Surgeon Writes of Death, Dying in 'Final Exam' When Pauline Chen became a doctor, she was troubled by inconsistencies in the ways that fellow physicians dealt with the emotional aspect of death and dying. Chen tackles the subject in her new book: Final Exam: A Surgeon's Reflections on Mortality.
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Surgeon Writes of Death, Dying in 'Final Exam'

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Surgeon Writes of Death, Dying in 'Final Exam'

Surgeon Writes of Death, Dying in 'Final Exam'

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SCOTT SIMON, host:

This is WEEKEND EDITION from NPR News. I'm Scott Simon.

Doctors are supposed to heal and cure. That's what all their exhaustive training and extraordinary technology is for. Isn't it? But a lot of doctors' patients die. The most accomplished surgeries and treatments can keep death at bay, sometimes for years, but so far not defeat the disease they fight.

Dr. Pauline Chen is a doctor and surgeon who grew up in Cambridge, Massachusetts, went to medical school in Chicago, and began her practice in Los Angeles. She is now also an acclaimed writer. Her new book reflects on her own cases and experience with the ways in which doctors have to deal with death. Her book is called "Final Exam: A Surgeon's Reflections on Mortality."

Dr. Pauline Chen joins us now from the studios of member station WBUR in Boston.

Thank you so much for being with us.

Dr. PAULINE CHEN (Doctor, Author, "Final Exam: A Surgeon's Reflections on Mortality"): Thank you very much.

SIMON: You suggest in here it's not just the patients that have denial but sometimes doctors.

Dr. CHEN: Oh, absolutely. Death, I think no matter how you slice it, is a very difficult topic for all of us. It's very difficult to talk about. It's very difficult to even to think about. And while it is difficult for people who don't have to face it every day, doctors do. They say that the average resident will see 28 deaths per year during their training. And that's a lot and that's not even including the number of times that a doctor will have to deliver bad news to a family. So it's a very difficult topic.

SIMON: Hmm. Now, I dare say it would often be good news to patients to think that doctors have a sense of personal identity in their work. Because then they extrapolate that the doctor feels a personal sense of identity with their survival.

Dr. CHEN: I think that is true, that it is important that we identify with patients, that we consider them a part of us in some way, a part of our responsibility. I think that leads to better care. On the other hand, I think part of what leads to the depersonalization is the sense that if you can't cure your patient then somehow you've failed. And you've failed so deeply, personally, that it's difficult to face. And I think that leaves a lot of doctors to end up denying that their patients have terminal diseases, or just sort of ignoring it.

SIMON: Hmm. Early in the book, you have a gripping and vivid description of your first dissection. You noticed something about the woman's face muscles, the muscles, which made her smile, that touched me.

Dr. CHEN: Yes. Our cadaver died of ovarian cancer and so much of her body, much of her musculature, was really sort of atrophied, except for her facial muscles. And that struck me because I had sort of half expected that her muscles would be as atrophied - her facial muscles - as atrophied as her back muscles. But, in fact, they were more developed.

And I came to believe - and I do believe, because I've seen this in patients subsequently at the end of life - that my cadaver, in facing the end of her life, ended up living much more fully than the rest of us. And so she probably used those facial muscles - those muscles of smile, of tears - just that much more than the rest of us.

SIMON: Do you mind talking about Dutch Smolder(ph)?

Dr. CHEN: Dutch was a patient of mine when I was resident, who was not one to talk very much, ever. He was sort of a gruff, flinty, old bachelor, a veteran of World War II. But, of course, I fell in love with him because I thought he was just wonderful. He had an esophageal cancer, which when it gets larger, patients have difficulty eating. So eventually we brought him to the operating room to take out his esophagus.

And that operation is one of the most intimate operations, because during the operation the surgeons needs to put their arm into the patient's chest to create a space to bring up the stomach. You remove the esophagus and you bring up the stomach.

Well, Dutch came through the operation fine. But that night, Dutch had managed to free one of his hands, which had been restrained, and pulled out his breathing tube. And at the time, our intensive care unit was under renovation, so nobody caught that in time until his heart started to slow down. I was on-call that night and got called to the intensive care unit to help resuscitate him. And he, unfortunately, did not make it, no matter what I did. And it was probably one of the most difficult experiences of my early residency, to have become so deeply attached to a patient, and then to have not only witnessed his death but to somehow have felt a part of it because I was running the resuscitation of Dutch and somehow we couldn't bring him back. One thing that Dutch has changed in me is the way I try to teach residents about death and dying and responsibility for our patients. I still think of Dutch a lot, but I think he's - his legacy in me is one of hope now, rather than despair.

SIMON: You saw something in an intensive care unit once, something that I guess a surgeon did, that fundamentally changed your thinking about what it is a doctor does. Because I didn't quite know until reading your book, that in intensive care units, a lot of the doctors try and get out of the way so that families can be alone with each other.

Dr. CHEN: Right. Commonly when patients pass away in the ICU at the very end, the doctors will leave, sort of in the belief that the family members and the patients, that they want to be alone at the very end. And I had been used to that sort of ritual. But there was one physician, one attending surgeon who changed all of that for me. What happened was, this patient looked as if he was going to pass within the next hour and I called the attending surgeon at home. I think it was about four in the morning, and I called the patient's wife. And the patient's wife came in, went into the room with her husband and the surgeon came in and went with her. And when I walked over to the room, I sort of expected the surgeon to come out with me and then leave the woman in there, alone. But he didn't. He stayed with her and I was confused and I looked back in wondering, you know, what's going on? Do they need me? And I saw him, I didn't hear what he was saying, he was whispering to her. But I saw him and I have to believe that he was explaining to her what was happening. He was pointing to the monitors and he was pointing to her husband. And I also have to believe that he told her that her presence there, in some way, comforted him because she seemed to find a lot of comfort in what the surgeon was saying. When the patient finally died, about a half hour later, both she and the surgeon came out. And about a week after that, she wrote a note that I kept in my coat pocket for weeks afterwards, thanking me for all that I had done and that although she wanted her husband to die at home that he had died the kind of dignified death she had wanted. And I've never spoken to that surgeon and thanked him or told him how many times I thought of that. I realized then that my job was not only to cure, but to ease suffering and to help others by just simply being an empathic witness.

SIMON: What if you had called him at home and he had said, look that's terrible news, but I have a very important surgery at 7 o'clock this morning and I really need an extra hour and a half sleep, or else I might make a mistake in the surgery that we hope will save someone's life - would that have been an equally proper thing to do?

Dr. CHEN: I think that one of the things that we understand in going into this field, is that we will have more than one patient that we have to take care of and conflicting issues and interests, but I think it's your duty to even the dying patient as well as the living, to be there for them. Unfortunately that can really wear down on your physical reserves. But that's part of, sort of the privilege of what we do.

SIMON: Pauline W. Chen, her new book is "Final Exam: A Surgeon's Reflections on Mortality." Dr. Chen, thank you so much.

Dr. CHEN: Thank you.

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