FINAL EXAM, A Surgeon’s Reflections on Mortality

GUEST: Dr. Pauline Chen
AIR DATE: 01/12/2013
VTR: 10/04/2012

I’m Richard Heffner, your host on The Open Mind. And perhaps you’ve wondered whether the increasing numbers of times I turn our attention here on these weekly television conversations to medical subjects – even to reflections on mortality – whether that isn’t because I’ve grown so long in the tooth myself.

And the answer, of course, is “of course”. But I’m fascinated, too, that so many of our younger viewers seem increasingly as well to be interested in medical matters … perhaps because health care considerations are so much in the air today, seem so much to dominate our economic concerns, surely our national political conversation.

Now, I was brought up to believe that along with taxes and religion, death isn’t a proper subject for polite discussion…but that’s all changed, though not enough, perhaps, among physicians and their patients.

Which is why I’ve been so taken with my guest’s compelling Alfred A. Knopf volume, FINAL EXAM, A Surgeon’s Reflections on Mortality.

A brilliant liver transplant surgeon, Dr. Pauline Chen writes that … quote … “…in a society where more than 90 percent of us will die from a prolonged illness, physicians have become the final guardians of life, charged with shepherding the terminally ill and their families through the intricacies of the end. Most patients and their families fully expect physicians to be able to comfort and provide that support. For doctors, this care at the end of life is … our final exam.

“Unfortunately, few doctors are up to the task.”

That’s all a major quote. And I would ask the author, Dr. Chen – whose regular New York Times online column, “Doctor and Patient”, is so revealing about their tribal dance – how and why so many doctors fail that final exam and thus their patients as well. How do you explain it, Dr. Chen?

CHEN: It’s a wonderful question and it’s one that I struggle to understand in writing the book, in writing the articles, the columns … but also, even in my everyday practice.

You know, it’s interesting because in medicine one of the things that you learn early on in your training, in your education is that illness is the enemy.

And the, the final outcome of many illnesses … more illnesses than we’d like to believe … is, unfortunately, death. And we learn to see death as the enemy.

It’s interesting because one of the first experiences that medical students, that doctors have with death is actually with their very first patient … which is in gross anatomy, which is what you do in your first year.

And I have … I, I think every doctor has incredibly vivid memories of the experience. At, at least if not of their cadaver, of how they felt going in initially.

And it’s, it’s quite a rite of passage. But that first patient of yours is dead and you are asked to do things that are absolutely inconceivable to you before you enter.

You are asked to take a knife to the body. To transect arteries and veins definitively. And yet this is also a person. And that juxtaposition of this being a real person, of our needing knowledge, of our needing to do certain things, with the fact that this person at one point was living … is really … I, I think it’s a struggle … it’s a struggle that starts Day One and that continues in many ways throughout medical school.

And, you know, I think things have changed for younger kids now, for the newer generation of doctors, I think we’ve become better at addressing that essential tension and the difficulties … the humanistic difficulties one can have with balancing that.

But they’re still hard. You, you know, it’s interesting, I … I very much remember that cadaver and I very much remember the difficulty I had in, in navigating the fact that I needed to do certain things and address certain things … to a person who … to, to another being.

I remember … I remember the first day … I remember going in and seeing these bodies in the laboratory covered with white bags … you know, they were in body bags and, and they were all face down because our medical school wanted to gently bring us into the experience.

But their humanity never left. Just much like patients, you know. You, you can try to objectify the experience. But people’s humanity is always there.

And so, what I saw of this women was her hands. And I saw that her hands had coral nail polish on them. And she had a tan line of a watch, a very slender watch, probably … I imagined a fine ladies watch. And a tan line where a wedding ring would have been. And so it was a reminder of her humanity.

Now, it’s interesting because I went through the process like every other medical student … we went through it and we became, for better or worse … inured to it … and we, we had to almost. But there was some sense of mourning through the process and I have to say one of the things that they’ve done recently … there are many medical schools now that allow medical students to have services … they have memorial services for their cadavers. Sometimes families of people who’ve donated their bodies come to the services as well.

