Sunday, December 27, 2009

Book Review: Final Exam - A surgeon's Reflections on Mortality by Pauline Chen



Not long ago, I was at a Pittsburgh Symphony Concert which had pieces that reflected on death and mortality Pittsburgh Symphony: reflections on death. This is another view of the topic, in this case the final exam is for doctor's, who have to face the fact that their patient is facing death and how dealing with this should be part of the doctor's profession. Pauline Chen, a transplant surgeon, makes the case that (1) providing care in death is not part of a regular doctor's training, (2) it really should be (3) there are experiences that can be used to provide this type of training (in the same manner that other parts of the doctor's training are provided through experiences)

When I was an EMT I was told a joke by a nurse. Q: What does 'MD' stand for? A: Made Divine. It was a reference to the fact that doctors had a tendency to believe they were as gods, with the power over life and death. But the problem is that this was not true. At some point, death wins. The reality is that most people are not able to face this honestly. In the case of doctors, because (for many specialties) they see death frequently in their training, one could expect they learn how to work with death. Pauline Chen's point is what they learn is coping mechanisms that allow them to avoid dealing with death. What they do not learn is how to continue care as the patient is known to be approaching death, which is something very different.

In the U.S., this is a controversial subject. There is a large portion of the U.S. population that believes doctors should have no part in discussion with clients how they want to die. (most obviously expressed during this past summer's controversy over what anti-doctor people called "death panels") And on the doctor's side, many of my friends have commented on how the care they were providing to patients who were beyond any reasonable expectation of recovery seemed to be tantamount to torture and mutilation. Forced by families that refused to let their loved ones die with dignity and wanted to fight, despite the costs in pain and suffering of the dying.

What Pauline does is to go through the stages of training of a surgeon, from medical school to residency to fellowship and show how doctors are trained, and then how their training involves the use of experience to teach them how what they learned in school relates to the realities of patients with actual conditions and histories. As she does this, she also talks about how death is dealt with as part of the training. How death is addresses, how the subject of death is ignored through denial or withdrawal, and how the practice of teaching and thinking about death is changing within the medical profession.

Pauline's book is not just the usual 'what is wrong about . . .' As she goes through the training program, she describes experiences that occurred that could have been used as teachable moments, along the same lines that medicine is taught in the modern day. In some cases they came and went without notice. In other cases, she observed mentors dealing with death in what she viewed as highly insightful and humane ways, but without an explicit teaching moment, leading her (as a trainee) to observe (or not) the example without comment. And she discusses some of her own cases. Some cases that she reflects on that she could have handled differently. And some cases where she did not know what to do, but from feedback later (after the patient is deceased) from the family she learns that there was genuine healing for both the patient and family from how she handled the case.

There are a number of lessons here, not just how the medical profession handles death (or avoids it) and how the medical profession could handle/train for dealing with death, but on how one trains others in a profession. I am teaching, not only in the classroom but also with students working on projects. And as part of these projects, we are aware that we are teaching values and an art form to the students working with us, not just the technical skills of our profession. It shows in the how we address the project, how we talk to those outside of our profession, the questions we ask, the questions we choose not to ask, and the directions we choose not to go in. And this book questions those values.
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