Courtesy of SarahMcD
We stand under the bright, warm lights of the surgery room with young surgeon Pauline W. Chen. As the lights illuminate the hairs on the back of her neck, we watch her as she pokes a hole through the patient’s belly, into his diaphragm. Our fingers fuse with hers, as she clears away the cobweb-like tissues between the heart and the spine. Soon our entire arm has penetrated the body of another person. Between the transgression of the act and the reassurance of that warm space, we feel, as she does, the hardness of the vertebral bones on the back of the forearm. Against the tender skin on the underside of our wrist, we, too, are surprised by the strong, twisting contractions of the heart.
In Final Exam, Pauline Chen — a transplant surgeon who graduated from Harvard and Northwestern University’s Feinberg School of Medicine, and then completed her surgical training at Yale University, the National Cancer Institute, and UCLA — takes us on a journey many of us would unlikely experience on our own. We confront death, our fear of it, and the busyness with which we fill our daily routines such that we temporarily forget own mortality. Alongside Chen, we grapple with what it means when a loved one is terminally ill, how to assist them in their dying, and how to die best.
Why are we so bad at taking care of the dying? Convinced that she was going to spend her days, like the heroic doctors of her imagination, in “triumphant face-offs with death,” Chen applied for medical school only to discover that even the best schools would not prepare her to ace the “final exam”: knowing how to take care of the dying. To do that, she would have to learn to place herself in her patients’ shoes.
Collected as a series of evocative essays, Final Exam depicts Chen’s years of experience as a physician-in-training and practicing surgeon. The book is divided into three parts. In the first, Principles, Chen walks us through the halls of medical school showing us what she deems the essential paradox in medicine: that “a profession premised in caring for the ill also depersonalizes the dying.”
As she tells it, aspiring physicians face death — both metaphorically and literally — in the form of the cadaver they learn to dissect. Convinced that the information the corpse reveals will somehow allow them to overcome death, young medical students learn to separate their emotional selves from their scientific selves. They learn to view the dead human body, she writes, “not as ‘one of us’ but as ‘one of them’, a medical case to be understood but not embraced.”
Even the lexicon that physicians-in-training are taught — including terms like “sagittal section” and “transverse incision,”— serve to build that separation until emotional detachment from the experience has been achieved. “[Medical students learn to] strip away the cadaver’s humanity, and soon enough they are dissecting not another human being but ‘the leg’ or ‘the arm’,” she says. The transgression they are committing, through this manipulation of another human being’s body, is an intrinsically violent act, and yet the distress it causes is never addressed during the physician’s formative years.
In Practice, the second part of the book, Chen draws on numerous expert opinions and research studies to inquire further: Is it possible to change the way that physicians care for the dying?
Her question is hardly trivial. According to a series of studies conducted since the mid-1990s, a majority of physicians had no idea what their patients wanted in terms of resuscitation. Family members surveyed in these studies revealed that fully half of hospitalized patients who remained conscious at the end of their lives complained of moderate to severe pain at least half the time. Supported by the data, Chen furthers her thesis that physicians have become blind—both to their own anxieties about death and to the way that learned callousness has become embedded in the medical system.
As a result, Chen says, “we learn not only to avoid but also to define death as the result of errors, imperfect technique, and poor judgment. Death is no longer a natural event but a ritual gone awry.” For Chen, it is a physician’s rituals that allow him or her to evade death, literally and figuratively. “Concentrating on the ritual becomes [the] professional method of coping, an action that allows him or her to spend as little time as possible with the dying patients, concentrating instead on the treatment algorithm.”
But this obsession with doing, the susceptibility to “the intoxicating power of treatment,” isn’t only a physician’s error. As Chen asserts in Reappraisal, the third and final part of the book, family members and patients are equally at fault. “We battle away until the last precious hours of life, believing that cure is the only goal.” During life’s final, tortured moments, says Chen, we often inflict misguided treatments not just on others but on ourselves. Ironically, the promise of the nineteenth century—that the body was not just an irrational repository of disease but a potentially reparable biological machine — has become the curse of the twenty-first.
But what is the alternative? In spite of the challenges, Chen remains optimistic. Discussing the changes introduced to the medical school curriculum in the past years, she puts forth an answer: “The fewer the therapeutic options available, the greater your involvement with the patient should be. When there is no cure, there is still much to be done to alleviate suffering.”
Despite the fact that Chen’s subject is, undoubtedly, one of great intellectual and emotional weight, Final Exam never feels heavy because her arguments are woven into a narrative that is dynamic and deeply moving. Nowhere is that truer than in her description Juliette, an elderly patient of Chen’s when Chen was in her last year of medical school. In the days leading up to Juliette’s death, she was near-constantly accompanied by her husband of 51 years, Joseph:
“More and more Joseph fell asleep at his wife’s bedside, his head against the safety railing of the bed and his hand still locked on hers. He stopped noticing when I walked up to Juliette’s bed and even when I tried to make conversation. His cheeks began to appear unevenly shaven, and occasionally, a white rim of dried toothpaste lined his thin, chapped lips. Joseph’s smell changed, too; there was the faint odor of urine now laced in with the mothballs and musty carpets.
On the night Juliette died, Chicago was buried by one of the worst snowstorms of the decade. One of the senior residents called Joseph to tell him that his wife was unlikely to make it through the night. I know Joseph struggled to get to our unit. I know because the radio kept announcing that a salt shortage would prevent Chicago streets from getting plowed until the morning… I sat at the nursing stations in front of Juliette’s bed and stared at her monitors. The heartbeats began to slow, and the once regular waveforms took on a jagged irregularity, images of the last contractions of life. I knew that Joseph did not have much time to get to Juliette.”
Chen’s fellow surgeon, Atul Gawande, recently wrote a remarkable piece in the New Yorker discussing what medicine should—and shouldn’t—do to save lives. Readers who enjoyed Gawande’s take will almost assuredly appreciate Chen’s. With a more lyrical touch of the scalpel, her cuts are deeper. And to her credit, she neither sugar-coats death’s terrifying presence, nor shies away from letting readers see her vulnerability.
After performing, for the first time, the three-step procedure to pronounce someone dead, she is disarmingly frank: “I had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.”
Originally published August 31, 2010