Final Exam: A Surgeon's Reflections on Mortality

Final Exam: A Surgeon's Reflections on Mortality

by Pauline W. Chen


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A brilliant transplant surgeon brings compassion and narrative drama to the fearful reality that every doctor must face: the inevitability of mortality.When Pauline Chen began medical school, she dreamed of saving lives. What she could not predict was how much death would be a part of her work. Almost immediately, she found herself wrestling with medicine’s most profound paradox–that a profession premised on caring for the ill also systematically depersonalizes dying. Final Exam follows Chen over the course of her education and practice as she struggles to reconcile the lessons of her training with her innate sense of empathy and humanity. A superb addition to the best medical literature of our time.

Product Details

ISBN-13: 9780307275370
Publisher: Knopf Doubleday Publishing Group
Publication date: 01/08/2008
Edition description: Reprint
Pages: 288
Sales rank: 339,925
Product dimensions: 7.96(w) x 5.16(h) x 0.62(d)

About the Author

Pauline W. Chen attended Harvard University and the Feinberg School of Medicine at Northwestern University and completed her surgical training at Yale University, the National Cancer Institute (National Institutes of Health), and UCLA, where she was most recently a member of the faculty. In 1999, she was named the UCLA Outstanding Physician of the Year. Dr. Chen’s first nationally published piece, “Dead Enough? The Paradox of Brain Death,” appeared in the fall 2005 issue of The Virginia Quarterly Review and was a finalist for a 2006 National Magazine Award. She is also the 2005 cowinner of the Staige D. Blackford Prize for Nonfiction and was a finalist for the 2002 James Kirkwood Prize in Creative Writing. She lives near Boston with her husband and children.

