Final Exam: A Surgeon's Reflections on Mortality

by Pauline W. Chen

A brilliant young transplant surgeon brings moral intensity and narrative drama to the most powerful and vexing questions of medicine and the human condition.

When Pauline Chen began medical school twenty years ago, she dreamed of saving lives. What she did not count on was how much death would be a part of her work. Almost immediately, Chen 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, training, and practice as she grapples at strikingly close range with the problem of mortality, and struggles to reconcile the lessons of her training with her innate knowledge of shared humanity, and to separate her ideas about healing from her fierce desire to cure.

From her first dissection of a cadaver in gross anatomy to the moment she first puts a scalpel to a living person; from the first time she witnesses someone flatlining in the emergency room to the first time she pronounces a patient dead, Chen is struck by her own mortal there was a dying friend she could not call; a young patient’s tortured death she could not forget; even the sense of shared kinship with a corpse she could not cast aside when asked to saw its pelvis in two. Gradually, as she confronts the ways in which her fears have incapacitated her, she begins to reject what she has been taught about suppressing her feelings for her patients, and she begins to carve out a new role for herself as a physician and as human being. Chen’s transfixing and beautiful rumination on how doctors negotiate the ineluctable fact of death becomes, in the end, a brilliant questioning of how we should live.

Moving and provocative, motored equally by clinical expertise and extraordinary personal grace, this is a piercing and compassionate journey into the heart of a world that is hidden and yet touches all of our lives. A superb addition to the best medical literature of our time.

Genres: Medicine, Medical, Nonfiction, Memoir, Science, Death, Biography

288 pages, Hardcover

First published January 1, 2006

Reviews

[Petra X · Rating 5 out of 5]

Doctors say you have to divorce your emotions from your work. Dr. Chen says otherwise. The book boils down to Dr. Chen questioning how far you should be involved with your patients - all the way - and how much treatment should you give when the outcome is going to be death and the treatment is very distressing and won't extend life by much if at all. It is a book about facing mortality. Her own. The patients. Medicine in general. It is a book about love and caring and nurturing through the eyes of a surgeon whose profession teaches them to leave these ideas at home.

I have a lot of admiration for Dr. Chen. She's a wonderful writer so the book was very enjoyable, but also it was deep and gave me much to think about.

[حبيبة · Rating 3 out of 5]

"You will be a better doctor if you can stand in your patients' shoes."

3.5⭐

أفكار كتير بتدور في دماغي فقلت أكتبها حتى لو مكانتش مراجعة بالمعنى المعتاد..
الكتاب حكايات وانطباعات أو بالأدق reflections زي ما مكتوب على الغلاف. بتبدأ الجرّاحة (باولين تشن) كتابها بحكايتها عن الحدث الأهم في حياة كل طالب طب وهو دخول المشرحة. والله يعني لا أخفيكم سرًا، الموضوع دا مرعب.

- دخول المشرحة بيغير كتير في نفسية طالب الطب حتى لو هو مكانش مدرك دا. بتخليه يعتاد على الموت. بيألف منظر جسم الإنسان وهو متقطع ومتبهدل ورائحته كريهة. بيحول نظرتك تدريجيًا من إن دا كان إنسان زينا كان له حياة وأحلام وإحباطات ومشاعر وروح، لمجموعة عضلات وشرايين وأعصاب و landmarks كل همك تحفظها عشان السؤال اللي هييجي في الامتحان. الموضوع له بُعد نفسي كبير، ولو منتبهناش للأثر دا ممكن يوصلنا لحالة من التبلد الواحد ميتمناش يوصلها.
والفصل دا كان من أجمل فصول الكتاب.

- الطب مجال صعب لا شك. ورأيي إن صعوبته مش بس بسبب صعوبة الدراسة وضغط الامتحانات وطبيعة ظروف العمل، صعوبته بسبب إنك بتتعامل مع مريض. مع إنسان بشكل مباشر. أنت مسؤول بالكامل عن صحته وأي خطأ هيبقى في رقبتك. من أول يوم في الكلية والدكاترة بيقولوا لنا "في يوم أنت هتبقى الفيصل بين المريض وقبره." فالطالب بيدخل بالنفسية دي. نفسية تحمل المسؤولية بشكل مفرط. ضغط فوق الاحتمال.

