communication tools, peer dialogue and experiential learning in the context of communications training focused on advanced questioning and listening skills. This is paired with meaningful practice; impactful, relevant didactics; ‘bedside’ feedback and support; and builds communities of practice within and among specialties; with the potential to reach deep into the organisation building greater inter-professional strength.
It creates and sustains culture change.
PCPS Implementation Strategy
Currently, the focus of the PCPS resources has been directed toward the following divisions within Henry Ford Health System:
- Departments of Palliative Care and Pulmonary Critical Care, providing early adopter support through Chairs’ Funds. Most Senior staff have been trained in CLEAR Conversations
- Departments of Medicine and Emergency Medicine (the two largest divisions within the system) have begun multi-year, multi-pronged longitudinal programmes for physicians and physician trainees; with Emergency Medicine expanding to inter-professional programming for their PA and nursing staffs. The cornerstones for these programs is CLEAR Conversations, CLEAR Fundamentals and CLEAR Shadowing which incorporate feedback loops along with training and intentional practice.
- Department of Medicine are now requiring CLEAR Conversations training for all residents and fellows
- CLEAR Provider Shadowing for all Primary Care providers
- Integration of CLEAR Conversations with Schwartz Center Rounds
- New integration of Narrative Medicine and Emotional Intelligence concepts into the CLEAR curriculum
- Full alignment of the Graduate Medical Education Institutional Curriculum (required for all HFH medical trainees) with CLEAR communications concepts within the contexts of difficult conversations, healthcare disparities, error disclosure, handoff/transfer of care and professionalism.
- CLEAR Conversations Training of first-year medical students
Physician Communication & Peer Support Growth TrajectoryOver the course of five years, the single strength of the CLEAR Communication Values and programmes has moved well beyond its original intent to help physicians interact more empathically with patients. These three elements together are reaching well into the soul of the culture of the Henry Ford Health System.
The trajectory of a physician communication strategy has required monumental effort associated with the belief that this work can change the culture of medicine – one conversation at a time. The initial implementation of the CLEAR Conversations programme laid the groundwork for expansive growth that far exceeds current levels of funding.
Are you starting to see the effects on patient and family experience?Not only in terms of patient and family experience where there has been clear improvement, but also with providers. This training, by integrating new with existing staff and creating bridges across divisions, among professions and between trainees and staff is enriching the lives of patients as well as staff.
Providers are requesting more physician communication resources and programmes at a rapidly growing rate. This work has ultimately created change of tidal wave proportions. This change is not only in how conversations take place, but also change that deepens connections among colleagues – hence building a renewed sense of purpose in the workplace.
Zoom On Rana Awdish
What are your key areas of interest and research?
Pulmonary hypertension, communication and compassion in healthcare.
What are the major challenges in your field?
A deeply entrenched culture moves so slowly—sometimes it is hard to appreciate the change.
What is your top management tip?
Know the individual strengths of the people around you, mentor them to find their respective area where they achieve success and then stand back and let them shine.
What would you single out as a career highlight?
Watching as my book, In Shock, is integrated into medical school curriculums, and residency and fellowship programmes… it truly gives me hope that we can change the culture.
If you had not chosen this career path you would have become a…?
Research scientist, but I preferred people to labs.
What are your personal interests outside of work?
I paint with oils, enjoy cooking, spending time with my family, listening to live music and doing Yoga.
Your favourite quote?
“Pain is inevitable, suffering is optional”—Haruki Murakami.