Customer Reviews

Final Exam: A Surgeon's Reflections on Mortality

5 star:		(40)
4 star:		(10)
3 star:		(3)
2 star:		(2)
1 star:		(1)

 

 

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)

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.

"I think it's like Dr. Courtney M. Townsend, a legend in surgery and a personal hero, recently told me. "We have two jobs as doctors: to heal and to ease suffering. And if we can't do the former, my God we better be doing the latter." Pauline Chen

A few years ago I was part of a poetry group of medical providers. We shared poetry written by or for medical providers that described our work. Most of these poems as it turned it were about the dying, the dead or end-of-life. Our professions had a need to share our profound feelings. Since that time Palliative Care has become a recognized service in many hospitals and communities. Our patients need us and we need each other to share our grief.

Pauline Chen discovered once she was house staff that pronouncing a patient's death was part of her job, the first 'code blue', the first agonizing long death on an intensive care unit, and the day to day life and death of her patients were taking a toll. She was taught it seems to hide her feelings, but then they would not go away and what was she to do? She had an eye-opening experience with a physician who stayed with his patient while he was dying and she realized 'this is what my job is all about." As a transplant physician, Pauline Chen realized that her life and death immersion in very ill patients brought her closer to death than life. As she stated, "zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate." She gives us many examples of her patient experiences and how other physicians reacted to their patient's deaths. As she so eloquently says, " That honor of worrying-of caring, of easing suffering, of being present- may be our most important task, not only as friends but as physicians, too."

"Exercising personal autonomy around one's death is no simple matter today -- especially in settings of ever-more sophisticated and fragmented medical care. As Pauline W. Chen points out in "Final Exam: A Surgeon's Reflections on Mortality," the medical profession bears a good measure of responsibility for this dilemma. But "Final Exam" is neither an angry rant nor a bloodless treatise about medicine's failings. By sharing stories of her own maturation into a healer as well as a technically skilled doctor, Chen in this fresh and honest memoir engages and educates on many levels. At the same time, the author's principal goal -- to hold herself and fellow physicians accountable for providing better end-of-life care -- is ever in view." Claire Dunavan

My role in my profession is to help my patients with their living through their dying. This would not be possible without my team mates and colleagues. My best friend, with whom I share each patient death, found this book and told me about it. Thank you. Pauline Chen has written a book that should be read by all medical providers. It is indeed a good thing to be compassionate and to be there, physically and emotionally with our patients. Highly Recommended. prisrob 3-04-07

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?

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.

"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.

Dr. Chen's book helped me as medical student's spouse, and I will recommend it to so many other folks because of how important I believe it to be. I believe this is a critical read for those directly or indirectly, as we all are I guess, related to someone in the medical field.

My wife is in her third year of medical school - the kinder, gentler medical school, with restrictions on the amount of hours that the hospital can officially work the students. However, there are still the studying hours and they "worrying hours" and sometimes in the midst of all this I feel invisible. I have to believe, as much as she does, that she is doing the right thing. When she comes home feeling so inept, I have to tell her to keep her head up and know that I cannot completely grasp what she is going through.

Dr. Chen's memories of memorizing medical terminology "like memorizing the phone book" sound pretty much like what my wife described in anatomy. The demands of the school and the profession are extremely high, and then each doctor-in-training places higher demands upon his or her self. I see what a difficult board or exam does to my wife, and I wonder how she will ever survive battles against bureaucracy and malpractice lawyers. I see her struggling to keep her self confidence and I preach to her that she cannot let her "perceived incompetence" undermine her dreams. To read that Dr. Chen suffered from those same feelings of ineptitude and managed to become an accomplished surgeon and gifted writer is encouraging.

I chat with older physicians now, and their conversations remind me of some higher ranked military friends who claim that, if they were younger they would have a hard time re-enlisting with the state of the current system. Despite their doubts, I believe that they still would because, fortunately for us, they are "called." Thankfully the medical profession is blessed with doctors who want to improve the system and not let it beat them. Dr. Chen is one of those doctors and has done her profession a great service by writing this book.

p.s. Malpractice lawyers - please read this book

Doctors train to save lives but the blunt truth is that many of them will spend more time in their careers facing death. Dr. Pauline Chen's musings on death, mortality and end of life medical care are moving, especially to anyone who has waited for three hours in an HMO waiting area in order to see a preoccupied doctor for five minutes.

Dr. Chen traces how doctors cope with death through business, avoidance, and by denying their own mortality. She writes with a grace and self-revelatory insight that exposes a physician's deepest fears and concerns.