Read an Excerpt

Chapter 1ResurrectionistMy very first patient had been dead for over a year before I laid hands on her.It was the mid-1980s, and I had at last made the transition from premedical to full-fledged medical student. That late summer from the window of my dormitory room, I could see the vastness of Lake Michigan dotted with sailboats and the grunting, glistening runners loping along its Chicago shores. Despite this placid view, I rarely looked out my window. I was far too preoccupied with what lay ahead: my classmates and I were about to begin the dissection of a human cadaver.Prior to that September, the only time I had seen a dead person was at the funeral of my Agong, my maternal grandfather. Agong had grown up on a farm in the backwaters of Taiwan at the turn of the last century. He barely finished high school, but by the time he was middle-aged, Agong owned a jewelry store in one of Taipei’s most fashionable districts and had raised five college-educated children. While he grew up speaking Taiwanese, Agong had taught himself Mandarin Chinese and Japanese, languages and dialects as different as German, English, and French.Agong loved my mother, his firstborn child, and lavished her with that gift of nearly blind parental adoration. As her firstborn child, I was in a special position to receive some of those rays of love. Unfortunately though, with my American upbringing I understood Taiwanese but spoke only “Chinglish,” a pidgin amalgamation of English and Mandarin Chinese. Moreover, Agong and I had been separated by half a world until he moved permanently to the United States when I was in high school. So while I loved my grandfather, our relationship always remained rather formal.Agong died in the fall of my sophomore year in college. One weekend, my parents mentioned to me on the phone that he was doing worse and might possibly “not make it.” A week later they called again to tell me that he had passed away.My mother was grief-stricken. She became consumed by guilt and remorse, feelings that I would later learn often plague relatives of the recently dead. For my part, while I did mourn Agong’s death, I was unsure how to cope with this phase of life or with my mother’s overwhelming grief. I had not been witness to his actual dying, and seeing my grandfather alive during one visit and lying dead in a casket the next made his death unreal to me. The funeral was not particularly long, but the parade of mourners dressed in black and my own uneasy feelings seemed to last forever.I was surprised by how un-lifelike Agong looked lying in the casket. Despite all the efforts of the mortician, the figure in the coffin simply looked like a model of Agong, like a wax figure from Madame Tussauds’s famous museum. His face and body as I had known them were gone. Even his nose, famous in our family for its Jimmy Durante profile, had changed; the nostrils looked less fleshy and even droopy, like a once majestic sail that had lost its wind.The fact that even the professionals with all their makeup and tricks could not re-create my grandfather’s likeness only served to emphasize that he was really dead and gone from our lives. That funeral, the telephone call from my parents announcing my grandfather’s passing, and the memories of my mother’s grieving were the most direct experiences with death that I had prior to medical school.The majority of my 170 medical school classmates were no more experienced than I, and our first real exposure to death would be that semester in the human anatomy course. While one student had worked in a hospital morgue during college and another had worked in an Illinois meatpacking plant (subsequently becoming a strict vegetarian), those two classmates were the rare exception. Instead, the summer before starting medical school most of us privately dreaded and fretted about dissecting a human being.During my medical school orientation week, I was finally able to share my dissection fears with others who harbored the same uneasiness. Anatomy quickly became a major topic of discussion at social events. The classmate who had worked in a morgue was a prime source of information for the rest of us. I kept wondering if the cadavers looked alive or like wax figures. I secretly hoped that they would look at least as unreal as my grandfather had, believing that the less they looked like the living, the easier dissecting would be. We asked the second-year medical students about their experience the previous year. “Wear your old T-shirts and jeans,” they said, sipping their drinks nonchalantly at receptions for the new initiates. “You’ll want to throw out those clothes at the end of the semester because they’ll just reek.” Holding on to their words, I replayed their cavalier responses in my mind. What smell would cling to our clothes? Death?From the moment I had begun contemplating this career path some fifteen years earlier, I knew that I would want to use my profession to help people. Most of my classmates were no different. We were an odd group, idealistic but intensely obsessive and competitive enough to have survived the grueling premedical curriculum. While a few of us might have harbored goals of financial security or visions of a certain lifestyle, we were for the most part determined to learn how to save lives.What many of us did not realize was that despite those dreams, our profession would require us to live among the dying. Death, more than life, would become the constant in our lives.The dissection of the human body had fascinated me since I was seven years old. I had some idea back then that I might want to become a doctor. At the time my Agong had just been diagnosed with a brain tumor, and my mother took my younger sister and me back to Taiwan for the summer to be with him. The diagnosis, the operation, and the neurologic deficits resulting from the removal of a part of my grandfather’s brain would eventually color the rest of my grandparents’ lives together. Nonetheless, at the time I was enthralled by the way his neurosurgeon comforted my grandmother and family. He was a big, bald Taiwanese man, with a round face, hands like bear paws, and a demeanor that was at once humble and confident. When he came out to the waiting room to an audience of anxious family members, his words—“I got it all out”—fell on us like a great light from the heavens. That experience convinced me that medicine was the work of gods.An aunt who was in medical school at the time heard about my interest and offered to take me to her anatomy lab. I was fascinated by the idea that there might be secrets about life and death lurking there. At that age I already had come to believe that dissection was the greatest event that separated physicians from the rest of us. To be able to stomach such an experience, I thought, would prove my mettle, and to sneak a peek into the inner workings of a body—a dead body, no less—would put me in a league beyond any other second-grader I knew. My parents, however, quickly vetoed the idea, fearing that such a close-up and possibly gruesome experience might scar me permanently.Like all initiation rites, the dissection of the human cadaver poses several obstacles to the neophyte. First, the new medical student has to memorize a vast array of anatomical facts. Such rote memorization can be mind-numbingly dull, and the overwhelming amount of information makes the task seem Sisyphean. One of my college mentors, a brilliant psychiatrist and anthropologist, counseled me before I started. He had completed medi- cal school some twenty years earlier. “It’s like memoriz- ing a telephone book,” he said. “You just have to get through it.”Memorization, however, is probably the easiest obstacle to surmount, and it has until recently been the only focus of medical schools. The more difficult, and often unspoken, obstacle for medical students is accepting death and the violation of the human body. In the human anatomy course, cadavers are laid before fledgling physicians, and the familiarity of their form reminds us that each lived lives not unlike our own. For those of us who wince from simple paper cuts, running a scalpel against skin and definitively dividing the essential structures that once powered a fellow human are acts that require a leap of faith. While all aspiring physicians fully expect to perform a human cadaver dissection in medical school, the expectation hardly tempers the brutal reality.Aspiring physicians face death directly in the form of the cadaver. And then they tear it apart. Each detail of the cadaver—every bone, nerve, blood vessel, and muscle—passes from the world of the unknown into the realm of the familiar. Every cavity is probed, groove explored, and crevice pulled apart. In knowing the cadaver in such intimate detail, we believe that we are acquiring the knowledge to overcome death.To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced. This ability to distance the self, I was to learn later, would be called upon again and again in my medical training. It was as if such separation would provide me with a greater sense of objectivity, a modicum of strength, and thus an enhanced ability to care for my patients. But this first lesson in disengaging from the personal was the most radical: it required suppressing that fundamental and very human fear of death.

