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Emily Silverman  

You're listening to The Nocturnists Conversations. I'm Emily Silverman. Today, our guest is the wonderful and wise, Dr Rana Awdish. Rana's book In Shock was published seven years ago and is basically canon at this point in the medical memoir world. The book tells the story about how when Rana was pregnant, a hepatic adenoma ruptured and caused her to bleed into her abdomen and very nearly die of hemorrhagic shock. It's a harrowing story, not just because of the disease state itself, but also because of the delays, missteps and other difficult aspects of the ordeal. Triaging her to L and D instead of the regular ER, because of her status as pregnant, not responding to her with nearly the urgency as was necessary, as demonstrated by sending in the intern and resident to take her history as she bled into her liver, focusing on her baby pretty much exclusively, and not really moving on to address Rana's health until the baby sadly dies, speaking about Rana in the operating room as if she couldn't hear and saying things like, "she's circling the drain", a nurse lying her flat, and then stepping away, leaving Rana to struggle with shortness of breath from pulmonary edema until she hit the Code Blue Button, the hyper vigilance that came with knowing that any little mistake in the ICU could harm her, and the exhaustion of that hyper vigilance her eventual stabilization and discharge and beginning the process of putting herself back together again, concretely and abstractly, also returning to work in the ICU, where inexplicably, she seemed to attract critically ill, pregnant patients. But in addition to these terrifying accounts, were so many moments of trust, healing and connection, her steadfast husband, Randy, who embraced her with unconditional love and support, the surgeon who exuded trustworthiness and resolve, the colleague who ultrasounded her liver in private when she noticed a new pain in her side, the nurses and doctors who said just the right thing at just the right time, like the anesthesia resident who looked her in the eyes and said, "I'm not leaving until you can breathe again. You're safe." Rana recounts this story with beautiful, clear prose and with such emotional precision and even dark humor that it's a pleasure to ride alongside her. She brings us as close as she can to her experience, internal and external, so we can glean as much insight as possible without actually having to go through the experience ourselves, which is the hallmark of powerful storytelling. And because of Rana's tremendous story skill and insight, she has made an indelible impact on the medical community, giving numerous Grand Rounds and seminars about her story and lessons learned, and always nudging the profession towards something more compassionate. Now, as I mentioned, it's almost exactly seven years later, and Rana is here to talk about what she's been up to since. How does she look back at her book In Shock? How have her ideas about healing and storytelling evolved? What is she working on? Now, there's a lot to dive into, but before we do, take a listen to Rana reading from her memoir In Shock.

Rana Awdish  

When the pain began, it came in a breathtaking wave that receded just as swiftly as it approached. My first thought was, "Okay, so there really is something wrong. I'm not crazy." I looked across the table at her and said, I don't think I can eat. The look on my face told her more than the words I had managed. I tentatively pushed away from the table, afraid any movement could bring on the next unwelcome wave, and walked out of the restaurant to anxiously pace the sidewalk. The adrenaline surge from the explosive pain had cleared my mind. I knew I had to use this time well before whatever was to come. After calming myself, I called my husband Randy. "I'm not feeling well. My stomach. It's weird, there's this pain, I don't know, but don't worry, the baby's fine." I cringed at the casual lilt in my voice, in attempting to reassure him, I had overcompensated and failed to convey an appropriate sense of urgency. I tried starting over. "I think you may need to take me to the hospital." I considered trying to explain my sense of displacement all day, the fugue state I had found myself in in the shoe store, the breathlessness and confusion I felt at the grocery store. Instead, I settled on adding I don't think I should drive hoping that that would suffice. That was at least a tangible fact. Randy, who was an attorney at a law firm in the city, answered something about leaving soon as he responded to the mythical one final email, confirming to me that I had indeed failed to convey the immediacy of my need. Dana, from her view out the restaurants window, recognized the elliptical and casual narrative I was constructing. She was well versed in my personality. She knew that I was not an alarmist by nature, that I generally assumed things would work out fine and I wouldn't want to worry him unnecessarily. My husband didn't have the benefit of that insight. Having been married to me not quite a year, Dana thankfully prioritized action above reassurance and called him the moment I hung up. "I don't know what she just told you, but come home now, I'm going to drive her and we'll meet you there."

Emily Silverman  

I am here with Rana Awdish. Rana, thank you so much for coming on the show.

Rana Awdish  

So happy to be here with you Emily.

Emily Silverman  

So your book In Shock was published on October 24 2017 which was almost exactly seven years ago. And I have been wanting to speak with you about the book for a long time, and it feels kind of cosmic that we're sitting here so close to the seventh anniversary of the book, because seven is a number that represents a lot in the world, cycles and rhythms in the periodic table, the number seven is important and represents the periodicity of nature. It's also significant in the Bible, obviously, with the seven day week introduced in the creation story and even the word sabbatical comes from the word seven, the idea being that every seventh year, we should let the land rest and rejuvenate. So I wanted to start by asking, how does it feel to look back at In Shock seven years later?

Rana Awdish  

I didn't know what I was creating when I set about to write the book. I was coming from a place of trying to reconstruct myself. I felt so disoriented and unsure of the plot of my own life, that I somehow thought I could write it into being. So in that way, it was a process of sense making for me that felt so personal that it's a little bit strange that it has its own life in the world and meets people in different places. It's something I'm incredibly grateful for. It has opened up conversations that I wouldn't have had access to. I was very scared of the amount of vulnerability that the book required, and I didn't know what would be on the other side of putting it into the world and being met with receptivity and welcoming community is more than I could have expected. So it's been this asymmetric return that's really difficult to quantify, but that I'm very grateful for.

Emily Silverman  

After rereading it seven years older myself, I found myself getting really emotional reading it, and I think part of the reason why is that you leave it all on the field, so to speak. Or I heard one person say that the best memoirs are the ones where the writer really leaves their blood on the page, so to speak. And I just felt like it was such a gift that you gave us this book, and the unvarnished truth in the book, and we were emailing recently, and you were reflecting on the book and reflecting on the fact that you wrote it, you say a little bit like a hero's journey, like a quest narrative, and that, in retrospect, you felt like you were writing more from a mind space, and that there was more to the story, there was more to the healing and that perhaps the body took years to catch up to the mind. So I was wondering if you could speak to that.

Rana Awdish  

It's really interesting how healing seems to take so manypasses, and my first pass was just the acute recovery, aided by everyone in the hospital and medications and ventilators and surgeries, and you're discharged. And to some people, that is healing. Certainly, as an ICU physician, that was my idea of healing. If someone left the ICU, I'd done my job, and it was a sort of awakening that I had when I went home and was left with all of this trauma to really reconcile. And I had two choices in that moment. I could feel it all, or I could intellectualize it all, and my tool kit was way more robust when it came to intellectualizing, because I was a physician and I could apply constructs to it. I could look at it through a lens of medical education. I could think about our culture like an anthropologist would. I could think about patient experience and culture change in medicine, there were all these lenses that were available that were very comfortable, and that was true. It was just so superficial, and the healing that had to happen in my body. I don't know if I could have accessed it right away. I think that process had to be slower, and I had to nourish myself so I could restore myself to do the next work. And it just had to unfold differently and take the time it was going to take, which is frustrating for people who like to be fixers. And on some level, I must have known that and just evaded it. The complication came that then I was represented as healed on the page and hadn't really healed at all in my body yet, and I had to learn to go back into it and reach for things like mindfulness and breath work and yoga and whatever I could find, even painting and movement to speak to it and let it speak to me.

Emily Silverman  

My story is very different from yours, but I've gone through some big changes recently in finding my biological parents. Some audience members listening may already know that I was adopted as an infant and didn't know my biological parents until right around the time I got pregnant, just a couple years ago, and getting access to that information, so many different types of information, of course, there's the names of my biological parents, but then there's the sound of their voice, photos of them when they were young, the story of them, finding all these similarities and differences and learning more about my relinquishment story and all of this. It's just a lot to process, and I've been playing with this framework that you can kind of process on three different speeds. So the mind speed is really fast. It's instantaneous. It's like when you're in a dream and suddenly you're in your kitchen, and then suddenly you're on the beach, and then suddenly you're over here, and it's like, really the blink of an eye. You can go from A to B. And then the next level is processing through your emotions, which is slower for me. It feels more like weather, like a storm, or a week where it's really cloudy, or the sun breaking through the clouds, and more on the level of days to weeks. And then there's processing that happens more at the level of the body, which to me, feels more like a geological time scale where changes just take a lot longer to integrate at the cellular level, like for all of that new information to get fully integrated. So. I was wondering if that framework resonates at all with you, and any thoughts you might have on, how do you move past intellectualizing? Is it just a matter of time, like it will happen on its own time, or is it something that we have to actively choose to participate in to really do that deeper healing at the level of the body?