And for me that is just such a huge step forward … I, I didn’t have that. My generation didn’t have that. But to be able to at least voice, or air the fact that “yes” this is a human being … I’m incredibly grateful and, and that person would like to celebrate that life in some way and to thank that person. I, I think it’s a huge step in going the right way.

But, but … absolutely, all along the way death is the thing that you are fighting against. And, you know, you also feel this sense of, of failure if your patient dies.

Even if it is … I mean we all know rationally that, you know, we all have to die at some point. This is a natural part of life. But imagine … okay, speaking as a surgeon …so put yourself in a surgeon’s shoes … imagine that somebody has come to you and you have put your hands in their body … and you have taken out the tumor or you have, you know, taken out the diseased part or re-connected the diseased … you know taken out the diseased part of the artery and fixed it in some way.

And that that patient dies. There’s a sense that not only of, of sadness for losing that person … but that somehow you can’t help but wonder, “Did I have some part in this? You know, if I had taken out an inch more … you know, of the colon, would that person have survived?”

So I think it’s something that all of us struggle with. We think about … you know, it’s interesting in talking with colleagues and discussing with … this with colleagues … patients never leave your consciousness.

I mean when you’re at home, you always think back on what you … what you did during the day, what people you saw during the day …”Did I do the right thing? Did I do the best for that patient?” And so death is very difficult I think for many doctors

HEFFNER: Then why do so many doctors fail that final test?

CHEN: Ahh. Because I think in many ways as well, it is almost easier to turn away, to not acknowledge that …

HEFFNER: Denial?

CHEN: To deny. Exactly. Or to objectify. Because it pulls out … you don’t have to bring up your sense of feeling … some way responsible or some way … you don’t have to acknowledge the fact that, that you feel like you might have had a hand in that. That, that you failed them. You failed these people who came to you for help … in some way.

HEFFNER: So move in the other direction?

CHEN: Yeah. Now you know there, there … there is a general movement in medicine … in the profession to, to become better at palliative … end of life care. To address that. To realize that as healers … you know, the most important thing … the one thing we don’t realize in sort of seeing death as the enemy … we don’t realize that our greatest gift … the greatest gift that we could possibly give many patients is to bear witness … to be there … to not leave them. That, that in fact is another form of hope.

You know they only hope … we often … I think all of us often think that you don’t’ want to lose hope … you don’t want to lose the hope of living and continuing.

But for many people at the end of life, there’s another kind of hope that comes up. And that’s the hope that you won’t be left alone, that people will be with you until the end … that, that you will be able to have a dignified death …however you define that.

And that is a role that I think the profession in general is coming to better terms with. And one reason we are is there is … a greater embrace of … and a greater … in the last I would say about five years or so, in the United States, there’s been another formal specialty called Palliative Care that has grown … grown incredibly.

And while Palliative care encompasses things like hospice and end of life care and comfort … it also covers palliating pain … you know, helping … palliating … making people who suffer from let’s say chronic diseases … more comfortable.

But in terms of their end of life focus … you know, I think that, that area has become a much more prominent part of healthcare than it was, let’s say, 10 or 20 years ago.

Thanks to the reformers in end-of-life-care … the people who have pushed for 20, 30 years to make this an important part of what we do as doctors.

You know there was a very interesting study that was done in the mid-90’s, called “The Support Study”. And it was …

HEFFNER: Support?

CHEN: Support Study. And it was very interesting because what happened was it … I, I think it, it sort of … it was a … it was a real wake up call for the medical profession.

Because what they did was they looked at people who were at the end of life. And what they found was that a lot of them were in pain, even at the end of life, that many of the physicians didn’t know what their wishes were at the end of life and so what the, the investigators did was they said, “”Well …” so they first did that, so that they got that data together and it was, it was very disappointing.

