No getting around it: death is hard

We cannot remove the pain of loss. Death—whether of patients or of loved ones—will always be difficult. We can create reforms, we can institute policy changes, and we can even write books. But our professional fear and aversion to dying is the most difficult—and most fundamentally human—obstacle in changing end-of-life care. Our grief is the price we pay for caring for the terminally ill, and our aversion is the weight that anchors our inertia and denia.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), Epilogue

Bad news, over and over again

The common thread running through our professional world is disease, and many of our conversations inevitably converge on "bad news." They may begin with an initial diagnosis, but those diseases can become catastrophic or just sputter along in a continuous decline until death. We doctors must be there every step of the way. Bad news thus occurs not just once but over and over again.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch.8

Scent of a resident

I learned that exhaustion leaves its own olfactory imprint. The white coats of residents who had been up through the night had an acrid, stale odor—the smell of dirtied polyester, sweat-stained cotton, and human flesh trapped too long away from sunlight and normal circadian rhythms. I could recognize my exhausted colleagues with my eyes closed.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 8

Dying can be full of potential

Perhaps all those scientific advancements have given us more than the panoply of treatments and longer life expectancies; they have created an impetus to reappraise how we live. By accepting the reality of dying rather than the misconception, we paradoxically give ourselves the luxury of time. The process of dying can be cast as full of potential rather than as devoid of any final opportunities. There is a chance for real interpersonal reconciliation and emotional expression rather than the hasty symbolic gesture of aggressive treatment.

It is this opportunity, then, and not necessarily the hope of cure, that is the final gift of the medical revolution of the last century.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Predicting death

We have no reliable way of ascertaining when someone will die. Even with the best medical predictors—physician assessments and statistics—there is often a huge gap between perceived dying and the actual imminence of death.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Doctors watch people

Doctors—like writers, artists, and spies—are professional people-watchers. More specifically, a doctor's work relies on the ability to discern, among thousands of biological cues, the underlying pathology. It is a skill that is part art, part science; and the more we can see, and sense, and sort, the better our care.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 6

Deconstructing patients

We dismantle people as art experts deconstruct paintings. Instead of seeing families gathered by the lake of a park or the stars in the sky, we see the purple and pink dots, the gray shading, and the yellow highlights.

Eventually we apply these skills not just to diagnosing but also to interpreting everything in our clinical world. Deconstruction becomes our professional tool of understanding, and we rely on it to absorb increasingly complicated clinical problems. A patient in multisystem organ failure, when reduced to bodily systems—neurologic, pulmonary, cardiac, and so on—becomes manageable for even the most junior of residents. . . .

In the course of my training, I actually came to enjoy this deconstructing. It was mentally satisfying, like taking a box of jumbled puzzle pieces, organizing the, then arranging them into a perfect picture. The only problem was that I could not stop doing it. I did it almost constantly at work and then would find myself still doing it during my time off. I saw people in the grocery store or at restaurants, and my eyes would fixate on the loping gait, the barrel chest, or the finely wrinkled skin. Stroke, emphysema, big-time smoker, I would think. It was strangely thrilling, the way having X-ray vision might be.

Then one day my Aunt Grace, my mother's younger sister, asked me for some medical advice. . . .

. . .

The skill that had once simplified my life now left me very much alone, and the profession that had once promised the power of cure now made me utterly helpless.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 6
 

M and M as death ritual

Our fingers, no matter how nimble and graceful, are always tangled up with the fate of our patients, and when one of those patients dies, it is impossible to divest ourselves of that sense of responsibility. We torment ourselves with the what-ifs. Perhaps, if we had put that stitch in just a little differently or removed that cancer a little higher up or worked a little longer, then maybe our patient's course might have been different.

. . . M and M requires a public accounting of loss and, in so requires a public accounting of loss and, in so doing, reconstructs the death into an event that affirms a core value of our professional identity: the need to be infallible in a highly variable world. In this way, M and M is like death rituals in other cultures; it seeks to transform death's loss into an affirmative experience.

. . .

By defining death only as the result of errors, we erase the face of our patients and insert our own fiercely optimistic version of immortality.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), pp. 118-19.

A surgeon starts to write

Soon after that procurement [of organs from a young woman], I began to write stories. Not much, for when faced with a decision between eating and sleeping for the first time in seventy-two hours or writing, the primal needs won out every time. But when I finished my training a year later, fortified with the relatively regular meals and sleep of an attending surgeon, I began to write with some consistency. To my surprise, the writing seemed to pour out from a locked-up data bank within, oftentimes in unmitigated, logorrheic, and exhausting bursts. And the fictional stories I thought I was creating were almost always thinly veiled narratives about my patients, many of whom had passed away sometime in the last decade.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 9

The down side of more humane resident hours

While residents these days do spend less time in the hospital than those who trained even a decade ago, the change has had some unpredictable repercussions. The increased "free time" has left residents with less time to form bonds with their patients. The pressure now is to squeeze as much experience as possible into the time limitations, usually at the expense of patient relationships. The transient physician-patient relationships of residency have only become more fleeting.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 8

A key professional habit could be wrong--surgeon changes hand-washing routine

The ten-minute scrub was one of the earliest rituals I had learned, and I thought that it was essential in surgical antisepsis, a crucial step in preventing my patients from developing debilitating postoperative infections. I had believed that my dedication to this operating room rite made me a good and responsible surgeon, but the research contradicted that belief. Suddenly my blind trust in the practice seemed almost foolish.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), p. 97. (After years of scrubbing for ten minutes with brushes, Chen read CDC guidance that recommended five minutes and said soft sponges were as useful as brushes.)

Young doctors get little guidance on the dying

As young students and doctors in the midst of profound sleep deprivation and chaotic personal lives centered on work, we are eager to find easy truths or at least comfortable lessons in patient care. Soon enough, however, we discover that death among patients is an inevitable part of our profession. We look to our attending physicians for guidance and we learn that many of them have not only their own difficulties in dealing with death but also little insight into how these attitudes affect the care they give terminal patients. Even our textbooks, usually overflowing with data, provide us with little or no help with the dying.

Thus, without guidance or advice, few of us ever adequately learn how to care for patients at the end of life.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), p. 61.

Despite our best efforts to improve, our apprenticeship system continues to produce doctors who are unable to care humanely for the dying. The attitudes we physicians have toward death become reinforced each and every time we learn from our attendings and then go on to teach others.

Id., p. 73.