Final Exam: A Surgeon's Reflections on Mortality [Paperback]

Pauline Chen is a surgeon who does liver transplants. She is also a fine writer as FINAL EXAM - A SURGEON'S REFLECTIONS ON MORTALITY proves so well. She writes with both passion and humility about the contradiction she sees in the field of medicine: that doctors, who witness death so often that it should almost become routine essentially are no better at dealing with the end of life than their patients are. (She actually uses the word "dysfunctional" to describe many physicians' attitudes toward death.) She believes there are many reasons for this phenomenon. Doctors are trained to be healers; that is why most of them went to medical school. To lose a patient to death somehow is an admission of failure. Many physicians will continue aggressive but useless therapy for a dying patient to pacify the patient's family. Sometimes they fear litigation or they may continue treatment-- we can only hope occasionally-- for financial gain. But whatever the reasons, they are not good enough. The patient loses, but the physician loses as well the chance to do-- what Chen would call-- "something more than cure" and "nurture our [physicians'] best humanistic tendencies."

Dr. Chen discusses candidly her first experience with death, when she was a sophomore in college, of her maternal grandfaather. Then in medical school she spent 12 weeks with a cadaver: "My very first patient had beeen dead for over a year before I laid hands on her." She writes about her first patient to die and her inability to contact a dying friend. She confronts her fears about her own mortality when she is about to harvest organs (a procedure she had done eighty-two times previously) from an automobile accident victim and discovers that the donor is a brain-dead thirty-five-year old Asian American woman: "For a moment I saw a reflection of my own life and I felt as if I were pulling apart my own flesh."

This beautifully written book reminded me of another fine book by another physician, Abraham Verghese's MY OWN COUNTRY, an account of his treating the first patients-- most of whom would certainly die horrible deaths-- with HIV/AIDS at the local VA hospital in Johnson City, Tennessee in the 1980's. Both these books should be required reading for medical students.

When I finished Dr. Chen's "reflections," I thought of (1) how fortunate her patients are to have a surgeon so sensitive and so human and (2) wondered how many physicians would take time out from their busy schedules to read her wise words.

"I think it's like Dr. Courtney M. Townsend, a legend in surgery and a personal hero, recently told me. "We have two jobs as doctors: to heal and to ease suffering. And if we can't do the former, my God we better be doing the latter." Pauline Chen

A few years ago I was part of a poetry group of medical providers. We shared poetry written by or for medical providers that described our work. Most of these poems as it turned it were about the dying, the dead or end-of-life. Our professions had a need to share our profound feelings. Since that time Palliative Care has become a recognized service in many hospitals and communities. Our patients need us and we need each other to share our grief.

Pauline Chen discovered once she was house staff that pronouncing a patient's death was part of her job, the first 'code blue', the first agonizing long death on an intensive care unit, and the day to day life and death of her patients were taking a toll. She was taught it seems to hide her feelings, but then they would not go away and what was she to do? She had an eye-opening experience with a physician who stayed with his patient while he was dying and she realized 'this is what my job is all about." As a transplant physician, Pauline Chen realized that her life and death immersion in very ill patients brought her closer to death than life. As she stated, "zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate." She gives us many examples of her patient experiences and how other physicians reacted to their patient's deaths. As she so eloquently says, " That honor of worrying-of caring, of easing suffering, of being present- may be our most important task, not only as friends but as physicians, too."

"Exercising personal autonomy around one's death is no simple matter today -- especially in settings of ever-more sophisticated and fragmented medical care. As Pauline W. Chen points out in "Final Exam: A Surgeon's Reflections on Mortality," the medical profession bears a good measure of responsibility for this dilemma. But "Final Exam" is neither an angry rant nor a bloodless treatise about medicine's failings. By sharing stories of her own maturation into a healer as well as a technically skilled doctor, Chen in this fresh and honest memoir engages and educates on many levels. At the same time, the author's principal goal -- to hold herself and fellow physicians accountable for providing better end-of-life care -- is ever in view." Claire Dunavan

My role in my profession is to help my patients with their living through their dying. This would not be possible without my team mates and colleagues. My best friend, with whom I share each patient death, found this book and told me about it. Thank you. Pauline Chen has written a book that should be read by all medical providers. It is indeed a good thing to be compassionate and to be there, physically and emotionally with our patients. Highly Recommended. prisrob 3-04-07

This book is really compelling, Dr. Chen brings you into her world and her work with clarity and a terrific knack for storytelling.

Her love of medicine and her genuine appreciation for her patients as people, not just interesting problems, is extremely touching.

Ultimately, she asks questions that dont just apply to medicine, but to society as a whole. How can our secularized society and our culture do a better job of facing death and caring for the dying?