- "أول مريض تبقى مسؤولة عن موته" دا كان شيء فارق في حياة الكاتبة وأكيد فارق في حياة أي طبيب. مش معنى كدا إنك تسببت في موت المريض، المقصود إن المريض مات وهو تحت عنايتك ومسؤوليتك. الحدث دا بيسبب خليط مشاعر ممكن تكون مش مفهومة، لكن لازم نتعلم ازاي نفهمها ونتعامل معاها صح لأنه حتمًا هنمر بيها.

- الكتاب فيه حكايات شخصية عن طفولة الكاتبة، جدها وخالتها وأصدقائها، طبيب الأطفال اللي كان بيتابعها.. وغيرهم. كانت بتدمج الحكايات بالفكرة اللي بتتكلم عنها ودا كان أسلوب مميز وجميل، خلق جو من الألفة والود مع الكاتبة وقلل من حدة وكآبة مواضيع الكتاب.

عمومًا كتاب حلو وفادني كتير.. وضح لي أفكار كانت في بالي ومكنتش عارفة أعبر عنها.

[Sarah · Rating 5 out of 5]

This is certainly not a feel-good, enjoyable read in the sense of warm fuzzies, but I believe it is something that most people should pick up if they have time. I wanted to include in my review my favorite lines from the book, as Dr. Chen is a very eloquent writer, but I realized quickly I would basically be copying the entire book. She covers some VERY controversial topics such as * how far DO you go with treatment in the face of a horrible prognosis, * why would you stop treatment, * why would you pursue treatment, * how do you approach family to discuss stopping treatment, * legality of a doctor not pursuing every single therapy available vs. hospice care, etc. I do think that this read has changed the way I am going to discuss end-of-life decisions with my family, even encouraged me that I do need to sit down with my husband and have a very serious discussion with him about these things. Many people suffering in ICUs have an extremely slim to nil chance of ever recovering, yet clinicians push on, either because they don't want to crush hopes/dreams, they don't want to be the ones to push the families to make this most-difficult decision, they don't want to be sued, they don't want to accept mortality. Apparently many physicians (and LOTS of surgeons) cannot accept mortality. They receive less than 1 credit hour of "end-of-life" discussion education while in medical school, and when offered courses as continuing education, they pass it up for more medicine-based courses. Dr. Chen has learned to embrace the mortality of life and be open with her patients about their actual chances of recovery. She discusses many cases, but one in particular that is interesting...a man she has diagnosed with metastatic cancer of the liver that is inoperable. He feels that he cannot just lie down and do nothing, so pursues chemotherapy with an oncologist. (she is a surgeon, so after her initial consultation with him, her "care" of him is basically over) He is going through chemo and dramatically worsening quickly, as a result of the disease, not the chemo, yet his oncologist continues to push for different therapies. His liver begins to fail dramatically to the point where he is suffering horribly and blood tests are fairly consistent with end-stage multiple organ failure, yet his oncologist never discusses dying/death and the real likelihood that he will pass very soon. Dr. Chen checks in on him on an ER visit because he is doing so horribly at home that his wife rushes in him. He feels a connection with her and asks her what they will do in the ICU. She basically describes that they will push fluids, hook up monitors, place catheters, begin to ventilate when he cannot breathe on his own, etc. She is the first medical person that he sees that tells him that he is dying and assures him that actually, he will die very soon. He begs her, "Please do not let me suffer and ensure that I die in my own home." She arranges for hospice care and releases him to his family. She struggles later (after he dies within 2 days) that maybe she should have done more or not been so blunt, after which she receives multiple thank you notes and calls from his family members, thanking her for being so honest with him.

Sigh.

Being of the medical profession in situations nearly daily where we make life/death decisions regarding our pets, I am appalled to see what we do to our HUMAN counterparts as they are faced with a grave prognosis and inevitable death, yet also terrified for the day that I will be the family member or the patient, in that exact situation.

What will I do?

Will I be able to face my own mortality?

Or that of my child?

Or that of my spouse/mother/father?

I hope and pray that I have a doctor like Dr. Chen to help guide me.

I am buying this book so that I can underline and tag the pages that I must reread again and again.

[Yara Yu · Rating 2 out of 5]

قبل أن تدخل كليه الطب وترغب في أن تصبح طبيب لإنقاذ حياة البشر فأنت أمام هدف سامي بالفعل لكن يجب أن تضع في عقلك أنك كما ستشاهد الفرحة بالانقاذ ستقف امام حيوات انتهت فالموت هو أكبر حقيقة تعيشها وتقف أمامها كطبيب
الكتاب عن طبيبة جراحة تحكي تجاربها مع المهنة كتاب كان من الممكن أن يصبح جيد لولا العشوائية فيه

[Fr. Andrew · Rating 4 out of 5]

Really mostly a memoir that focuses on end-of-life patient care memories, but some thoughtful consideration of what it means to be a doctor in such situations. Some of the stories are heartbreaking.

[Hanane · Rating 5 out of 5]

كتاب رائع جدا، يجمع بين ما هو مفيد ومؤلم، بين التحديات والتجارب الصعبة لطبيبة جراحة منذ مرحلة دراستها إلى حين تخرجها، بين صفحات الكتاب أحسست أني عشت معها جميع الحالات التي وصفتها، وكم كانت مؤلمة تلك التي كانت تنتهي بالموت و الفراق، عندما يعجز الأطباء ويفقدون الأمل في إنقاذ المريض، عندها يكون الرجاء الوحيد هو أن يحظى المريض بنوع الموت الجيد الذي يستحقه٠

[diana · Rating 4 out of 5]

4☆

Read for my history of health/death class📚

Such an interesting perspective on death and mortality. Told through the eyes of a liver transplant surgeon, this narrative delves into the evasion of death and immortality that the medical field as a whole exhibits. Chen details the importance of acknowledging this evasion as a surgeon but, above all, she compels her peers to follow as a means to achieve medicine’s one true objective: save others’ lives.

- - - - - - - - -

Wait I’m actually excited to read this for class

[Wren · Rating 5 out of 5]

Before reading this book, I understood that physicians deal with matters of life or death. Chen highlights the raw truth that physicians have to confront death daily and find ways to address this reality. Yes, physicians save a lot of lives with their state-of-the-art techniques, their experience, their collaboration with others, and even the instincts they draw on in fast-past emerging crises. However, physicians also have to develop an attitude, a manner, a relationship with death.

The book has a lot of detail about bodies in trauma, decline and even decay, but Chen does so without sensationalizing. She is dignified but she also communicates respect and even affection.

Chen pulls back the curtain to show us how she meditates about death, really wrestles with death, through the twenty years she has studied and practiced medicine.

As a medical student Chen learned to dissect a body without being too emotional but also how she could honor the life of the people who donated their bodies to science. That's a tightrope to walk.

As an resident, Chen learned to push her body to the limit (lack of sleep, lack of food, abundance of stress) in order to perfect life-saving techniques.

As a surgeon, Chen learned to talk with patients and their family members about grave diagnoses. Actually, the book really reveals how difficult this is and how many physicians don't really ever feel as though they've "mastered" talking about the risks of surgeries, the complications possible, the transition from life saving to offering comfort to the dying. These are not clear cut issues, and they are difficult for everyone involved -- if they are to keep their humanity.

Chen is brilliant in showing that physicians are human beings with limits, faults, and biases. But she is also brilliant in showing how she and others strive to overcome the very worse of human nature by employing the very best of human nature.

[Laurel · Rating 3 out of 5]

I was drawn to this book for obvious reasons (death and dying) and was excited to read a book about the medical field that wasn't all fiction-y and soap opera-y. I heard about this in the New York Times, and someone had cited it as one of the best books of 2007. After reading it, I find that title somewhat surprising, unless it was judged on the unique subject matter and not the writing itself.