Rana Awdish  

That framework resonates with me very much. It felt like the emotions to me had been walled off by medicine. I had come out of training really feeling like if you access them, they may overwhelm you and crowd out everything that's good and useful, and you won't have the intellectual ability that you need to have to do this work. And so I sort of had that bias, and what I really had to allow was a faith in my own capacity to meet the emotion and withstand it, because that wasn't necessarily something that was modeled to us in our training, and something about this all being a medical event kept me in my physician mindset. It wasn't as if we had a house fire, and I was processing that. It was in the world that I'd been trained in. And so I was reaching for all of those teachings, the capacity to just be with a feeling and let it just be what it is was so unfamiliar to me that I really didn't know what to expect. And I can remember an instance where I was flooded with this ambiguous grief about everything, about how I couldn't protect us when we were trainees, and I couldn't protect the baby, and I couldn't protect myself, and all of this kind of shame and grief, and I remember deciding to stay with it, and actually trying to just conjure each of those losses visually, to see them as much as I could, and to feel what it felt like to be in that body. And then I just felt like, "Oh, I get it. They want to be held." Just like, if someone's hurt and they need to be held before they can move on, they just want me to hold them. And I did that, and it was like they just walked off, and it all lightened. And that was the first time I think I had a sense of my own ability to move through the emotion and come out the other side and still be whole.

Emily Silverman  

There's this idea that we have all this subconscious stuff that needs to be dealt with, and once it surfaces from the subconscious to the conscious, it's subject to the light of consciousness that then and only then can it walk off or be resolved or be, I guess, maybe some level of closure. Do you find that that's a process that happens once and then you move on? Or is it something that happens again and again? Because I do find myself perseverating a lot on certain things. I bring it into the light of my consciousness. I think about it, I feel the sadness of this or that, and but then it comes back.

Rana Awdish  

Oh does it ever and I really think of it as a circle that we just revisit these feelings, these experiences, these traumas with a little T, with skills and awareness and capacity that we've developed, but we come back again with new awareness and a different lens. And it's always a circle, and I find that there are some things that I think I've made enough passes over that they have been flattened and they're not sharp and spiny, and they don't hurt anymore. And there are others that still have more to say, but I haven't really figured out how to let them say what they need to say to me, but it's endlessly recursive.

Emily Silverman  

Have you been writing through this process?

Rana Awdish  

I went back to writing after a recent cancer diagnosis, and that was important, because there was no way not to be in my body, like cancer is such a interesting existential and bodily threat where you have to do this weird actuarial calculation of "I'll leave this on the altar of sacrifice so that I can have this much more time. And this is the body part that I will donate in deference to this cause." But it's also still you. It's not that you're being invaded by bacteria. It's not some external threat, it's like your own cells. And so it felt so intimate and personal, and the experience felt so embodied that it felt like a time to write again and rather than reconstruct myself on the page to actually access what was really there as a way to inform the process. I know they sound similar, but in my head, they're very different. One is having agency over what you put down, and the other is more a process of revelation and just allowing it to surface and being passive in a different way, and it's been helpful.

Emily Silverman  

Yeah, the hero's journey and the quest journey. 

Rana Awdish  

It's a lie. Emily, it's a lie.

Emily Silverman  

Well, you write here that the questions that pulled you back to the page have been endlessly recursive. Whenever you thought you'd found an answer, there was always another question waiting right behind it, always finding yourself back at the start, albeit with a slightly altered awareness. The questions were so dominant that halfway through writing, I started to think that the answers weren't mine to find. I had to accept that I was writing a book about growing into the space that the questions made available. A beautifully warm, wild space that is also somewhat challenging to inhabit. And then you say the questions led you deep into the rich, earthy, sometimes messy substrate of healing. So is it's more of a probing way of writing, a more exploratory way of writing, not writing to find out so much, but you are writing with questions. What's the difference in posture as a writer?

