One of the saddest moments of my medical internship occurred at the end of a 30-hour shift. Along with my attending physician and supervising resident, I entered the room of a previously healthy middle-age man who had developed seizures for the first time in his life. His brain scan showed multiple spots that likely represented cancer. After introducing himself to the patient and his wife, the attending doctor, a gray-haired man in his 60s, took a step back toward the door as he dropped this bombshell: "We saw something on your scan, it doesn't look good, so we'll have someone else come by to talk about it with you later." Before anyone could utter a word, the doctor was out the door, never to return again. The resident and I looked at each other, bewildered. We told the patient that we'd be back after finishing our rounds, but caught up in the scramble to treat acutely ill patients, we didn't.
According to Dr. Pauline Chen, a liver transplant surgeon, all three of us failed our "Final Exam," the term she uses to describe the test physicians face to act compassionately as they lead patients through the process of death and dying. Her debut effort, "Final Exam: A Young Surgeon's Reflections on Mortality," continues in the tradition of physician-authors such as Sherwin Nuland ("How We Die") and Jerome Groopman ("The Measure of Our Days"), as Chen explores the tension doctors face in meeting the emotional needs of terminally ill patients in a profession that encourages them to depersonalize dying. Using her own story as the guide, Chen urges her fellow physicians to connect with patients at the end of life by "recognizing our own mortality and our shared humanity." To this end, Chen delivers a deeply moving and well-constructed work.
Chen begins by recounting her initial experiences with death as a medical student -- the cadaver dissection, the first resuscitation, the first pronouncement -- showing how the idealism with which she enters medical school is systematically chipped away by prevailing traditions of her training. In this model, aspiring doctors are encouraged to disengage emotionally from patients so they can deliver more objective care, and to pull away from death because it is seen as a failure. Initially, Chen adopted this state of detachment. As she advanced, gaining more autonomy and time for reflection, she realized that this approach did not result in better care. It was, instead, an ineffective way to reduce her own anxieties about death.
Over time, she shook off these "learned responses," to provide dying patients and their families with something she calls "greater than cure" -- compassion and comfort. Chen's personal transformation is especially resonant as she sets it against the backdrop of broader changes in medical education aimed at teaching physicians to be more attuned to the needs of dying patients, such as the widespread creation of specialized programs in end-of-life care over the last decade.
Throughout "Final Exam," Chen deftly weaves poignant anecdotes about former patients, friends and family members with more academic discourse on broader issues in medical education and end-of-life care. On the academic front, her historical look at cadaver dissections is sure to delight fans of the CSI television franchise. But Chen is at her best when exploring her own experiences with patients and family members. The passages on the death of her first patient, the protracted death of a 2-year old child with liver failure, a young man with liver cancer, and that of her aunt from kidney failure are memorable.
"Final Exam" does have some omissions. Most notable is the absence of any mention of formal religion, a subject that undoubtedly pervades any conversation about death for large numbers of people. There is also only scarce mention of physician-assisted dying, a controversial issue that, thanks to the infamous Dr. Jack Kevorkian, was at its peak as a hot-button issue during her surgical training years in the 1990s.
I also would have been interested to know whether Chen feels that the influx of women in medicine has influenced the profession's evolving approaches to dealing with death. Such a discussion would have helped further distinguish her work from the writings of other physicians in this area.
Nevertheless, Chen's work is a valuable addition to the body of narrative medicine publications. As I finished her book, I could not help but think back to the patient that my attending doctor clearly wanted to avoid. Chen would contend, and I would agree, that his behavior was in large part related to feeling powerless about the patient's prospects for treatment. At the time, I attributed my actions to the stress of multiple patients and sleep deprivation. But those were convenient excuses: I am disappointed to admit that it was more about my own discomfort with the patient's illness than anything else.
But over the years, I have made a similar journey as Chen. About two years after my experience with this patient, I was consulted to perform a psychiatric evaluation on a 40-something man. Before I could interview him, he suffered a massive stroke that left him in a coma. As a psychiatrist, I had no further role in his care, but instead of moving on to the dozen other patients I needed to see, I spent the next half-hour listening to his mother and sister talk about his life. They wanted to make clear that he was once vibrant. Weeks later, I received a call from the man's sister. She said her brother had died. She thanked me for the time I spent with them, saying it helped her and her mother begin to grieve his loss. All I had to offer them was my presence on a busy day, but that alone had made a difference.
As Chen states in the book's conclusion: "that honor of worrying -- of caring, of easing suffering, of being present -- may be our most important task ... and when we are finally capable of that, we will have become true healers." True indeed.
(Damon Tweedy is a physician at Duke University Medical Center.)