Pauline Chen is a doctor, not a writer (she described a nurse's eyebrows as "luxuriant"), but nonetheless deserves respect for creating a document about something few really want to talk or think about, especially doctors. That said, I sort of wish this were written by a social worker instead. Chen details many interesting cases but basically says the same thing over and over again: doctors have a hard time talking and thinking about death. Wow. Revelatory. She seems surprised to make the connection that doctors feel immortal after being desensitized to death-and Chen herself is only really touched it seems when she is dealing with either a family member or someone who looks exactly like her. Now, if a social worker had written this, elementary transference would probably not be so surprising, and perhaps the revelations would have been a little more interesting coming from someone trained in self-reflection. Instead, I feel more knowledgeable about how doctors think, but not what it's really like to connect with someone who's dying.

I am glad that there is a doctor out there who really cares about doing good work with terminal patients, though. There are only a few of them. You don't really get a lot of glory if all of your patients die, but I don't think there are many more rewarding things to do.

Now, off to get started on MY book...

[Carey · Rating 2 out of 5]

My biggest complaint with this book is that the author can't seem to decide who her target audience is. There are large sections that read like something you might find in a medical journal or textbook. The language is peppered with medical terminology and jargon that, as a lay person, didn't allow me to fully engage in the narrative. The sections where she recounts specific episodes with her patients were interesting, but the transitions between the two sections were awkward and clumsy.

Chen's "revelations" on how to better care for dying patients seem like common sense. Of course doctors need to have difficult discussions with and listen to their patients and family members.

I am sure my opinion of the book is shaped in large part by my experience with my premature son who died in the NICU. Our experience with his medical staff was a positive one. His doctors, nurses and entire medical team were with us when he passed on. They freely cried with us and offered us emotional support in the months ahead while our other son remained in the NICU. I am forever grateful for this amazing team of people who realized they also had a responsibility to their patient's family to help care for us in our beginning stages of grief.

Finally, the author lists changes the profession has made in terms of training to better prepare doctors for caring for terminal patients. I wish instead of simply stating what others are doing in the field to improve care for the dying and their families she had offered her own original ideas.

[vicinthemeadow · Rating 4 out of 5]

This is a beautiful memoir written by a surgeon about her relationship with mortality and death throughout life. She takes us through trying to be the tough kid who can stomach anything on track to go to medical school, to her first code in residency, and how her relationship with handling patient death ebbed and flowed through the years. I read this for a few reasons. If you follow me on Instagram you probably know I’ve been working through fears of death and reading books on death for the past few years. When I stumbled upon this it felt like divine timing. Part of my journey getting into remission with OCD has been exposure response prevention therapy. So last week when my therapist suggested I watch a documentary about cancer, or read a book about dying, I knew just the one to pick next from my stack!
I found this very raw and realistic, but at times clinical. If I didn’t have a post secondary education in health sciences I may have been a little lost, something to consider if you’re going in blind!

[Tonsina · Rating 4 out of 5]

Going into the medical field (I'm a Nursing Student) you hear stories about the attitudes of Doctors that have been pervasive throughout the years. Some people have excellent experiences with doctors that interact well, listen and truly try to work with the patient; on the other side are experiences of "Doctor knows best", never questioning and rarely explaining the full situation to the patient. Surgeons are one of the specialties that suffer from this particular stigma. That attitude has finally been changing in training for all levels of medical personnel, and I could see parallels between the old methods and the new training. It was raw, informative, and honest, while at the same time graphic that lead to the revelations of conscious. Part of me was revolted, another part sympathetic, still another sad and fascinated. It runs the gamut of emotions and has an excellent conclusion. Highly recommended for anyone involved or interested in medicine. Some good references for follow on reading as well.

[Elaine Qian · Rating 5 out of 5]

4.4 rating

do you ever get that feeling when a writer’s writing style just makes sense? i don’t know how else to describe it except to say pauline chen’s writing feels as if it could be mine in an alternate universe. or in 20 years.

through poignant patient stories, she navigates death as a juvenile medical student, a lost resident, and a struggling attending. what i loved about her is that she never admitted to having answers about how death should be dealt with, or that she cracked the core on how to deal with death in patients. she lends space for continuous growth and learning, using each and every patient experience as one that teaches her something else about the role of a physician in maintaining the cycle of life and death.

