Surgeons and mortality

Final Exam: A Surgeon's Reflections on Mortality
Posted 05/08/2007
Sidney Schwab, MD, FACSAuthor Information
Final Exam: A Surgeon's Reflections on MortalityBy Pauline Chen, MDAlfred A Knopf2007268 pagesISBN: 978-0-307-26353-7$23.95 US

Doctors have a problem with death. And surgeons, whose work is immediate and very public, might have the biggest problem of all. If there's tangible reward in an operation well done and successful, there is a palpable sense of failure -- toward the patient, colleagues, and oneself -- when an operation falls short of its aim. Death, the worst possible result of our attempts to heal, makes us turn away in shame, in sadness, and -- as Dr. Pauline Chen explains it -- in fear of our own mortality.
Dr. Chen transplants livers, thereby having chosen a career into which death finds its way on a regular basis. And, as is clear from her deeply personal and introspective writing, she has struggled to face it. Final Exam: A Surgeon's Reflections on Mortality is a deeply felt plea to all of us to turn away from turning away; to recognize that even when we've failed them, our patients need us, and that in staying with them to the end, resolution is a two-way street.
The realization did not come easily, and Dr. Chen shares her journey to understanding candidly, self-critically, and movingly. Evocatively written, intertwined with affecting and beautifully rendered stories of the people -- family and patients alike -- whose lives and deaths formed who she is, Dr. Chen's book takes us on her journey as if we were holding hands. (And lest the reader think the book is unremittingly heavy, there are flashes of humor and chord-striking tales of surgical training.)
There are ample citations of research on the subject of physicians' attitudes toward the dying, and of attempts to change them. But it's the stories that are most affecting. We meet Frank, a fellow New Englander and a retired cop. Too old for transplant when he developed a form of liver cancer, he wants his tumor cut out. No chemo for him. Dr. Chen tells him the risks of surgery, the odds, to which he replies, "I believe you, Doc. I really do, and I hear what you're telling me. There's a good chance I won't make it, but I need to do this... You'll be with me, right?" (pp. 185, 186)
The surgery goes well, but soon Frank's liver fails. Dr. Chen writes:
For the next week I forced myself to visit Frank twice a day. I watched his consciousness slip away, his family members become more and more enveloped in their grief, and my voice dwindled in their presence to breathy whispers. When I was with Frank I wanted nothing more than to leave; and when I was away from him, I thought of nothing but home...(p. 187)
After Frank dies, she finds no way to express her sadness, until she receives a note from his daughter telling of her father's affection for Dr. Chen, of how her spirit gave him strength:
I put the card down and felt a sudden wave of relaxation across my arms, surging up to my throat. It felt as if the cartilaginous rings around my trachea loosened for a moment and great breaths of air could at last pass through....and in the quiet of my office, began to cry.(p. 190)
In part, the book is like a confessional. She writes of Bobby, a young man with incurable liver cancer, and of Lou, the nurse who advocated for him. After a courageous struggle, Bobby lay dying in the intensive care unit, while his doctor refused to let him go. Lou urged Dr. Chen to visit her former patient:
She urged me again to talk to Bobby's wife, but I found other work to do... I remembered all of this when Lou brought up Bobby again that morning... I saw a tear forming, the rounded drop rolling over her lower eyelid and trickling down her cheek.
"Bobby died, you know," Lou said.... "He was dying, Pauline. He had cancer everywhere, and they still poked him and prodded him and thumped on his chest..." Lou's lips became thin. She put her index finger against my chest and rapped it with each word. "That is how Bobby died." (p. 179)
In this passage, we realize the writer's shame at not having saved her patient, enough that we can't help but think of similar instances in our own lives; but we also see the dawning realization of what she thinks her problem is and what needs to be done. Physicians, Dr. Chen believes, cultivate and maintain an exaggerated sense of their own immortality because they are used to fixing people. She writes about learning to harvest donor organs for transplant. "And by the time I had operated on more than sixty donors," she writes, "my own immortality was beyond question." (p. 197)
And so, she argues, we doubly dishonor the dying: Our own fears may lead us to continue treatment for too long and then to fail to be there at the end. In this, there may be room to criticize the book, although it may be too fine a point: Some doctors, if they disagree with this view -- that it's our own misgivings which lead us astray -- might find an excuse to ignore the real message. Yet Final Exam is so beautifully and convincingly written that it is hard to resist Dr. Chen's argument. Most physicians, for complex reasons, find it difficult to deal with the dying patient. And they need to find ways to do a better job of it. As Dr. Chen finds on her journey, and as she reveals to the reader, doing so is not only a necessity, it's as fulfilling for doctor as it is for patients and their families.