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A doctor learns to cope with death

Yale Medicine Magazine, 2007 - Spring


In her new book, a surgeon explores the ways in which physicians respond to dying patients.

Pauline W. Chen, M.D., HS ’98, often recalls the words of the late Yale surgeon C. Elton Cahow, M.D. She once heard him remonstrate with an exhausted resident for thinking he could head home without checking on a certain patient.

“Once you put your hands on a patient,” Cahow said, “they’re yours.”

Chen liked to think she was keeping close watch over all her patients. But something was still wrong: “As early as internship,” she said, “when patients were dying, I found it difficult to go into their rooms, to talk to their families, to discuss their diagnoses and prognoses.” She even shunned a dear friend with terminal cancer.

And her fellow physicians generally shared her anxiety about death. “We’re all susceptible to this,” she said in a recent telephone interview from her home near Boston. “Dying is frightening.”

This fundamental human anxiety, she said, is ratified by medicine’s “hidden curriculum.” When a patient’s death was imminent, Chen often saw attending physicians close the curtain around the patient and the grieving family, and then depart. Chen did the same. “We thought that family members wanted to be alone at the end,” she recalls. “It never occurred to most of us that the actual process might be frightening, and that we could alleviate that fear by being present. And perhaps too, some of us—I include myself here—did not have the insight to realize that we were also leaving them alone because it was easier for us to stay away from the dying altogether.”

“This deeply rooted angst about death,” she later wrote, was being passed on by doctors from one generation to the next “like some tragic hereditary disease.”

Chen said that physicians recognize their limitations. Almost half the oncologists in one study described themselves as only “poor” or “fair” at breaking bad news. Chen herself abandoned a favorite patient to painful and futile end-of-life care because she could not bear to see him diminished by his cancer. In the idiom of her Taiwanese heritage, the young man became a wan ong kuei, a restless soul who haunted her.

Five years ago, pregnant with twins, she took time off from her work as a transplant surgeon at UCLA to care for her daughters and write about the ways in which physicians cope with death. Her book, Final Exam: A Surgeon’s Reflections on Mortality, was published by Alfred E. Knopf in January.

Chen begins Final Exam at the moment when she unveils the cadaver that she will dissect as a medical student. Through anecdotes from medical school at Northwestern and residency at Yale, she traces her growing awareness of the extent to which doctors deny death, and tells of the moment midway through residency when an attending surgeon provided a better model. The surgeon closed the bed curtain around a dying patient but did not leave. He remained inside the curtain, sitting with the patient and family during the final hour of the patient’s life. “It was a major turning point,” Chen recalls. “I realized that I could do more than just cure. I could be there for my patients and their families.” She might offer what the medical anthropologist Arthur Kleinman, M.D., calls “empathic witnessing.”

“My greatest hope for the book,” she said, “is to get people to talk about the issue and to share their anxieties.” Although she recognizes that complex cultural, psychological and institutional forces determine how we cope with death, “the more awareness there is, the greater the chance that we’ll improve end-of-life care for all of us.”

Chen now works full-time as a writer, lecturer and consultant. Her blog carries a link to an excerpt from the book, which was published in The New York Times Magazine last December: