Staff Book and Media Recommendations

Final Exam: a surgeon's reflections on mortality

Pauline W. Chen

Dr. Chen's training made her a competent and trusted surgeon specializing in liver transplants. This book is not primarily about that aspect of her professional life. Instead, her book is about how a physician learned to deal with mortality and how it deepened her practice of medicine.

Inevitably, over her years of practice, some of her patients died, despite her most heroic efforts. With each one, she faced a Mortality Board review. Although she was always exonerated, each death left her feeling defeated until she realized that she, and most doctors, saw death as their enemy. She realized that they often held an unconscious, irrational belief that if they knew enough, could do enough, and had enough time, they could save everyone, every time. Death was an enemy to be defeated by any means, never a friend who could relieve patients of their intolerable burden of life. She realized that physicians were never trained to rid themselves of this irrational belief that led them to push survival onto even the most exhausted patient, even if it led to more suffering than anyone should endure.

She says that medical training is ritualistic, actions practiced over and over until they are deep habits. This isn't bad training. Absolute trust in these rituals is essential in avoiding errors, but it also has the consequence of looking past the human while performing the ritual. Her advice is to build emphathy into the curriculum and have it become part of the rituals of medical practice. These few seconds of making a human connection can reconnect caregivers to their own humanity and help them avoid burnout. It is also essential in alleviating stress for the patient. Equally important, medical personnel should also have thorough training and practice on how to walk out of one situation and into the next without carrying the psychological burden with them.

This is far from a bleak book. It is full of fascinating and moving stories. During her residency, she would often be asked to do one of the trickiest maneuvers in lung transplants because she had smaller hands. She described putting her hand, and then her forearm up to the elbow, into the belly of a patient, breaking the connective tissue under the ribs, and pushing her fingers all the way to the top of the chest cavity. As she worked, she could feel the patient's heart beating against the back of her hand. The sheer wonder of the moment fascinated her. In a different story, she recalls harvesting a liver from a very young donor. The donor was completely draped except for a square over the liver. She had to concentrate intently to work on such a small organ. As she was leaving to rush to the recipient, she saw the donor for the first time. He was a young boy with ginger hair, perfect except for an angry abrasion across his upper chest. She learned later that his sister had knocked the gearshift of his mother's car and it ran over him. It was an unspeakably sad tragedy. From then on, she remembered to take just a moment, even within the rush of a transplant, to pay her respects.

It's that kind of detail that will keep you reading. I recommend this book for our wonderful nursing students and anyone else interested in reflections on medicine and mortality. ~ Abbey Warner

Reviewed November 2013