Physicians on Mortality & Dying: Part I

Physicians -- who daily treat victims of serious accidents or patients with terminal illnesses -- can teach us much about mortality & dying, if they observe & share, and if we listen to them. Two physicians recently wrote their observations -- Pauline W. Chen and Deepak Chopra; and we should listen.

Final Exam: A Surgeon's Reflections on Mortality, published January, 2007, was written by Pauline W. Chen, a transplant surgeon with twenty years' experience. It was recently reviewed nationally with great acclaim for a writer's first book.

Her personal website lists articles that she wrote previously. One listed there is available in full length free: "Dead Enough? The Paradox of Brain Death", published in the Virginia Quarterly Review (Fall, 2005). See also: "The Most-Avoided Conversation in Medicine" (New York Times, December 26, 2006).

Her credentials as a physician -- as noted by the Virginia Quarterly Review in 2005 -- are impressive. Pauline W. Chen was educated at Harvard University and Northwestern University Medical School, and completed her general surgery training at Yale University. Dr. Chen is the recipient of numerous awards, including the UCLA Physician of the Year Award in 1999, and the George Longstreth Humanness Award at Yale for “most exemplifying empathy, kindness, and care in an age of advancing technology.”

Her publisher, Alfred W. Knopf, a division of Random House Books, offers a fifteen-question interview with lengthy answers by the author here at the Borzoi Reader website that reveals her personality & purpose.

The interview concludes with the question: Who does she hope that the book will reach?

I wrote Final Exam with the hope that it would inspire much needed discussions about end-of-life care. People have a hard time talking with one another about dying — we talk around the topic or ignore it all together — and this has been one of the biggest obstacles to all the efforts to improve end-of-life care.

The issue becomes particularly problematic when it occurs between doctors and their patients because any miscommunication means that patient care will in some way suffer. Doctors and non-doctors are often portrayed as standing at odds with one another. But I think that we ultimately share the same difficulties in grappling with death, albeit colored by our personal and professional experiences and by our cultural and ethnic backgrounds.

I hope that Final Exam will bridge the divide between doctors and their patients. I hope that it helps to support the current professional reform efforts in end-of-life care and even helps to accelerate the pace of political change.

But my greatest hope is that Final Exam will create a common ground from which we can all begin to have meaningful discussions: about how we die, how we care for the dying, and ultimately how we live.

Her compassion is evident, as displayed during a different interview, broadcast on Saturday morning, January 27, 2007, by National Public Radio. Scott Simon's interview with Dr. Chen, headlined Surgeon Writes of Death, Dying in 'Final Exam', confirms her genuine intention in writing her book. You can find a link to the interview here for listening through your multimedia computer. It is worth hearing.

Weekend Edition Saturday, January 27, 2007 · 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 tells Scott Simon about her new book: Final Exam: A Surgeon's Reflections on Mortality.

Other literary reviews -- many by physicians -- either compliment or rave about Dr. Chen's new book:

• "Doctor Confronts the Human Drama's Inevitable Finale", by William Grimes, of the New York Times (01/10/2007) -- "When it comes to confronting death, doctors are as much at a loss as the rest of us. They are in the business of saving lives, not ending them. By instinct and by training, they avoid what Pauline W. Chen calls ''the final exam,'' the emotional challenges posed by terminally ill patients. Death represents failure. It asks unanswerable questions. Perhaps most vexingly, it threatens to crack the hard professional shell of detachment that medical training puts in place. In modern American medicine, death is everywhere and nowhere at the same time.

• Review: "Final Exam", in Time Out Chicago (Issue 98, January 17, 2007) -- "If you’ve ever wondered why the doctors on Grey’s Anatomy seem more compassionate than your own M.D., Dr. Chen will tell you why. Chen contends there is a breakdown in the field during real-life medical dramas when it comes to handling end-of-life care — something you don’t see on television. 'Few choose this career to care for the dying; instead they believe they will save others from the inevitability of death.'"

• "Why physicians fight the wisdom of death", by John Vaugh, M.D., of the San Francisco Examiner (01/21/2007) -- "Patients in denial without advance directives, families racked with guilt about losing their loved ones, physicians petrified of being sued for missing something and everyone feeling an overwhelming need to do something during a crisis have made many people's last days a needlessly traumatic, often atrocious experience. Pauline Chen has written Final Exam: A Surgeon's Reflections on Mortality to explore how modern medicine has come to such a state."

• "Final Exam": A surgeon reflects on the nature of mortality and the medical profession's failure to acknowledge it, by Claire Panosian Dunavan, M.D., in the Los Angeles Times (January , 2007) -- "As Chen so eloquently argues, a zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate. Any book that calls a spade a spade on these touchy topics deserves high kudos for candor and compassion. In particular, I commend "Final Exam" to every medical student and young physician. * * * It may seem paradoxical, but as life expectancy increases in privileged societies, a mature awareness and engagement with death is incumbent on us all. The alternate scenario — large-scale warehousing of end-of-life disasters in lieu of wiser societal investments in health — is no longer mere medical sci-fi."

• Must Read: "Final Exam", by Rachel Rosenblit, in ELLE Magazine (January, 2007) -- "In her first book, Final Exam (Knopf), surgeon and writer Pauline W. Chen indicts her profession for too often viewing a patient's imminent death as a procedural failure instead of a final chance at grace. 'The process of dying can be cast as full of potential,' Chen writes. 'There is a chance for real interpersonal reconciliation and emotional expression rather than the hasty symbolic gesture of aggressive treatment.' "

With her book's publication, Dr. Chen began a "blog", found on the Amazon site here (where her book can be purchased), and found also on her personal website here. She writes clearly, openly, & kindly in these entries. I intend to read her book; and I expect the same approach in it, but much greater depth. Her book must have substance & accuracy, given the number of reviewers -- many of them her physician-peers -- who recommend a reading.

Another author-physician attending to the subject of mortality & death is Dr. Deepka Chopra. He approaches the subject from a more universal perspective in a book that he describes as the culmination of a twenty-year writing career. I'll note his contribution tomorrow.

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Update: 02/04/07:

Dr. Chen is mentioned in an interesting article published on February 2, 2007, in the Floridian / St. Petersburg Times:

"A lesson in dying", by John Barry, Deputy Editor (02/04/07) -- Synopsis: While medical students dream of saving lives, the University of South Florida tries to make sure those students are also equipped to deal with death.