April 5, 2007

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Final Exam: A Surgeon’s Reflections on Mortality, by Pauline W. Chen (Knopf, 2007, 217 pages plus notes etc.)
Reviewed by Lisa Parsons news@hippopress.com

We all need to reflect on mortality, and who better to join in that reflection than someone who’s groped around in the chest cavity of a living human? And been granted license to pronounce the moment of death?

Pauline Chen, a highly successful surgeon, explains in Final Exam how doctors, herself included, must overcome the natural human aversion to death in order to do their job. You’re not going to get far in medical school, never mind residency, if you can’t handle being around death.

And yet doctors can be worse than anybody at handling death.

Surrounded by it though they are, doctors are deeply trained to avoid death at all costs. Their training takes the natural human aversion to death, which if anything they might already have extra helpings of (why, after all, are they in this business?), and enshrines it in their psyches. Doctors become like robots programmed with one instruction: Don’t let anything die.

That’s a valuable thing, for which we pay Chen and her peers highly and thank them profusely. Without their work, many of us would be dead who prefer not to be. We owe them everything. (That point is my own entirely; Chen doesn’t go there.)

Yet we pay a terrible price for that success. And that is: when it comes time to die, when there’s no way around it, your doctor might be nowhere to be found. The one person you thought could handle it, the person you expected to have special insight, is missing. Surgeons, Chen reports, will hastily usher a lost-cause patient out of the O.R. just so the death doesn’t happen on their watch. Doctors learn to treat death as something they are far above, separate from, immune to, something essentially foreign even though it lives in their midst. Something they simply refuse to accept. Once they know you’re going to die, they move on to a patient they can actually (as they see it) do something about.

Society-wide, we all yield to the desire to shrink death to manageable proportions. Thus we have doctors pronouncing people’s time of death down to the minute, when in fact dying isn’t nearly so precise. Says Chen, “[It] is this belief — that death is a certain, discrete event completely distinguishable from life — that cripples us most when we are deciding about end-of-life care.”

And crippled we are. You know this.

One of the best parts of the book is when Chen describes her own apprehension about getting close to dying patients or friends — her difficulty in sitting with them, her hesitancy to tell them all she knows (do they want to hear it?), her procrastinating on sending them cards — it’s a relief to see how doctors, despite their place on a well-earned pedestal, are like the rest of us.

Don’t let anything die, indeed, and yet, “When asked what they would request for themselves if diagnosed with a terminal illness, the overwhelming majority of doctors choose to limit or withdraw life-sustaining therapy.” It’s a conflict that needs airing out, and Chen’s book is a good start. She points to hope in the form of new training programs and broadening attitudes. Put simply, none of this is easy for anybody, but it’s worth the effort.

Final Exam is a fast read but with plenty to stop and think about. It’s essentially a series of personal stories from Chen’s experience with patients, colleagues, brain-dead organ donors and one special cadaver: in other words, a book full of insights most of us would otherwise never have access to.

Pauline Chen was UCLA’s “Outstanding Physician of the Year” for 1999 and now lives near Boston. A+