Rana Awdish  

There was an experience I had early on, after a surgery that was relatively recent, where I woke up in my bedroom, very much in a panic attack, like an episode of PTSD, where I didn't know where I was. I didn't know if the pain I was having was post op pain or the pain that was going to lead to surgery, I was just completely disoriented, and I drew on every resource that I could to pull myself out of it. I remember trying to use context clues, like the bedside table, I remember trying to listen for the sounds. Everything was going so slow, and I just felt stuck in this loop, because my body was dominating my awareness. It had stored all this information, and I couldn't access any rationality, and so I had to settle into that sensation. And working through the re- experiencing of all of the bodily trauma in real time was such a dark and difficult thing that there's no way to write about it with any clarity or even sequencing. It's just kind of a mess, but you come out the other side. And so what I really hoped to do was just illustrate that while possible, it's incredibly messy and incredibly hard, and it takes you to really dark places and not to refine it back to something that's accessible, even because it's not. It's this complicated, messy, intertwined, nebulous thing, and yet we come out the other side, being honest about that. You know, I'm told I'm vulnerable a lot, and that's true, but we all. To show what we know we can show without having it dismantle our own healing, and it's still measured. There's still elements that I keep to myself. There are things that are more intimate, that I don't share. I'm aware of what I'm putting out, and it's a different kind of vulnerability to put people in the moment of your panic and just paint a picture of it and let them be in it with you without having the answers. I think I always felt like if I was going to take people somewhere, I had to have a way to get them out. And with this, it's a little bit more like maybe this is what it is, and that's okay.

Emily Silverman  

You were joking earlier that the hero's journey is a lie. And you have this friend, Tiffany, who has cystic fibrosis.And you wrote in this email to me that Tiffany had always found the hero's journey to be too contrived to be believable, and would tell you so. And she urged you to consider what your body might need from you, instead of focusing on what you might need from it. Tell us about Tiffany. Who is Tiffany? How did you meet? Tell us about your friendship, and then tell us about what you've learned from her.

Rana Awdish  

She is someone that I met when we were both asked to give a talk in Connecticut, and she had been born with cystic fibrosis and had two double lung transplants, which was really unheard of. I think she got her first one around the age of 18, and it failed really quickly. And in that space between when it failed and when she received the second set of lungs, she had to come to terms with what felt like her impending death, and she found a lot of love and acceptance there at the time, so much so that when she learned that she was getting allocated another set of organ, she was annoyed. And it was comical that she was annoyed about it, but there was something so true about that, and we just hit it off right away, perhaps because it was something she was born with, and she'd never lived in a healthy body. She had a degree of acceptance of her body that was just so exceptional, and it was this counter narrative to what I had felt, which was always trying to get back to something, always trying to recover, something that was lost, that was never possible for her. It was only ever learning to live with debility in one way or another, in one form of severity or another. She died in March of 2023 and she died not unexpectedly, but unexpectedly, as these things always happened. She'd gotten renal failure and was just unable to tolerate dialysis, and the end of her life was really difficult because of the uremia. She was having terrible hallucinations and delusions, and every step of the way, really in our relationship, challenged what I thought I knew, but especially at the end, because I had told people in the ICU that uremia was a pleasant way to die. And then hearing one of my best friends explain her experience of uremia, I thought again, how ridiculous it was that we thought we knew anything and could speak to it with a measure of confidence, and when I shared that with her with a lot of shame. She said, "Maybe you were describing death from your own perspective, a bloated but quiet patient dying wasn't a bother to you. It wasn't an emotional burden. So easy for you should be easy for me, right?"And she had this way of just cutting through all of the lies that I think we tell ourselves sometimes in medicine, and helping me to understand how much we don't know and yet, how much we assume. And I don't mean to say that it was one sided. We nourished each other in different ways. It was rewarding to her, I think, to see a doctor struggle so much with the doctor things after seeing this for near of just professionalism forever and the vulnerability was something that she was proud of for me, and she was very quick to call me out on my bullshit. Those are my favorite friends. Who were like, "This is what I love. Now you're lying to yourself. Let's talk about why you're doing that. What's the hard thing you're not facing?"

Emily Silverman  

You describe Tiffany as having an exceptional comfort in her body, or relationship to her body, understanding of her body, sense of embodiment. Can you bring us into that some more?

Rana Awdish  

What felt exceptional to me was that she wasn't waiting for anything to live in it and whatever place she found herself, whether it was post op in the hospital, whether it was needing a feeding tube or a port or a dialysis access, she was figuring out how to live now with as much joy as she could. She loved ballroom dancing. If she could dance, she would dance, even if it was only for a little while. If she couldn't dance, she would still get dressed up and go to the place where she would dance and watch Dancing, and I think so often we delay things for some future state. Certainly I did, because I always had that sense of sick or well recovered or not. And that lesson that now is all there is, was really something I needed.