Reading Group Guide

“Uncommonly moving. . . . Revealing and heartfelt. . . . Pauline Chen takes us where few do—inside the feeling of practicing surgery, with its doubts, failures, and triumphs.”
—Atul Gawande, author of Complications: A Surgeon’s Notes on an Imperfect Science

The introduction, discussion questions, and suggestions for further reading that follow are designed to stimulate your group’s discussion of Final Exam, Pauline Chen’s searing memoir about her medical education and its failure to prepare doctors to deal with one of their most disturbing—and frequent—experiences: the death of a patient.

1. What ideals and expectations does Pauline Chen begin her medical career with? How does the reality of life as a doctor challenge these ideals?

2. Final Exam is about Pauline Chen’s education by two very different sets of teachers: doctors and patients. What does she learn from doctors? What does she learn from patients? In what ways are these lessons incompatible? Which education proves to be most important?

3. In what ways does Chen change during the time period covered in Final Exam? How is she different by the end of the book? What experiences have been most crucial bringing about these changes?

4. What are the major problems with the medical establishment as revealed by Final Exam?

5. Chen writes that doctors “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” [p. 95]. What are the consequences, for patients and for doctors, of this way of defining death? What would be a more realistic and helpful definition?

6. Chen writes of dissecting a cadaver as a kind of initiation and says that “to complete the initiation rite successfully . . . we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as ‘one of us’ but as ‘one of them,’ a medical case to be understood but not embraced” [p. 8]. Why is traditional medical training so concerned with repressing, ignoring, or denying such natural human emotions as empathy, compassion, fear, and love? What supposed advantages is this suppression of emotion thought to confer upon the doctor? What is inherently problematic with such a view?

7. Why do doctors, in Chen’s view, feel the “need to be infallible in a highly variable world” [p. 119]? What are the consequences of such a need?

8. Chen draws upon her experiences with real patients. What do these people add to the story she tells in Final Exam? Which of these cases is the most moving? How do the patients Chen writes about change her?

9. Chen writes that doctors grow to feel immortal because they survive while so many patients do not. By the time Chen has operated on more than sixty organ donors, she feels her own immortality “was beyond question” [p. 197]. Then she must operate on a woman whose body bears an uncanny resemblance to her own. How does this affect her?

10. When Chen begins writing stories about her experiences as a doctor, she tells “the truth, painfully uncovering each fictional persona and finding the memory within” [p. 202]. What does writing stories reveal to Chen? Why would writing about her experiences, rather than simply reflecting on them, lead her to a revelation about herself?

11. What makes Chen’s writing so compelling? In what ways does Final Exam read more like a novel than a book of nonfiction?  