i dislike how death is something to be fearful of in our society and i love how this book challenges that fear in physicians as doctors and as people. it reminds us as futures physicians to confront death and never become complicit in its wake. i am truly touched and am now more seriously considering surgery as my future specialty 🤓

[dfchen · Rating 2 out of 5]

Pauline Chen clearly is a dedicated and earnest physician. Courageous of her to show her vulnerabilities in this book, particularly as a member of such a high powered perfection driven specialty like transplant surgery.
Still the writing is a too unrelentingly somber in its tone. Yes, I know the book is about the theme of death, but other medical writers manage to bring tones of something else - inspiration, gallows humor, what have you - to the topic. Chens writing overall doesn't do much for me. It's technically good writing I suppose, and provides good fodder for discussion but never really struck me as being especially insightful into anything. It's just a series of vignettes about a patient death her musing on how difficult it was. Didn't really need 200 pages to figure that out.

[Mike · Rating 3 out of 5]

Thought this would be a good book to read as the health care debate unfolds in the US. I highly recommend the book to anyone in the medical professions, but think there are more appropriate treatises on death and mortality for other audiences. Mary Roach's Stiff: The Curious Life of Human Cadavers offers a more lighthearted glimpse into that which awaits us all. For a philosophical and psychological examination of mortality, Ernest Becker's The Denial of Death is indispensable and potentially life-changing. Still, Chen does an admirable job of presenting the physician's dilemma between the struggle to save lives and the responsibility to prepare patients for the inevitable.

[Ashley · Rating 4 out of 5]

I had to read this for a literature course I am taking this semester. It was a wonderful read. Incredibly descriptive and insightful. A joy to read.

[Erin Neville · Rating 5 out of 5]

Totally, unexpectedly fascinating. I could read Dr Chen’s stories all day. She has a lot of wisdom to impart about end-of-life care. Highly recommended to anyone interested in modern medicine.

[Tabby Cat-Paw]

I really enjoyed this book. It sparked lots of discussions with friends on the topic of medicine and death. This memoir made me think, and also taught me new things.

A few reviews mentioned this book being very technical. I did not have that same experience. I have read biographies that were truly just professional jargon, but every medical fact in "Final Exam" was backed up with a human story about compassion and empathy. I never felt that the informational parts became too overwhelming.

[Josh Singh · Rating 1 out of 5]

this book felt slow and repetitive. it also goes into a lot medical details about human anatomy, which lost me. This book was probably better than my review but was in a rush to finish because i’m reading two other books that I’m obsessed with

[Louis · Rating 4 out of 5]

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.

[Pris robichaud · Rating 4 out of 5]

Caring For the Ill and Personalizing Their Dying, 4 Mar 2007


"I think it's like Dr. Courtney M. Townsend, a legend in surgery and a personal hero, recently told me. "We have two jobs as doctors: to heal and to ease suffering. And if we can't do the former, my God we better be doing the latter." Pauline Chen

A few years ago I was part of a poetry group of medical providers. We shared poetry written by or for medical providers that described our work. Most of these poems as it turned it were about the dying, the dead or end-of-life. Our professions had a need to share our profound feelings. Since that time Palliative Care has become a recognized service in many hospitals and communities. Our patients need us and we need each other to share our grief.

Pauline Chen discovered once she was house staff that pronouncing a patient's death was part of her job, the first 'code blue', the first agonizing long death on an intensive care unit, and the day to day life and death of her patients were taking a toll. She was taught it seems to hide her feelings, but then they would not go away and what was she to do? She had an eye-opening experience with a physician who stayed with his patient while he was dying and she realized 'this is what my job is all about." As a transplant physician, Pauline Chen realized that her life and death immersion in very ill patients brought her closer to death than life. As she stated, "zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate." She gives us many examples of her patient experiences and how other physicians reacted to their patient's deaths. As she so eloquently says, " That honor of worrying-of caring, of easing suffering, of being present- may be our most important task, not only as friends but as physicians, too."