Emily Silverman  

I was speaking to someone recently who was born with pretty severe congenital heart disease and growing up in childhood, was told again and again by doctors that he probably wouldn't live very long, and now he's an adult and has had a lot of different medical things done to him. But we were having this conversation, and it just got me thinking about what you said about now is what we have like, if you told someone, "You don't have very long to live", you would imagine maybe that person would snap into like YOLO mode, like looking at the bucket list, trying to live in a way of joy and all of that. But then when you unexpectedly get more time, it is a different way of being. There's planning. We had a story here on The Nocturnists about somebody who got a brain tumor diagnosis, and then it was obviously very sad, but the joke was that he got a phone call about his dental cleaning that was coming up in three months, and he, like, happily canceled it, and then ended up having to reschedule it. But just this stretching of time, like, how long do I have? Is it days? Is it years, when we don't know, or when we think we don't have time, and then we do, or we think we do have time, and then we don't, with all of that you've been through, have you hadany whiplash with that and not knowing whether to be like in the Yolo place or to be in the six month dentist appointment planning space?

Rana Awdish  

One of the things I notice about myself is that when I get acutely ill, I have joy in canceling things like, there's true joy like the dentist, of just being like, "I didn't want to do that anyway, and now I don't have to, because this thing that's more real and more serious has supplanted all of this trivia." And it's happened enough times, you know, I've had 10 major surgeries, if not more, that there's a pattern to it. And thankfully, I recognized the pattern and started to not build the things that I would be excited about canceling into my life. So for me, it was strange that, and this was another thing I talked about with Tiffany, that I could only give myself permission not to do things I didn't want to do if I felt like I had a valid excuse and not wanting to do it was not enough when I was well. And why was that? What was I trying to uphold? Who was I trying to please? What was making me feel that I didn't have agency in my own time if I was well? And part of that, I think, is there's this beautiful thing that happens when life gets pared down to just what's critically important in those moments where no one's fighting about stupid things, and you're not annoyed about someone who didn't take out the trash, and you're present for other people's emotions, because, you know, there's no other way to be. It's so beautiful and hard that it feels sacred and figuring out how to live that way more when I'm not acutely dying, being more present, being more open to what the people around me need, being less willing to put things on my calendar that I really just want to cancel. That's what I took away from all of this, is that I don't need the permission of illness to live that way now.

Emily Silverman  

When we were emailing you, talked about how over the last seven years, since the book was published, you havebeen thinking a lot more about your body and speakingwith your body and respecting the intelligence of the body and so on and so forth, and that's something I'm super interested in. But when I was reading your book, I noticed that a lot of that was there already, and I picked out a couple parts from In Shock. When you first feel the pain, you say, "I was certain something inside of me had burst. I knew I needed surgery, and that was immediate." And then at one point, you turn to your husband, Randy, you say, "If I could live another year or two, I think that would be really amazing." And then he says, "You're gonna live another year or two. Why are you saying that?" And you take a breath and answer, "Honestly, I don't know. Something just tells me I'm still gonna die." And he goes, "Well, tell it to stop." And you say, "I don't know if I can. It feels real. I'm sorry." And then you write, "Somewhere inside of me, the next catastrophe lurked, and I sensed it, the subtle signals, the imbalance. When I sat quietly and fully inhabited the space of my body, it told me things." And you weren't wrong, because later in the book, we learned that you had another tumor inside your liver that was at risk of rupturing, so maybe that's what you were in tune with. And then the third one I have is from the earliest weeks of that pregnancy. "I knew two things.I knew it was a boy, and I knew he'd be okay. I had no idea how I knew either of those things, but I told my husband less than one month in, I don't want you to worry he's going to be fine and I am going to be fine. I knew it the same way. I knew I would marry you from the day we met." So I love these examples, and I'm wondering how you think about them now, is this intuition? Is this interoception? What is this?

Rana Awdish  

Yeah, I really appreciate you pointing those out to me, because it felt very tentative, I think, at the time, and maybe when I talk now about trusting my body more. It's not that I didn't know things then, it's that I had devalued the knowing, because it wasn't something I could explain, and if I couldn't present data, then I was always worried it would be just a feeling, just an intuition, just a superstition, nothing that held water. And I didn't know how to bridge those two things. I didn't know how to say, there's not anything I can point to as data. And this is just as real to me as if I had a pile of data I could point to. When I was recently found to have cancer, I had a similar sort of experience where I was in clinic. One day, I was seeing a patient. We had a conversation. She left the room. I was thinking about how things hadn't really gone to plan, and in that space of reflection, this voice came up that was like, "I'll be dead in five years." It was like a friend that came to the door with a letter that got misplaced. It was like, "Hey, I have this thing for you. I'm just gonna set it here." It wasn't threatening, it wasn't morose, it was just, "I'm flagging this for your awareness. Do with it what you choose." And it was so vague that I didn't know what to do with it. It was in the pandemic. 

