Executive Times






2008 Book Reviews



Final Exam: A Surgeon's Reflections on Mortality by Pauline Chen








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Liver transplant surgeon Pauline Chen shares many stories from her experience as a doctor in her book Final Exam: A Surgeon’s Reflections on Mortality. Training doesn’t necessarily prepare physicians for their own complicated feelings when their patients die. With wisdom and understanding, Chen expresses her feelings and reactions when her patients face death. Here’s an excerpt, from the beginning of Chapter 3, pp. 55-:


Every morning around 7:20 in the hospital where I trained, the junior residents would gather in the cafeteria for breakfast. Work rounds would be done, and the senior residents and chiefs would have already gone off to the operating rooms for the day, leaving us junior residents with lists of scut to complete before evening rounds.

In the midst of overwhelming days, these fifteen min­utes in the cafeteria were a symbol of our united defiance. We would put all but the most urgent pages on hold and stake out the same section of tables on the far end of the cafeteria. Together, we would cavalierly devour what we called the “cardiac special,” an intoxicating, heart-stopping, artery-clogging glob of eggs, cheese, and sausage between a grilled kaiser roll—the caloric equiva­lent of a clay’s worth of meals—and then poke fun at those attendings and senior residents in whose thrall we nor­mally cowered. We learned to squeeze a day’s worth of socializing and gossip into fifteen minutes, and by the end of those brief breakfasts, we would trudge back to the wards, our bellies and souls filled.

Inevitably these hurried conversations ended up cen­tering on work—how much there was, what we had to do, and how our lives were unbelievably difficult because of it. We would take turns spinning our own tales of woe; it was, alter all, a personal badge of honor not only to have lived through such horrors hut also to have survived intact enough to join everyone else at the breakfast table. There were stories about “crashing” patients, those whose clini­cal courses took a sudden turn for the worse, traumas that involved half a dozen victims, and, of course, chief resi­dents or attending surgeons who reprimanded unreason­ably. All of us would talk, each with a horror story worse than the others, the subtext always being that the person who told the worst tale was the hardest-working, and therefore best, intern.

One morning late in my internship, the intern taking care of Mr. Roberts began talking. We were all quiet because we knew that no one could outdo him. John Roberts had been in the hospital longer than we had been interns, and every one of us dreaded the month when we would have to take care of him. Mr. Roberts had a particu­larly intractable case of Crohn’s disease, an inflammatory disease of the bowel that can result in pain, diarrhea, bleeding, and blockage of the intestines. Mr. Roberts had had several blockages and operations previously, but on this hospital admission, his blocked bowel was so inflamed that even the gentlest surgeon’s fingers wreaked chaos in their path.

He never healed. One loop of his bowel stuck up against the wall of his abdomen and developed a fistula, a tunnel between that bowel and the outside that leaked abdominal contents through the nearest opening, his inci­sion wound. Copious amounts of fluid with ribbons of green bile and flecks of sloughed tissue splashed daily onto Mr. Roberts, breaking up any tenuous skin cells that tried to cover both the wound and the fistula. In an effort to decrease the amount of fluid coming out from his bowel, the medical staff forbade Mr. Roberts from eating and nourished him instead with bags of intravenous nutrition. The nurses set up suction tubing to clear the liters of secretion, but his dressings still saturated quickly, turning the skin around the wound into a waterlogged mess. Mr. Roberts thus passed the days alone in his hospital room hooked up, sucked on, and bathing in his own intes­tinal contents.

By the time my turn came to care for him, Mr. Roberts had been hospitalized for six months. I dreaded going into that room. Every morning when I went in to examine him, lie looked neither at me nor at what I was doing. The shades were always drawn, and the smell of skin soaked in small bowel contents, a strangely sweet, less intense ver­sion of rotting pears, permeated the room. His answers to my awkward attempts at conversation were usually terse. And I always felt like part of the cause of his misery. Even if I had not been at the operation and even if there had been no other alternative than surgery, entering that room made me feel more a part of the brethren of medicine than any other thing I did that year.

He was thin, that much was easy to tell from the gaunt figure that lay on the bed. He had a pleasant face—oval but chiseled by male hormones. And he was tall; his legs were always bent up, and even then his feet hit the end of his bed. The nurses had miraculously rigged up a way to move all his accoutrements, but I saw him outside the room only once, escorted by a nurse who pushed along the pole and cart that carried the bags of intravenous nutrition and the tangle of suction tubing. I was shocked hut recov­ered quickly enough to stop and say hello. Mr. Roberts looked at me for a moment, as if he was trying to focus his eyes on my face and could not quite remember who I was. He smiled and then, looking at my white coat, said, “Hi, Doctor.”

So when the intern who was in charge of Mr. Roberts that month began to talk, none of us dared utter a word. Instead we sat mute, eating our breakfasts and relieved for once not to be the best intern.

Mr. Roberts was not getting better, and the surgeon in charge was contemplating surgery. It was a drastic step; Mr. Roberts would have to gamble on the slim hope that surgery would help, even though the odds were that it would only complicate things further. Or he could choose to live out the rest of his life in his current state. Even at our tender ages, the choice seemed excruciatingly difficult for a man who was not yet fifty. As the intern continued to speak, his beeper went off. He looked at it. “It’s Roberts’s floor. I bet it’s his nurse.” We watched our fellow intern as he took one last bite from his roll and started walking out of the cafeteria, coffee cup in hand.

John Roberts died a week later without the surgery. His death was the topic of discussion the next morning at breakfast, and a few of the second-year residents weighed in with their opinions. “You know every class of interns has a patient like Roberts, someone who is in the hospital for the entire year,” said one of them. “We had a guy like that, too.” The two other second-year residents nodded, smiling and remembering their “John Roberts.” By virtue of the several thousands of hours of clinical experience they had acquired in the year before us, they seemed infi­nitely wiser than we interns were.

Another second-year resident began to talk. “The key,” he said, “is not being the poor sucker that’s on the service when the guy dies. You do everything to keep that guy alive until you rotate off-service.”

The interns all looked at him. We leaned in, waiting fur the punch line.

The resident took a bite of his breakfast sandwich and began waving it around, like a professor at his chalkboard. “You do everything to keep the guy alive because you don’t want to he the poor bastard who has to go through a year of medical charts to dictate the death note.”

We all sat back. All of us had humbled through dis­charge dictations on patients we hardly knew; it required wading through the charts late at night after all the ward work had been done and piecing together events from scrawled, usually illegible notations. For John Roberts’s dictation, I envisioned our fellow intern sitting in front of a colossal tower of charts for an entire sacred weekend off.

The following year when I heard that the next intern class’s “John Roberts” had died, I remembered my Mr. Roberts and the awkward morning visits, the smell of his bowel contents on skin, and the gnawing discomfort I felt every time I left his room to eat the breakfast he never could. Two years later, when another similar patient died, my best friend in residency, Celia, and I spent a few min­utes over dinner remembering Mr. Roberts and discussing his medical case before we went off to see our next patient.



Thanks to Chen’s fine writing, Final Exam comes alive for all readers. She worries about her patients, and whether she has done all she can for them. By sharing her introspection and reflections, readers can appreciate what many doctors grapple with daily, and how, as patients, we are part of being together with those doctors in a struggle that for all of us eventually ends in death.


Steve Hopkins, February 21, 2008



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The recommendation rating for this book appeared

 in the March 2008 issue of Executive Times


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