"Exercising personal autonomy around one's death is no simple matter today -- especially in settings of ever-more sophisticated and fragmented medical care. As Pauline W. Chen points out in "Final Exam: A Surgeon's Reflections on Mortality," the medical profession bears a good measure of responsibility for this dilemma. But "Final Exam" is neither an angry rant nor a bloodless treatise about medicine's failings. By sharing stories of her own maturation into a healer as well as a technically skilled doctor, Chen in this fresh and honest memoir engages and educates on many levels. At the same time, the author's principal goal -- to hold herself and fellow physicians accountable for providing better end-of-life care -- is ever in view." Claire Dunavan

My role in my profession is to help my patients with their living through their dying. This would not be possible without my team mates and colleagues. My best friend, with whom I share each patient death, found this book and told me about it. Thank you. Pauline Chen has written a book that should be read by all medical providers. It is indeed a good thing to be compassionate and to be there, physically and emotionally with our patients. Highly Recommended. prisrob 3-04-07

[Charles Matthews · Rating 4 out of 5]

Hospital shows – ER, Grey’s Anatomy, House and so on – have inured us to the sight of the moist workings underneath the skin, and inspired us with the drama of dedicated (and usually good-looking) young doctors saving lives. As for death, Luka and McDreamy and Gregory House take it in their stride – on TV it’s just the occasional unfortunate byproduct of so much heroism.

Pauline Chen, a real-life surgeon, has another way of looking at it. Death is one thing medical school doesn’t do a good job in preparing physicians to handle. Young doctors are trained “to endure and embrace what might be considered by others to be difficult and even ghastly.” But even the most promising medical students, she says, are not made ready for patients who die and the families who survive them. And especially not for patients who are known to be dying. “Rather than setting out to improve treatment as we do with diseases,” she writes, “we continue to treat dying as ineffectively as our professional forefathers.”

Final Exam is a memoir of Chen’s experiences with death – from the cadaver she dissected in gross anatomy class to the patients, relatives and friends whose last days she witnessed. It’s a confession of failings, both her own and her profession’s, but it’s also a chronicle of growth, of coming to terms with the inadequacy all of us feel in the face of mortality, but which doctors are, at least in the popular imagination, supposed to be able to rise above.

Fortunately for readers, one of the ways Chen discovered she could cope was by putting her experiences into words. In writing courses she discovered that “the fictional stories I thought I was creating were almost always thinly veiled narratives about my patients, many of whom had passed away sometime in the last decade.” A teacher’s encouragement gave her the courage to reread and rework what she had written, an experience that brought her to tears. “That is when I began to see what I had become,” she writes.

From the reader’s point of view, what she has become is yet another member of the remarkable community of eloquent surgeon-authors, such as Richard Selzer, Sherwin Nuland and Atul Gawande, who have made it their mission to explain to us both the physical workings of the human body and the emotional workings of the physicians who try to heal it. Chen joins this distinguished company with a candid memoir that’s sometimes disturbing, sometimes gently funny, and always poignant.

[Kyle Wendy Skultety (gimmethatbook.com) · Rating 5 out of 5]

This review originally appeared on my blog www.gimmethatbook.com.

Final Exam was a book I picked up myself from the library. It was on my own personal reading list, which I haven’t been really able to get to these days. This is not a new book; it was published in 2007, but the ideas that Dr Chen speaks of should be relevant and in use today.

The mission of all doctors is to maintain life–by performing surgery, by prescribing medication, by encouraging life changes such as dieting or quitting smoking. But–everyone eventually dies, no matter how brilliant the surgeon was, or how much weight a patient lost. Many doctors gloss over this fact and prefer to focus on living and making a better quality of life.

Who will champion a better quality of death? No, Dr Chen is not going to talk about euthanasia, or discuss funeral services. She is going to bring to the forefront a subject that has been assiduously avoided in human medicine for a long time: death is very much a part of life, and it should not be spoken of in hushed tones or pushed to the back of one’s mind. To truly care for your patients, you must realize that death is truly part of life.

No one wants to consider their own mortality, especially someone who is going to the hospital for an operation. Dr Chen postulates that all doctors can give better care by embracing their own personal feelings and fears about death, and listening to what their patients are telling them, either with words or what their body is saying.