Emily Silverman  

This was before the cancer diagnosis.

Rana Awdish  

Yes, before I knew anything was wrong. And like all of us, I think in some way or another, during the pandemic, I was neglecting my health. I was fatigued. Who was really in their body during that time? I was probably ignoring lots of things, and it felt like my body wasn't going to let me ignore the things. It was going to make me more aware that I had been suppressing it, and I ran into that same paternalistic physician mindset. My first thing I did was I surveyed my body for proof that it was true. Couldn't find any. So then I was like, "Well, this is just a feeling. Feelings don't mean anything." I tried to negate it. I told myself that feelings that aren't anchored in data are delusions, and I was acting crazy. I dismissed myself the way physicians have always dismissed women and their knowing. And I caught myself in the moment doing it, and was so annoyed that with all of my thinking about this and writing about it and speaking about it, that I was still enacting these cultural scripts that were so ingrained in me that I wouldapply that lens to myself. And so in the end, I had to justsay, I don't know what this is, but I'm going to trust it and I'm going to get it checked because it feels true. And I think the difference for me now versus then isn't that different. I still negate these things. I still don't knowwhat's trustworthy that arises from my body and what isn't it's not all sorted. It's still messy and complicated, and I'm still trying to learn to trust it.

Emily Silverman  

I've been thinking about this too, and it seems to me, just like you said, it's not like we're all born without this intuition, and then later in life, we have to go out and find our intuition. It seems more like something that we're born with, and we have all the time, and it's always there in the background, but then it gets overridden or ignored or supplanted. And I'm thinking about this beautiful part from In Shock, where you're talking about subtext. And I actually asked this question to a playwright the other day. I interviewed a playwright. I don't know if that episode will come out before or after this one in our lineup, so audience forgiveif there's some discontinuity, but I was talking to her about it, because in playwriting, subtext is so important. You don't want your dialogue to be on the nose. You just kind of have to read between the lines for it to be compelling dialogue. And in In Shock, you're talking about this surgery you're about to have for hernia, and you're talking to the surgeon about the different types of mesh for this surgery, and you're doing all this research about this type of mesh and that type of mesh and the tensile strength and the quality of the material, and which is safest and which is most successful. And you're asking him all these questions, and he's very politely receiving all the questions and answering them very concretely and very directly. And then you say somewhere in the book that it wasn't really about the mesh. The subtext was, "I'm afraid", and how we as physicians sometimes when we're getting these questions from patients, you know, and answering them, and then the questions keep coming. Did I not explain it right? Like, did they not hear me the first time? But really, there's a conversation happening under the conversation, and I feel like we're all human beings, and we all know how to hear that subtext the same way that we all know how to hear something. Doesn't feel right in our body, but the microphone is just not turned toward that subtext at all. It's like we're so up here in theconcrete.

Rana Awdish  

Well, I remember, as you described, that the the magical thing that he did was like, not let me get away with trying to stay cognitive and to directly ask me, "I want you to tell me what you're most afraid of." And I was like, "Whoa, we're gonna talk about that? I thought we were just gonna talk about tensile strength." And when he asked me, I was able to tell him, but he went that extra step of decoding my questions and seeing the emotion behind it to me that's the work is growing our capacity for whatever will come with the question. So if I know that whatever my patient tells me when I ask, I want you to tell me what you're most afraid of, and I can hold whatever that fear is and offer whatever support is available, and that it won't deplete me. I can do that, but if I don't trust in my own capacity, then I'll never broach it. And something that small can make all the difference.

Emily Silverman  

You're continuing to practice. How are you now, as a decoder, you've been on the giving end, on the receiving end, do you find that you're able to just move faster, in a way, cut through the stuff that isn't really pertinent, and just really drive to the heart of a matter with your patients? I hate to frame it in terms of efficiency, really getting underneath and figuring out what they're really saying is that something that you find you have more ease with now with patients?