Some of the vignettes of patients she had treated - the ex-Connecticut cop, the former anthropology professor with liver cancer - brought tears to my eyes. This is a compassionate look at end of life care that can prompt the reader to reflect on their own mortality. Doctor. Chen does not discuss God or spirituality but it is difficult to read the book without considering that life force and pulsates within us.

Surgeon Pauline Chen's "Final Exam" is a searing indictment of the way in which the medical establishment often fails to provide palliative care for dying patients. The introspective Chen puts her own behavior under the microscope as well; she admits that she has avoided giving her dying patients the time and treatment that might have made their final days more meaningful and less painful.

Medicine is "a profession made attractive by the power to cure," says Chen. Few medical students yearn to care for the dying. However, as the population ages, more and more people will pass away after a prolonged illness. Physicians play a role in "shepherding the terminally ill and their families through the intricacies of the end." Chen calls this ability to help guide patients through end-of-life illnesses their "final exam." Unfortunately, most doctors, until now, would earn a failing grade.

There are a number of obstacles that prevent physicians from helping and comforting the terminally ill: many physicians (and laymen) have an aversion to death; some doctors believe that getting too emotionally involved with patients may lead to a loss of objectivity; since medical schools have traditionally avoided discussing end-of-life care with their students, most doctors are poorly prepared to deal compassionately with their dying patients. Fortunately, new programs are being established across the country that, one hopes, will help doctors treat both the living and the dying with equal skill.

"Final Exam" is divided into three sections: "Principles" describes how medical schools teach their students to approach death; "Practice" shows how the clinical work that a doctor performs each day influences his attitude towards death; "Reappraisal" is Chen's look at some hopeful signs that end-of-life care is at last being taken seriously.

Chen culls examples from her fifteen years of clinical experience to illustrate her points. There is a haunting anecdote about Joseph and Juliette, an elderly couple who had been married for over fifty years. They were childless retired teachers and virtually inseparable. When Juliette developed an intractable pneumonia during a frigid Chicago winter, Joseph was bereft. He stood by helplessly while his beloved spouse deteriorated. Juliette passed away after futile antibiotic treatment, dialysis, and the use of a ventilator left her little more than a shell of her former self. Juliette's doctors edged away from her more and more as her condition worsened. When his wife died after nearly four weeks in the hospital, eighty-five year old Joseph shuffled off alone, with no one to offer him consolation or guidance. Juliette's physicians lost interest in her case when they saw that they could not save her.

"Preparing for death may be the most difficult exam of all, but it is one that will, finally, free us to live." What will help physicians pass this crucial test? There are some promising ideas that are changing the face of patient care. Specially trained doctors and nurses will routinely discuss diagnoses, prognoses, and treatment with dying patients and their families. When a patient is clearly failing, the medical team will provide palliative care to relieve the patient of her physical pain. The team will also discuss with the patient and her relatives what options they have to make her last weeks more comfortable. Although Chen's prose is elegant and heartfelt, "Final Exam" is not easy to read because of its bleak subject matter. However, it is necessary for all of us to be more aware of how we, as a society, have failed to treat our dying with the love and respect that they received when they were healthy and fully productive members of their communities.

"Final Exam: A Surgeon's Reflections on Mortality" by Pauline W. Chen is outstanding on many levels. Its purpose is to reveal what is wrong with the medical profession's attitude toward the treatment of terminally ill and dying patients. But don't expect an academic discussion; Chen makes this issue very personal. The book is a recounting of the many experiences in her own medical career--from medical student to transplant surgeon--that shaped and later changed her attitude toward care of patients at the end of life.

I had no particular reason to read this book--I am not a doctor, the parent of a doctor, or involved in any way with the medical profession. I just saw this book on the New Books shelf in my local library and checked it out. What is amazing is that I could not put this book down--I know that sounds so trite, but it's true. What grabbed me first was the wholly unexpected openness and honesty of the author. What grabbed me next was the beautiful clear prose. Here was a brilliant woman doctor telling me all about the many experiences in her medical career that shaped her current convictions about medical care at the end of life. But she was not just telling me about these medical experiences, she was turning herself inside out to reveal how she actually FELT about each experience. How many doctors have you ever heard talk to you about their feelings? This author brought me close to her heart--I felt like a sister or a dear friend.

I came away from this book with a far greater respect for physicians; especially all they have to deal with, physically and mentally, throughout their long years of training and practice. I also come away with a far greater appreciation for the human frailty of physicians, particularly when dealing with-end of-life issues. This is a profession that has to deal with far more than a normally allotted human share of agony, grief, and soul-searching.