Monday, November 1, 2010

"Final Exam" by Pauline W. Chen

Okay, I am probably late on this one since the book was published initially in 2007, but I have finally had a chance to read Pauline Chen's "Final Exam: A Surgeon's Reflections on Mortality(Knopf, 2007; Vintage, 2008).

Dr.Chen is a surgeon who does both liver transplants and liver cancer surgery.  Most recently on faculty of UCLA department of surgery, she speaks nationally and writes a column for The New York Times.  

Her book, as the title implies is a autobiographical reflection of her experiences regarding death; beginning in medical school and moving through various training periods. We in palliative care, of course, deal with death frequently, thus reading this book you will surely find things that resonate with you as well as things that frustrate you. 

Her writing style is very engaging in its authenticity and narrative form. I read about patients that could easily have been people I have taken care of in my own training. The honest insight into her thoughts is refreshing. I enjoyed watching the transformation of her own avoidance of death, to a timid acceptance of death.

There are fundamental ideologies that she depicts that are very entrenched in our medical system as the following quotes illustrate:

"Along the way, then, 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.....By evading death, we miss one of the best opportunities for us to learn how "to doctor" because dealing with the dying allows us to nurture our best humanistic tendencies" (p95)

"Over time we come to believe so deeply that sublimating our fear of death makes us better doctors that some of us will skip around the very word during our conversations with terminal patients."(p205)

She records poignant questions around the idea of when to stop curative measures, and when care becomes more about doing something "to" someone instead of "for" someone in vignettes about Sam, a young man with brain mets and Max, and infant born with gastroschisis who required a liver and bowel transplant. Having had these conversations with people, I found myself wanting to answer Sam's wife when she wonders, "When do you know....when you have done enough?" (p145)

Because Dr. Chen was so honest in recording conversations I at times felt a surge of agony as prognosis questions were avoided. One example of this follows as she talks to one of her liver failure patients:

"Your liver is struggling" I said. But Franks's liver was not struggling; it was failing. I knew that in the next few days he would likely fall into a coma and die....I could not bring myself to describe that outcome." (p187) 

She ends her conversation with a hopeful remark about checking the labs tomorrow to see if they improve.
It was moments such as those I wanted to jump into the pages and say " can do it... you can be honest to Frank in a compassionate way!"

The final story is I suppose the transformation Dr. Chen makes. She recounts a patient with cholangiocarcinoma who wanted to die at home. As he gets sicker and she realizes his prognosis, she allows him the decision to decide his outcome, whether to head to the ICU for more invasive interventions or head home to die.  There is no surprise that he opts to go home. I found it interesting that still, in the final paragraphs of the book that she continued to struggle with his death. She closes out the book with these words: 
"I began to speak, saying what I always did with grieving loved ones. I wish I could have cured him, I wish I could have done more....It was then I realized that I had done more. I had comforted my patient and his family. I had eased their suffering, I had been present for them during life and despite death." (p211)

If I had one wish about the book, I would have hoped to read more about palliative care. In so many of these examples I longed for their presence to offer guidance in communication and discussions about goals. While it is refreshing that Dr. Chen is being transformed as a physician to have these talks in a compassionate way, the truth is, most health care workers still find themselves trapped in the ideologies about death and prognosis discussed in the beginning chapters. While it is lovely to envision a medical education system that trains up physicians comfortable with death, it remains an ideal at best.  In the meantime, let's get those palliative care teams involved!

Overall, this is a book I would absolutely recommend; an engaging narrative that we can all identify with!  

3 Responses to “"Final Exam" by Pauline W. Chen”

JerseyRN said...
November 1, 2010 at 4:49 PM

Dr. Chen spoke at our facility for Doctor's Week shortly after her book came out in 2007. She was a thoughtful speaker, and an eloquent writer. Good book.

Wendy S. Harpham, MD said...
November 2, 2010 at 6:27 AM

As a physician/survivor/writer, I agree with every point you make in your review. I, too, found Chen's book one of the best of its genre.
With hope, Wendy

Wendy S. Harpham, MD said...
March 16, 2011 at 11:53 PM

As a physician/survivor/writer, I agree with every point you make in your review. I, too, found Chen's book one of the best of its genre.
With hope, Wendy