Rana Awdish  

What I think has changed the most for me isn't good or bad, but I think I've been able to release a lot of my own agenda in these encounters. And really be open to what the patient needs from me, instead of believing that I know what they need from me, which is absolutely what I was trained to believe, and that's opened different possibilities in terms of both what they're willing to share, what I learn about them as people, what goals we can set together. It just feels more like a co creation than me recommending a plan of care without knowing who they are. And that turns out to be a really enjoyable way to practice because I don't have to elicit an HPI. I can listen to the story they want to tell me. I can discern the details that I need for the HPI out of the story that they're telling me about their life. I can find what's important to them and know what makes their life meaningful. There's a lot of joy in that. It also took a lot of deprogramming, because I still had this feeling that my patient needed to make the right choice, because their choice was a reflection on me as a physician, and if I didn't somehow convince them to be on goal directed medical therapy right away, then I was bad. It was a value judgment. So what I find right now is I have this constant pull between the physician I was trained to be in the physician I'm trying to become, and they're in conversation, and sometimes it's loud and they're pulling me one way and back, but I at least know where I'm trying to go, and I'm willing to stay on that path, even if I get some pushback.

Emily Silverman  

Yeah, there were some insights in In Shock about the way that we're trained that I thought were really on point. For example, you wrote, "The resident is practically giddy as he describes the splinter hemorrhages and osler's nodes. His enthusiasm was the result of reading and hearing about such findings only to finally see them manifest in an actual patient. The disease states were exalted. They represented the mission and the destination. Like explorers, we suffered in pursuit of them, sometimes spending years on their trail. I saw the team now with their brains laboriously imprinted with sheets upon sheets of the clinical features and laboratory findings of every possible condition, superimposing these sheets like transparencies over their patients, searching for a best fit. Those sheets were the filter through which they viewed the world. The patients were placeholders, positions in space where the diseases would land." And then, I think later you put it more simply, and you say, "The physician is trained to have a relationship with the disease, or with the disease template, or with the illness script, more so than the person. And that's definitely something that I feel.

Rana Awdish  

And is that a rewarding way to be? Is that really all that's available to us, or is there both? Is there? Yes, we get to interact with these conditions that we've studied and that we've wondered about and hope to cure and are fascinated by and the people that hold them are actually the most fascinating thing of all.

Emily Silverman  

We got into this conversation about subtext and doctor patient interaction, but I do want to circle back to the dialogue between you and your body. So you get this message, a non threatening, neutral, maybe even friendly, message, that says you'll die in five years. And then you learn that you have cancer. Were you like, "Oh my God, how did I know?" Or how was that?

Rana Awdish  

It took some time to find the cancer. After the message, I went looking in the places that I thought it would be. I was sure it would be in my liver, because my liver had been exposed to so much radiation, and I'd already had those two adenomas resected and they can be pre malignant. And it just made sense. And at the same time, I was like, "That's not where I'm gonna find it. But objectively, I know I have to look there first. That just makes sense." And so it was a little bit of a fishing expedition, and when we found the mass, which ended up being breast cancer, it was really interesting, because everyone around me was like, "Well, let's just hope it's nothing. Let's hope the biopsy comes back benign. Let's hope it's fine." And I felt in opposition to that. I just wanted it to be what it was. I felt a kind of reverence that my body had led me to it, and I wanted to honor the fact that it felt true to me. And that was a strange time of being so ahead of people in my own acceptance of it because of this awareness that I felt weirdly isolated. The other strange thing about cancer is how you know, if you have a ruptured hepatic adenoma and fulminant shock, there's not a support group for that, right? There aren't people who get together on Tuesday nights to talk about it. Everyone has some experience with cancer. People can stage it in their sleep. They know what to recommend to you, their acupuncturist, phone number. It's so just a part of our culture that it almost felt like I couldn't have a unique experience of it, because it was all too known, and I found myself missing my rare diseases. And that was also difficult, because when something's known like that, people have ready questions, are the lymph nodes positive? What's your receptor status? And I had this sense of, you know, I'd already been so public about my illness, why was I then not going to talk about this? What was that line? So I would answer those questions and literally watch people staging me and estimating my mortality as they looked at me. And I thought, "This feels weird. I'm gonna stop doing this." But that was another point of learning for me that you don't owe people answers to questions because you've answered previous questions. You can carve out whatever space you need in real time and change the rules of the game anytime you want to. And in the end, I felt a lot of gratitude that something in my body had alerted me to go looking and identified it at a point where I won't die in five years. And I saw this resonance with all of the technology that they would use during the process, like when you go for surgery, and they inject the mass with radioactivity, and they map where it spreads to, and then they listen with this invisible device. And I thought, "Yeah, you're doing what I did. You're pointing the microphone at something you can't hear, and that's what we all do." It's just that's accepted, and sometimes it's not as accepted.

