Final Exam: A Surgeon's Reflections On Mortality

Paperback | January 8, 2008

byPauline W. Chen

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A brilliant transplant surgeon brings compassion and narrative drama to the fearful reality that every doctor must face: the inevitability of mortality.

When Pauline Chen began medical school, she dreamed of saving lives. What she could not predict was how much death would be a part of her work. Almost immediately, she 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 and practice as she struggles to reconcile the lessons of her training with her innate sense of empathy and humanity. A superb addition to the best medical literature of our time.

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From the Publisher

A brilliant transplant surgeon brings compassion and narrative drama to the fearful reality that every doctor must face: the inevitability of mortality.When Pauline Chen began medical school, she dreamed of saving lives. What she could not predict was how much death would be a part of her work. Almost immediately, she found herself wre...

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 (National Institutes of Health), and UCLA, where she was most recently a member of the faculty. In 1999, she was named the UCLA Outstanding Phys...

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Format:PaperbackDimensions:288 pages, 7.97 × 5.15 × 0.6 inPublished:January 8, 2008Publisher:Knopf Doubleday Publishing GroupLanguage:English

The following ISBNs are associated with this title:

ISBN - 10:030727537X

ISBN - 13:9780307275370

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Extra Content

Read from the Book

Chapter 1ResurrectionistMy 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.The dissection of the human body had fascinated me since I was seven years old. I had some idea back then that I might want to become a doctor. At the time my Agong had just been diagnosed with a brain tumor, and my mother took my younger sister and me back to Taiwan for the summer to be with him. The diagnosis, the operation, and the neurologic deficits resulting from the removal of a part of my grandfather’s brain would eventually color the rest of my grandparents’ lives together. Nonetheless, at the time I was enthralled by the way his neurosurgeon comforted my grandmother and family. He was a big, bald Taiwanese man, with a round face, hands like bear paws, and a demeanor that was at once humble and confident. When he came out to the waiting room to an audience of anxious family members, his words—“I got it all out”—fell on us like a great light from the heavens. That experience convinced me that medicine was the work of gods.An aunt who was in medical school at the time heard about my interest and offered to take me to her anatomy lab. I was fascinated by the idea that there might be secrets about life and death lurking there. At that age I already had come to believe that dissection was the greatest event that separated physicians from the rest of us. To be able to stomach such an experience, I thought, would prove my mettle, and to sneak a peek into the inner workings of a body—a dead body, no less—would put me in a league beyond any other second-grader I knew. My parents, however, quickly vetoed the idea, fearing that such a close-up and possibly gruesome experience might scar me permanently.Like all initiation rites, the dissection of the human cadaver poses several obstacles to the neophyte. First, the new medical student has to memorize a vast array of anatomical facts. Such rote memorization can be mind-numbingly dull, and the overwhelming amount of information makes the task seem Sisyphean. One of my college mentors, a brilliant psychiatrist and anthropologist, counseled me before I started. He had completed medi- cal school some twenty years earlier. “It’s like memoriz- ing a telephone book,” he said. “You just have to get through it.”Memorization, however, is probably the easiest obstacle to surmount, and it has until recently been the only focus of medical schools. The more difficult, and often unspoken, obstacle for medical students is accepting death and the violation of the human body. In the human anatomy course, cadavers are laid before fledgling physicians, and the familiarity of their form reminds us that each lived lives not unlike our own. For those of us who wince from simple paper cuts, running a scalpel against skin and definitively dividing the essential structures that once powered a fellow human are acts that require a leap of faith. While all aspiring physicians fully expect to perform a human cadaver dissection in medical school, the expectation hardly tempers the brutal reality.Aspiring physicians face death directly in the form of the cadaver. And then they tear it apart. Each detail of the cadaver—every bone, nerve, blood vessel, and muscle—passes from the world of the unknown into the realm of the familiar. Every cavity is probed, groove explored, and crevice pulled apart. In knowing the cadaver in such intimate detail, we believe that we are acquiring the knowledge to overcome death.To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced. This ability to distance the self, I was to learn later, would be called upon again and again in my medical training. It was as if such separation would provide me with a greater sense of objectivity, a modicum of strength, and thus an enhanced ability to care for my patients. But this first lesson in disengaging from the personal was the most radical: it required suppressing that fundamental and very human fear of death.From the Hardcover edition.