But they said, “Okay, we are going to put our all into this and try to improve communication” because this is a communication issue … they had specialized nurses come and help to facilitate discussions between doctors and patients, to help doctors understand what prognosis is, help the doctor’s tell the patients the prognosis … all kinds of things to sort of bridge that gap.

They did this for two years and at the end of that time … nothing had changed.

Now, the investigators to that study have postulated several reasons for it. But I think one of the reasons that this remains so difficult is that because in many ways it is very difficult to, to switch the culture, to change a culture that is so entrenched in believing … a professional culture … that death is the enemy … that, that what we need to do to help our patients to succeed with our patients … is to cure them. But that’s not always true.

HEFFNER: What do you think …

CHEN: (Hmmmph)

HEFFNER: … wisdom dictates?

CHEN: You know, I think that was part of what inspired the book. I had gone to medical school … I went to medical school filled with the ideals that I think a lot of my colleagues were filled with. I wanted to help people. I wanted to do the right thing for patients.

I had these visions of patients coming back to me, you know, cured and you know … slapping me on the back and thanking me and, and I went through … including medical school … I went through nine years of education and training.

And at the end of that time, I, I realized that I had changed … that instead of having the, the wherewithal to have conversations with patients, I was more interested in the next big operative case.

Instead of sitting by and talking to the patient who was at the end of life, I was more interested in, you know, preparing for the next day’s operations.

And I, I think it started to eat at me and around the time I finished my training, when I finally had some time, I found myself starting to write.

And most of the stories … and I was writing stories at that time … were, in fact, thinly veiled fictional accounts of what had happened over the previous nine or ten years.

And many of them, actually, were stories about grieving … grieving for the patients I had lost. And grieving for what I had become. And I continued to write and I, I finally decided … it, it sort of took over my life, the writing actually. I found myself in the lab that I had at that time just looking for paper to write … you know, going to the nursing stations and finding paper and just writing all over and having like pieces of … bits in my pockets.

So I took a writing course because I thought that this was something crazy and I needed to sort of get a’hold of it.

And it was very interesting because at one of the writing courses, one of my teachers … I’m very grateful to both of them … pulled me aside and said, “Pauline I need to talk to you”. And of course, my initial reaction was “I’m going to flunk this course because I’ve missed it, because I’ve had to … I’ve had so many emergencies.”

But she pulled me aside one afternoon and she said, “You know, you need to write these stories”.

And when she said that to me, I think it gave me permission to write what I really wanted to write. And I began to write the stories of my patients. I began to write about what had happened to me … the changes. And I did it in a more organized way and started to see the themes come out … of grief and of death and of the sort of distancing that I had sort of taken part in.

And, and that process …and that process of putting those together which eventually became the book … Final Exam was really … it was an incredible experience because I think I’ve become a better … I hope I’ve become a better doctor because of it.

HEFFNER: Well, you’re a wonderful writer.

CHEN: Oh. Thanks.

HEFFNER: Which leads me to ask … I’m thinking of a beautiful piece that you wrote … one of your articles for the Times … “Doctor and Patient” … can you teach empathy … because you are talking about empathy, it seems to me …

CHEN: Right.

HEFFNER: … to doctors? Do you believe that?

CHEN: I think it’s fascinating … I think it’s a … you can talk to some people and they’ll say, “No, you can’t teach empathy … that people are either born with it or not.” And then they’re …

But, there is very interesting work being done by … I, I have to say I’m constantly inspired by colleagues … there is some very interesting work being done on how empathy works.

