Cutting to the Core
Surgeons Are Taught to View Death Coldly; This One Chose to Turn a New Page

By Bob Thompson
Washington Post Staff Writer
Monday, January 29, 2007

By the time she got to her 83rd organ donor, during her fellowship in liver transplant surgery at UCLA, Pauline Chen was so accustomed to the procurement routine that she felt she could perform the operation one-handed or in her sleep.

There would be the brain-dead donor awaiting her team's arrival: heart still pumping, chest still rising and falling, hooked up to life support machinery. Chen and her colleagues would open the donor's body as if operating on a patient still fully alive. They would call for the machines to be disconnected only at the last moment, so the organs they were harvesting would be as fresh as possible.

Like most doctors, Chen, then 35, had seen a lot of death. Paradoxically, this had only reinforced the illusion of personal immortality that helps medical professionals -- and the rest of us, for that matter -- get through the days and years.

The 83rd donor shattered that illusion.

She was a 35-year-old Asian American woman who looked so much like the doctor now operating on her -- as Chen writes in her new book, "Final Exam: A Surgeon's Reflections on Mortality" -- that opening her body "felt as if I were pulling apart my own flesh."

Finishing the operation, exhausted and sleep-deprived, Chen found herself assaulted by "an unbearable, unspeakable grief" that she didn't fully understand.

Writing about it would help, but she didn't know that at the time.

Chen is over 40 now, though she doesn't look it. Slim and dark-haired, she speaks in a soft voice you sometimes have to strain to hear. Over breakfast at a restaurant in Union Station, she talks about how she came to write her book, what it did for her -- and what she hopes it can do for others.

The early word on "Final Exam," published this month by Knopf, has been favorable. Writing in the New York Times, William Grimes described it as "a series of thoughtful, moving essays on the troubled relationship between modern medical practice and the emotional events surrounding death" -- not to mention "a crash course in the specifics of human mortality."

Chen grew up in Windsor, Conn. Her parents had emigrated from Taiwan, and when she was 7, she traveled there with her mother and sister to be with her grandfather, who had a brain tumor. The family waited together during his operation, and when the surgeon came out and said "I got it all," Chen thought: Being a doctor is something I might want to do.

She has an even earlier memory, though, of wanting to learn how to write letters and words "because I had these stories that I had to write down."

At Harvard, she got hooked on medical anthropology and decided on medical school. During the long years of training that culminated in her UCLA fellowship, she wrote a little fiction and "some journal-like entries." But with time-starved interns and residents needing to grab sleep and food every chance they got -- "see a doughnut, eat a doughnut," they were advised -- writing regularly wasn't an option.

A year or so after encountering her 83rd organ donor, Chen finished her training and finally had a bit of time for herself. She signed up for a couple of writing classes. Fictional variations on her medical experiences poured forth.

One day, one of her writing teachers asked to talk with her. The teacher had seen that there was something Chen needed to get out, something to do with the human reactions to death and dying that doctors learn to suppress -- and she thought it would work best in nonfiction form.

"Pauline, you have to write these stories," she said.

So Chen wrote them: draft after draft, story after story. Too often, she felt "like I was just skimming on the surface." What she needed to confront came down to a single painful question: "Why do you keep thinking about these people?"

Why did she keep thinking about the elderly couple she calls Juliette and Joseph -- most names in her book have been changed for privacy reasons -- whom she'd met while in medical school at Northwestern? Juliette had checked into the hospital with pneumonia. As it became more certain that she would never leave, Chen noticed, the doctors supervising her care began to ignore her.

She also noticed how relieved she felt that it wasn't her job to tell Joseph his wife was dying.

Why did she keep thinking about Bobby, the patient with whom she'd promised to discuss the options for end-of-life care, and about the tearful, angry nurse who told her what her failure to do so had meant?

"He was dying, Pauline. He had cancer everywhere," the nurse said. But instead of sending him home or even just leaving him in peace, doctors "poked him and prodded him and thumped on his chest." She poked Chen's own chest for emphasis as she spoke. "That is how Bobby died."

And what about her earliest intimate confrontation with death -- the one for which she and her fellow medical students had been so thoroughly unprepared?

Dissecting a human body taught her "the concise and efficient beauty of human anatomy, the pleasure of using my hands as an extension of my mind," Chen writes. It helped her decide to be a surgeon. Yet this initiation rite also served a more problematic function.

It taught her and her peers to separate their emotional selves from their scientific selves. They learned to suppress their fear of death by viewing "this dead human body not as 'one of us' but as 'one of them.' "

It wasn't easy. Chen recalls one student who dealt with his dissection anxiety by launching into an elaborate air guitar routine at the beginning of each session. It didn't work and he soon dropped out of school. She herself balked at using an electric saw on her cadaver's pelvis. The student who ended up wielding the saw stayed silent the rest of the afternoon.

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.