12. What promising signs does Chen see in the ways doctors are learning to treat the terminally ill? What remains to be done?

13. Which doctors in Final Exam does Chen most admire? How do their words and deeds affect her?

14. At the very end of Final Exam, Chen writes, “I had comforted my patient and his family. I had eased their suffering. I had been present for them during life and despite death. I had caught a glimpse of the doctor I could become” [p. 211]. What essential truth does Chen embrace here? What kind of doctor is she likely to become?


“Uncommonly moving. . . . Revealing and heartfelt. . . . Pauline Chen takes us where
few do—inside the feeling of practicing surgery, with its doubts, failures, and triumphs.”
—Atul Gawande, author of Complications: A Surgeon’s Notes on an Imperfect Science

The introduction, discussion questions, and suggestions for further reading that follow are designed to stimulate your group’s discussion of Final Exam, Pauline Chen’s searing memoir about her medical education and its failure to prepare doctors to deal with one of their most disturbing—and frequent—experiences: the death of a patient.

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Final Exam: A Surgeon's Reflections on Mortality 4 out of 5 based on 0 ratings. 23 reviews.
gaylene21 More than 1 year ago
Pauline Chen speaks candidly about how doctors are ill-equipped to handle patients' end of life care and how some doctors have found their own ways to help patients through this tough time through their own trial and error process. The book is not nearly as morbid as one might think upon first glance. Chen is an excellent and engaging writer.
Guest More than 1 year ago
Final Exam is a captivating book that opens the door into medical school and the inward fight of a surgeon. Chen's honest confessions and frustrations with time and medical policies encourage the reader to fight for a change in the way society handles the dying and death. The audience is people involved in the medical field or striving to be¿but anyone can thoroughly enjoy it. She speaks of real life cases and the struggles and difficulties of a being in a profession aiming to cure. Final Exam is a timeless account of something we all have to deal with. It provides insight and sympathy with an issue no one enjoys discussing: death. It¿s a quick read¿I highly suggest it!
Guest More than 1 year ago
Final Exam: A Surgeon¿s Reflection on Mortality, by Pauline Chen. I first came across this surgeon in the splendid Virginia Quarterly Review, and her thoughtful, moving writing guaranteed that I¿d pick up this book. Her tender reflections on end-of-life care, not to mention her honest discussion of dealing with people who have no choice but to view life from the vantage point of the end, is an illuminating meditation on the relationship between medicine and mortality. Chen¿s book is a vivid reminder of the necessity of compassion in our technology-driven age.
Guest More than 1 year ago
This is a great book in several ways: 1' as a personal story of some one falling short of their expectations and then finding their way back, 2' as a glance into what medical training feels like, and 3' as an examination of why doctors and patients don't talk more about death/the dying process. This book is not just for doctors or medical students. Some of the passages are incredibly beautiful, and the patient profiles are powerful--in just a few pages, I came to really care about the people. I am truly impressed by Dr. Chen's ability to observe and communicate the key details of a situation, her ability to make scenes and people real to me. Sometimes, I could FEEL her exhaust as she went through her training 'there is a great description of the SMELL of exhaust.' To give you a better idea, I have typed in a passage below. Each time I read it, I again think, 'Wow.' 'and I wish there was some way I could have the same experience'. From pages 102-103 If you poke a hole from the belly into the diaphragm and, with your fingers, clear away the cobweblike tissues that separate the heart from the spine, there will be just enough space back there to fit your entire arm. And if you put a small incision along the base of the neck, as you do when you remove an esophagus, you might even see, if your forearm is long enough, the tips of your fingers poking out while your elbow remains enveloped by the soft, rubbery stomach and a flap of liver. It¿s tempting to leave your arm in that warm, reassuring space. On the back of the forearm, you can feel the hardness of the vertebral bones, at the tips of the fingers, the coolness of open air, and at the elbow, the slithering contractions of the small bowel. But what you will marvel at most, and what will make you keep your arm there for just a few seconds longer than you probably should, is the sensation you notice against the patch of skin on the underside of your wrist, the most tender area where mothers gauge the temperature of milk for their babies. Against that small swath of skin, and squirming of its own accord, you will feel the strong, twisting contractions of the heart. And it will remind you as you look down at the open belly and warm skin and bloodstained instruments on the table that the person whose body embraces you is very much alive.
