Final exam A surgeon’s reflections on mortality

Pauline W. Chen. Alfred A. Knopf Inc. New York, New York, USA. 2007. . $23.95ISBN: 978-0-307-26353-7 (hardcover).288 pp.

One might have thought that medical education would equip physicians with the knowledge to treat disease as well as training in the art of comforting the dying. In Final exam: a surgeon’s reflections on mortality, transplant surgeon Pauline Chen shares with us the ironic reality that medical education and the culture of medicine eschew any confrontation with death. She chronicles the effects of a systematic depersonalization of the dying throughout her own medical education. Chen draws on her clinical experiences to explore how physicians avoid talking about death among themselves as well as with patients. In gripping accounts of real cases, Chen explores the limits of a medical culture that is so focused on curing disease that it has lost sight of its equally important role in helping patients confront death with dignity. Reading this book will enrich those considering a career in medicine, young physicians, and the public alike. Those contemplating a career in medicine will gain insight into the paradoxes of modern medical practice. Patients will better understand the struggles of physicians caught between a desire to cure disease and the limits of medicine and, one hopes, be encouraged to take a proactive role in directing conversations with their physicians toward the topic of death and dying.

Final exam is divided into three sections. The first section focuses on the transformative encounters of medical students with death — the experience of dissecting a cadaver, attempts to resuscitate a dying patient, and the process of pronouncing a patient dead. Chen reminds us of how little formal preparation medical schools provide for these formative experiences. In the anatomy lab, we are conditioned to suppress the fears and emotions engendered by dissecting a dead body so that we can learn. This is the beginning of a culture of avoidance. The second section explores the clinical practice of medicine and how the profession tries to rationalize behavior that seems inhumane. She confronts the fact that physicians avoid difficult conversations, overtreat patients with terminal diseases, and use morbidity and mortality conferences to transform death into an affirmative experience. Chen shares with us medicine as it actually is, not an idealized version of the profession. In the final section, Chen reappraises the situation and probes the possibility of a change in the way physicians approach end-of-life care. She reflects on the core problems that are responsible for our failure to confront death. Physicians and patients confuse medical intervention with hope, equating more treatment with love, and physicians see death as a personal failure. Thus, we continue to focus on cure even when there is little hope of meaningful recovery.

The most captivating narratives in the book are those in which Chen discusses her own shortcomings and mistakes: her relief as a medical student at not being responsible for sharing grim prognoses with her patients, her evasion of a former neighbor and friend who was dying of cancer, her guilt at having a patient she encouraged to undergo surgery die in the postoperative period on her watch. She shares with us how the pressures of medicine led to her own avoidance of difficult conversations. She became adept at “turfing” to others the challenging task of comforting the dying. Dodging discussions of prognosis and death, she knew that someone else would eventually take care of this aspect of a patient’s care. As a surgeon, she convinced herself that she could provide competent technical care without “lingering in the shoes of the dying.”

We learn through Chen’s experiences and her process of self-reflection. The power of positive role models is driven home when Chen learns from the example of a senior ICU physician who takes the time to comfort the family of a dying patient; witnessing this transformed her approach to end-of-life care. Before we can confront the suffering of our dying patients, Chen argues, physicians need to acknowledge our own mortality and our shared humanity.

Chen’s introspection provides a model for a creative method that we should seek to integrate into our system of medical education. The self-awareness that results from reflection on difficult encounters with patients should be transformed into an educational tool to develop and explore professional identity in medical schools. This process of self-reflection should be formally incorporated into medical education so that it can occur among a group of supportive peers. Our educational system needs to create a formal infrastructure for self-reflection and dialogue. Through this process, we may come closer to developing the sensitivity and character that we would all want in the physicians who care for our families and ourselves.

Final exam is a well-written book that reminds us of the complex and paradoxical reality of the medical profession. We who are given the sacred privilege of caring for the ill must continually confront our own human limitations if we are ever to become the kind of physicians we value.