Actually looking at the neurobiology of empathy. And whether or not you can actually tap into that and train physicians to recognize those signals … so there’s a woman, actually at Mass General named Helen Riess who has done a fair amount of work on this, and put together … it, it was fascinating, actually doing the research for that column because what she has done is that she’s put electrodes on people’s skin and … both doctors and patients … and had them go through an interaction. And it is fascinating because you can see spikes in the skin … the, the conductives … that correspond to how … the emotions that are going on. And when you show doctors videos of this … so if you look at an interaction and you see the patient’s spikes going up … but then the doctor is not reacting … or the doctor’s spikes going up and then the patient’s spikes going up even higher … when you show doctors that … at least for me (SHE PATS HER MIKE AND IT MAKES NOISE) when I saw it … it was such a visual sort of epiphany of what goes on.

And what she has done is she has done this and she’s also studied sort of facial expressions and how you can … you can better understand facial expressions and use that understanding to be more empathetic.

And her, her work has actually … she, she’s done a small trial in it and it has actually been effective when you show doctor’s this information, this data … teach them this course … they actually … according to patients become more empathetic.

There are other courses, there are other physicians that are doing this as well. There is a guy named Anthony Bach who is doing this with oncologists … with cancer doctors.

And showing that, you know, sometimes … I think sometimes what happens is during training we end up … we end up getting inured from this because it is … you know, the average … okay the average trainee … so this is a 26 year old out of medical school … sees an average of 28 deaths a year.

That’s a lot and if you multiply that by however many years of training and you multiply it by however many years of practice … you know … they may see fewer deaths in practice, but it’s still, it’s quite a lot.

That, that I think sometimes … I think some of these courses on some level, they allow us to go back … they, they give us the tools, sort of like a … like a little ladder or a little … something that we can begin the conservation that is so difficult for us to do … a little opening or, you know, being able to recognize something … opening our … opening our hearts … opening our minds to the thing that we had trained ourselves to close to.

HEFFNER: Opening our hearts …

CHEN: Yeah.

HEFFNER: 32A … do you think a course like that will appear in a medical school curriculum?

CHEN: You know, I, I think … I would love that (laughter).

HEFFNER: You’d love to teach it.

CHEN: Yeah. I, I would love that. You know, I think … I, I think it’s a very exciting time right now in medical education … I really do.

For all the flaws that existed and for all the flaws that exist … I think there are people …I mean there’ve been people all along who have been pushing … who really care … who really care and really want to make great doctors.

But I think now is a particularly exciting time because there is so much that is going on … that is feeding into that desire to do better.

There is, for instance, the whole idea of transparency. It is infiltrating into the way we, we train our doctors and improving things … I think … inspiring people or allowing people to do, to initiate the kind of programs that we couldn’t do before.

For instance, in medical school for years was a notorious place for hazing, for bullying … the whole medical training program … education program, residency … and what’s going on in the greater society … sort of an openness … acknowledgement of bullying … greater transparency … is filtering into medical schools.

Medical schools are talking about that now in ways that, you know, I graduated from medical school (laughter) a little over 20 years ago now … that we never did before. And I think it’s really wonderful. Hours, duty changes, that has opened up a whole new conversation on … what do we really need to give to doctors in medical schools … to young doctors to be in medical school? Do we really need to stuff them with everything? Or do we need to sort of … you know, how do we choose among all that needs to be done. It’s forced us to make decisions and, and, and do certain reforms that I think ultimately will be better for patients.

HEFFNER: Do you think they’ll fail or pass then … more likely pass that final exam of dealing with patients at the end of life.

CHEN: I think they will pass. And I think … I, I really do. And, and granted I’m an optimist … an incurable optimist … but I have to say that one of the things that I do is I speak to medical students across the country and, and resident trainees.

And one of the things that I particularly like do is meeting surgical residents, surgical trainees at the very end of their training. Because I was there about 12 or 14 years ago.

HEFFNER: Dr. Chen … you won’t believe this … but we have a guarantee that our viewers are going to watch the next program because we’re out of time now …

CHEN: Ahhh …

HEFFNER: … and I have to stop you and you have to pick up right at that point.

CHEN: Okay.

HEFFNER: Thank you for joining me today on The Open Mind. And thanks, too, to you in the audience. I know you’ll join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”

And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.