Guest More than 1 year ago
I really liked this book and found it absorbing reading. It is a fascinating look at the interior life of a surgeon and a very honest look at how the detachtment required of a surgeon can be so great that genuine compassion is lost. Dr. Chen is to be commended for her ability to learn from the times she blew it with patients and to continue to move closer to those tough places where none of us want to go, in particular when the medical options have pretty well run out.
jonesjohnson on LibraryThing More than 1 year ago
First off, let me say this: I love a book with a good bibliography. It makes me feel like I am in knowledgable hands. No, that was not a surgeon joke. Because of this exhaustive bibliography I want to subscribe to all these medical journals. I know Dr. Chen reads them to stay up on her field, but I would just love to see her filing system. It must be stupendous. Either that, or she's got a wicked e-subscription file.A close family member died recently, and this book is exceptional in explaining what was happening. Not from a biological system standpoint, but from a medical system standpoint. Dr. Chen delves deeply into the reflexive reaction a physician has to the process of dying. They were taught to fix problems. When the problems are no longer fixable, then things become much more personal. Our family member died at home, surrounded by those she loved. She was not given false hope, and she was not subjected to the "full court press" in her final days. Reading this book made me glad that was the case, and made me much more conscious of the decisions there are to be made within the bounds of medicine.
apartmentcarpet on LibraryThing More than 1 year ago
A fascinating look at how doctors deal with death and dying, from the first cadaver they dissect, to the patients that they are unable to save. Dr. Chen proposes that doctors need to take a more intimate and caring role in dealing with dying patients and their families.
prima1 on LibraryThing More than 1 year ago
Excellent view of death-related issues by a physician
zina on LibraryThing More than 1 year ago
Thoughtful, intelligent author. Interesting insights.
NancyKuhnClark on LibraryThing More than 1 year ago
The real Grey's Anatomy! Inside look at med school, procedures, and the profession vis a vis the sick and dying. Ethics and morality discussed as well as "the naming of parts" for a compassionate and informative read.
msbaba on LibraryThing More than 1 year ago
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.
phalaborwa on LibraryThing More than 1 year ago
A surgeon reflects on dying and how doctors should deal with patients' deaths.
Anonymous More than 1 year ago
I found this to be a very interesting book. Clinical, yet far from boring. Personal, that brought me close to tears. I found it easy to like the Dr/Author. This book should have been written decades ago. How to describe and articulate what I think and feel about this book! Easy to read, and everyone should read it! I am surprised it isn't a best seller, unfair for such a wonderful, informative book!
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Guest More than 1 year ago
This is an outstanding book by an outstanding surgeon. She does a great job of expressing both the triumphs and the sadness involved in her profession.
Guest More than 1 year ago
I found myself in a B&N bookstore in Atlanta this past weekend and picked up this book off an end cap display. The title intrigued me both because of my interest in surgery and the concept of dying. The only reason I continued to read the entire book after the first chapter was to possibly find a plagiarized paragraph after noting a very simliar sentence refering to 'Jimmy Durante' as to one in a book I read a while ago by Dr. Ira Byock, M.D. The author scatters her thoughts and jumps around the entire book, never fully giving any description justice or fully reflecting on morality like she promised in the title. Its ok though, her first profession is a surgeon and from her biography she sounds like a great one. Her experiences are definitely interesting, but she really does not convey them properly. Overall, I was disappointed with her lack of originality, the disjointedness of the chapters, and complete lack of literary skill and poise.