Emily Silverman  

I want to end on a note that I don't know if it's playful or dark or both, maybe it's both. So you wrote in an email to me that living through what you lived through felt nothing like a hero's journey, and in fact, instead, was akin to a very dark fairy tale. And In Shock, you wrote that when you couldn't sleep, you painted, and you painted what haunted you. And I noticed that you seem to have this joy inside the darkness. You do up Halloween, you decorate you and your family, dress up, and reminds me of Tim Burton like Nightmare Before Christmas. And a lot of your paintings have this too, thiscircus, dark joy. And so I was wondering if you could speak a little bit to that sensibility. Is that something that you had your whole life, or did that come later, after these experiences? And is that a place to play for you?

Rana Awdish  

I love that you refer to it as a place to play because I think that it's been a process of befriending it. And I first started painting when I just was recovering from the first worst illness, and was basically bed bound and couldn't do anything, and my vision was terrible, so I couldn't read. All I could really do was see color on a canvas, and so that's what I did. And I was so deep in it that the only thing present for me to paint was my nightmares. That was all I had was okay, I'm drowning. Let's paint a girl who's immersed in water and trying to rescue herself with this pile of books. And that was what was available to me. And something kind of wonderful happened with that, because the feelings were coming on so fast that I would create something, a representation of that feeling, and then I could look at it later and be like, "Oh, it passed." That was a moment, and I wouldn't even remember that feeling, but that it's represented there now. And then there's another feeling, and it's pinned to the wall like a butterfly, like you're collecting them, but they're removed from you. And that was a form of processing when I didn't have language and I didn't have a construct that I could superimpose on my experience, I could see that things were temporary. They moved through me. They could even be beautiful when they were scary. And that experience of learning that through the art felt like play, as you said, it almost desensitized me to some of the hard things. It diffused some of the emotions, and it allowed me to go deeper into them where I might not have before, because it made it safe. I sometimes think that that process was still a way of containing the hard things. It was still like giving them a space to live outside of my body and not really allowing them to breathe, but containing them in the same way a book can contain them or a talk at Grand Rounds can contain something and not let it change. And so my interest now is really in accessing things that allow what's in my body to change shape and not be static.

Emily Silverman  

So instead of a painting, would it be... what?

Rana Awdish  

I'm engaging a lot more with movement than I have before. It feels important, not just the breath work movement, but the almost walking meditation of it, the allowing the thoughts to come as you're moving and allowing your body to move differently with the thoughts. Yoga has always been a place of healing for me and using yin yoga, where I hold these uncomfortable postures for longer periods of time, and just try to soften into that rather than tell myself a story about it, or think about how tight that muscle is, but find space for it. That's another way that it changes something in me. I'm always looking.

Emily Silverman  

I just keep thinking again and again about how embodiment is so important. In my experience, doctors tend to be relatively disembodied. I think what you said earlier that we're just so up here in our cognition and so some of these things like movement and having conversations with our bodily intelligence, whatever that looks like. I think athletes have this too, like the level of bodily intelligence in somebody like Simone viles just knowing where every part of her body is at every moment. You know. I'm sure it bypasses her cerebral cortex, and all that coordination is just happening at lower levels of the brain, but I can't wait to read this next book. Like you said, the earthy, messy substrate, rooted in the body, rooted in the flesh, rooted in the earth, rooted in stuff, in soil, in substance. It's just substrate. It's exciting. And do you have any teasers on the book. Is it still early stages? Or might we have it soon? Or what's the timeline?

Rana Awdish  

I think sometime in 2026 is probably true. I've integrated all of the voices that I felt like I marginalized. I feel like I told In Shock in my most salient physician voice, because I wanted the story to be heard. And here I'm like, these are the other aspects that have been just as healing for me, including a lot of art, which is so much of what we don't talk about on the other side of the discharge, the things that really do bring us back to ourselves.

Emily Silverman  

Well, I think that's a wonderful place to end. This has been such a wonderful conversation. I love being in your presence, and can feel your presence. It's palpable even through a zoom screen. So thank you so much for coming to speak with me today Rana.

Rana Awdish  

Thank you, friend.