Resurrectionist

Final Exam: A Surgeon's Reflections on Mortality
by Pauline W. Chen, M.D.

A brilliant young transplant surgeon brings moral intensity and narrative drama to the most powerful and vexing questions of medicine and the human condition.

When Pauline Chen began medical school twenty years ago, she dreamed of saving lives. What she did not count on was how much death would be a part of her work. Almost immediately, Chen 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, training, and practice as she grapples at strikingly close range with the problem of mortality, and struggles to reconcile the lessons of her training with her innate knowledge of shared humanity, and to separate her ideas about healing from her fierce desire to cure.

From her first dissection of a cadaver in gross anatomy to the moment she first puts a scalpel to a living person; from the first time she witnesses someone flatlining in the emergency room to the first time she pronounces a patient dead, Chen is struck by her own mortal fears: there was a dying friend she could not call; a young patient's tortured death she could not forget; even the sense of shared kinship with a corpse she could not cast aside when asked to saw its pelvis in two. Gradually, as she confronts the ways in which her fears have incapacitated her, she begins to reject what she has been taught about suppressing her feelings for her patients, and she begins to carve out a new role for herself as a physician and as human being. Chen's transfixing and beautiful rumination on how doctors negotiate the ineluctable fact of death becomes, in the end, a brilliant questioning of how we should live.

Moving and provocative, motored equally by clinical expertise and extraordinary personal grace, this is a piercing and compassionate journey into the heart of a world that is hidden and yet touches all of our lives. A superb addition to the best medical literature of our time.

Chapter 1

My 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.

Copyright © 2007 by Pauline W. Chen.

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 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.