Bookclub Guide

US1. What ideals and expectations does Pauline Chen begin her medical career with? How does the reality of life as a doctor challenge these ideals?2. Final Exam is about Pauline Chen’s education by two very different sets of teachers: doctors and patients. What does she learn from doctors? What does she learn from patients? In what ways are these lessons incompatible? Which education proves to be most important?3. In what ways does Chen change during the time period covered in Final Exam? How is she different by the end of the book? What experiences have been most crucial bringing about these changes?4. What are the major problems with the medical establishment as revealed by Final Exam?5. Chen writes that doctors “learn not only to avoid but also to define death as the result of errors, imperfect technique, and poor judgment. Death is no longer a natural event but a ritual gone awry” [p. 95]. What are the consequences, for patients and for doctors, of this way of defining death? What would be a more realistic and helpful definition?6. Chen writes of dissecting a cadaver as a kind of initiation and says that “to complete the initiation rite successfully . . . we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as ‘one of us’ but as ‘one of them,’ a medical case to be understood but not embraced” [p. 8]. Why is traditional medical training so concerned with repressing, ignoring, or denying such natural human emotions as empathy, compassion, fear, and love? What supposed advantages is this suppression of emotion thought to confer upon the doctor? What is inherently problematic with such a view?7. Why do doctors, in Chen’s view, feel the “need to be infallible in a highly variable world” [p. 119]? What are the consequences of such a need?8. Chen draws upon her experiences with real patients. What do these people add to the story she tells in Final Exam? Which of these cases is the most moving? How do the patients Chen writes about change her?9. Chen writes that doctors grow to feel immortal because they survive while so many patients do not. By the time Chen has operated on more than sixty organ donors, she feels her own immortality “was beyond question” [p. 197]. Then she must operate on a woman whose body bears an uncanny resemblance to her own. How does this affect her?10. When Chen begins writing stories about her experiences as a doctor, she tells “the truth, painfully uncovering each fictional persona and finding the memory within” [p. 202]. What does writing stories reveal to Chen? Why would writing about her experiences, rather than simply reflecting on them, lead her to a revelation about herself?11. What makes Chen’s writing so compelling? In what ways does Final Exam read more like a novel than a book of nonfiction?  12. What promising signs does Chen see in the ways doctors are learning to treat the terminally ill? What remains to be done?13. Which doctors in Final Exam does Chen most admire? How do their words and deeds affect her?14. At the very end of Final Exam, Chen writes, “I had comforted my patient and his family. I had eased their suffering. I had been present for them during life and despite death. I had caught a glimpse of the doctor I could become” [p. 211]. What essential truth does Chen embrace here? What kind of doctor is she likely to become?

Editorial Reviews

“Incandescent . . . The real power of her book lies in her stories. Balanced and perfect, each one seeks out the reader’s heart like a guided missile, and explodes.”—The New York Times“Final Exam is a revealing and heartfelt book. Pauline Chen takes us where few do. . . Her tales are also uncommonly moving, most especially when contemplating death and our difficulties as doctors and patients in coming to grips with it.”—Atul Gawande, author of Complications: A Surgeon’s Notes on an Imperfect Science“Chen has a clear and unwavering eye for exposing the reality behind the mythology of medical training. . . . We would all do well to listen to what she has to say.”—San Francisco Chronicle“In graceful, lucid prose, [Chen] narrates key events through which medical students and trainees first encounter death and, ultimately, depersonalize it. . . . Fresh and honest.”—Los Angeles Times Book Review