Cutting to the Core

The subject of a patient called Dutch comes up. "You're going to make me cry," Chen says.

A World War II veteran with cancer of the esophagus, Dutch is someone she can't possibly forget. This is partly because she let herself get so fond of him and partly because of the awesome intimacy of surgery: "I mean, I had my arm in Dutch's chest and I felt his heart."

But it's mostly because she was afraid she'd killed him.

The story is complex, but the essence is that after a successful operation, Dutch had been put in a corner of a temporary intensive care unit that was difficult to monitor properly. He pulled out his breathing tube, and by the time Chen was alerted and tried frantically to save him, it was too late.

Reading her anguished account, it seems clear that she's being too hard on herself. Yes, doctors are human. Yes, they sometimes make mistakes. But how could she think she'd caused Dutch's death?

"Fifteen years later, with much more experience, I don't think I did," she says. "But doctors tend to take responsibility. Especially surgeons."

"If a hundred surgeons read her book, a hundred surgeons would know exactly what she was going through," says Celia Chao, a surgical oncologist who trained with Chen. Yet Chao also believes that Dutch's death -- and the other deaths her friend reports in her book -- hit Chen harder because of who she is.

"She's the most unsurgeonlike surgeon I've met," Chao says, noting that Chen gives her home phone number to patients' families, goes to funerals, stays in touch with spouses and children and generally behaves in ways that "would be detrimental for most of us."

Chen, who lives near Boston with her husband and 4-year-old twins, is not currently doing surgery. She stopped as the birth of her daughters approached, though she still lectures and consults.

Will she go back? Being a surgeon, she says, is part of her identity, "and practicing is sort of like feeding that identity, feeding that part of your soul. So I don't think I can get away from it."

She's torn, though.

Writing is part of her soul, too, and there's the added temptation that "you can potentially affect more people" than you can one-on-one. She says her goal in writing "Final Exam" was to inspire patients and doctors alike "to talk about these things, to have these discussions" about the emotions that surround death.

It took her far too long, she thinks, to learn how to have those conversations. And she remains grateful to one surgeon in particular who showed her that it was possible -- by acknowledging the fear and anguish death arouses in the living -- to heal even when you couldn't cure.

A man was dying. His wife had wanted him to die at home, but it was too late for that. Instead of leaving her to face his death alone, the surgeon took the wife's hand and drew the bedside curtains around the three of them. He stayed with her, Chen writes, "explaining how life leaves the body -- the last contractions of the heart, the irregular breaths" -- until the end.

Ever since, Chen has done the same thing herself.