Final Exam: A Surgeon's Reflections on Mortality

Towards the end of FINAL EXAM, author Pauline Chen describes harvesting organs from a brain-dead patient who bore a strong physical resemblance to herself. Soon afterward she began to write stories, mostly about her experiences with patients. When she took a creative writing class, her teacher was clearly impressed by the authentic quality of what Chen had to relate and told her, "Pauline, you have to write these stories." This book is the the completion and gathering of those stories. FINAL EXAM is an account of Chen's evolving understanding of what she could and couldn't accomplish as a physician and surgeon. She begins with a description of her "relationship" with the cadaver she was assigned in medical school and goes on to describe a number of patients who died under her care. It is gratifying that she seemed to learn something from each experience and was able to use these experiences to strengthen her skills as a caregiver. Also important to these stories are Chen's descriptions of her relationships with her medical colleagues (including nurses, interns, and medical students) and of the bonds she was able to forge in spite of the impossible schedule and stresses that are unavoidable in that profession. Each story is powerful and moving. And each story made me think about the kind of care I want to receive (and demand) as the end of my life approaches. This is a wise and gentle book. Chen's vision and power of expression come mightily close to the poetry found in S. Nuland's masterpiece, HOW WE DIE, a work Chen is familiar with and quotes from. One can only hope that many doctors will read her reflections and absorb their important message.

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.

"Final Exam" is humbling in at least two dimensions - producing greater respect for physicians (their knowledge and skill - both practicing medicine and handling grief and death), and reminding the reader that he/she is not immortal, and has over a 90% chance of dying from a prolonged illness - with plenty of time to reflect. Care at the end of life provides the theme for "Final Exam," and Dr. Chen takes us through her earliest lessons on death in medical school (her cadaver dissection - imagining the person in real life and covering up emotions with black humor, first resuscitation scene - failed, but wondering if she could do as well, and her first pronouncement of death). Then its on to professional medical practice experiences - eg. evading difficult discussions with patients and family, trying to avoid long-term terminally ill dying on one's shift and incurring subsequent paperwork, seeing the devotion of a spouse to his/her long-term partner, ramping up treatment in terminal cases - even though it made little medical sense (accounts for about 22% of all medical expenditures and usually simply prolonged patient and family suffering; avoiding lawsuits is a major reason, unclarity regarding who is the physician is another). Finally, it's on to Dr. Chen's experiences as a transplant surgeon - removing organs from those declared "brain dead" and then deliberately ending their lives, followed by hopefully bringing life to the donor-organ recipient.

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?

I read this book in one sitting! I HIGHLY recommend this fantastic read to anyone considering going to medical school, everyone IN medical school, and middle-aged readers who find themselves faced with the challenge of caring for aging parents. Chen's stories, told in a humble and genuinely caring voice, reveal the fascinating--and at times disturbing--realm of end of life care in the emergency rooms and operating rooms of American hospitals. Through her heartfelt accounts, beginning with her first dissection of a human cadaver in med school anatomy lab, through her practice at UCLA as one of the nation's top liver transplant surgeons, Chen tackles the difficult issues of caring for the dying candidly and honestly, often citing her own failures as a young doctor before making certain realizations about how to overcome the depersonalization of death required in medical school. There are also exiting scenes, such as her vivid description of tearing down the Californis coast in a helicopter at 3:00 in the morning to harvest a fresh liver from a child just recently run over by his mother's SUV. The stories are gripping and moving, heart-rending yet touching. Chen's writing is fabulous: caring and empathetic, yet clear and precise. The little book is easy to read. It should be required reading for first year medical students and premeds, since it not only is about death and dying and how to improve end of life care, but also offers a candid look inside med school life and the gritty, messy, day-to-day grind of busy teaching hospitals. Overall, a solid 5 stars, get this book today. -Dan (biology student)