There is a great deal of explicit description in Final Exam: of medical procedures and people struggling to die, those with sickness or those who have developed complications after surgery. Dr Chen starts out with her own personal experience with a cadaver in medical school and brings us all the way to her visceral reaction when a good friend of hers dies.

This book’s message is a powerful one, and not for the faint of heart. I thoroughly applaud Dr Chen for suggesting that doctors make themselves more emotionally available and vulnerable. Too often a patient’s death is couched in a sense of failure, of medicine gone wrong. A delicate balance needs to be attained, and I hope Dr Chen has started a dialogue by writing this book.

I loved this. You can pick up your own copy here.

[Ashlyn O · Rating 5 out of 5]

This book caught my attention, especially because my previous book had been When Breath Becomes Air by Paul Kalanithi. My interest in the author’s medical school and experience as a surgeon made me want to continue reading similarly themed biographies, memoirs, etc. Also, because of my interest in the field, I have been looking into these books to prepare for my own future. I have really been enjoying diving into these genres and I continue on doing so while searching for my upcoming reads.

Focusing mainly on end-of-life care and patient mortality, Pauline W. Chen reflects on her experiences through college, medical school, and her years as an intern making her way to become a surgeon specializing in liver transplants. Learning how to properly care for and deal with patients in their last years, months, weeks, and even days was a crucial part of Chen’s education. She deeply cared for all of her patients whether they awaited a long future or were about to come to an end of their journey. She emphasized their worthiness of individualized treatment plans in order to fulfill their last wishes. Her passion for this particular care in the time of a patient’s most vulnerable stage motivated her to advocate teaching opportunities for anybody who could benefit. This includes all tiers of medical personnel from student to the most successful, experienced surgeons and doctors. As she reflects on her past in college and plans for her future in the operating room, Chen provides her heartfelt insight on the importance of patient care, in hopes of helping people when it matters most.

I thoroughly enjoyed this book. Her personal stories and emotions were brought through in a very effective and powerful way so much that I felt like I learned something. Being able to read her accounts on the most memorable patients was impactful, and the way she brought across her ideas and passions was empowering.

I do not think that this book could get any better. Like I said about When Breath Becomes Air by Paul Kalanithi, some may find this book difficult to read if they are unsure or uncomfortable about ideas revolving around dying or mortality. Other than that, I would strongly suggest this book to anybody wanting to learn more about the truths of being in the medical field and the behind-the-scenes struggles that come with it.

[Melissa Lee-Tammeus · Rating 4 out of 5]

If I had to pick a surgeon, this author may definitely be the one I would chose. I picked up this book to get a better understanding of the doctors I am dealing with during my internship and I have to say I now have a much deeper respect for medical doctors overall than I did before. The first chapter is all about the trials and tribulations of working with and through a cadaver from head to toe in Gross Anatomy and how that experience defines a doctor's life. I realized right after that chapter that I was definitely not cut out for that line of work (which I had always suspected) and that it is very easy to see how some doctors gain that "god complex" we all have dealt with while sitting in that little paper smock. Chen is honest to a fault and explores her own inabilities to work in a "fuzzy" capacity and how she managed to become that way. Denial of the feeling part of a patient makes a good doctor, no doubt about it. But too much denial makes you not much of a good doctor either. Chen discusses teetering between the two with grace and directness, filling her readers in with stories of lives she's saved and lives she's lost. A wonderful read that makes me want to give that annoying doctor of mine a hug.

[Tracey · Rating 4 out of 5]

A thoughtful look at how doctors in general and the author in particular cope with death and dying in their professional lives.

The book begins with Ms. Chen's first-year cadaver studies as an introduction to the clinical side of death. She continues with stories from her training and internship/residency (with her eventual focus on transplant surgery) combined with a more general look at how her profession is slowly beginning to address death and dying issues within their training. Since so much of a doctor's self image is tied to making their patients better, it's very difficult to cope with situations where that won't happen. Chen's own experiences show the progress she and the profession overall are making on that front.

I found the content a good balance between personal experience and professional information; her writing style may seem dry to some, but I was engaged throughout. I plan on going through the bibliography for suggestions on further reading.

[AGC · Rating 5 out of 5]

I really enjoyed Dr. Chen's reflections and personal experiences about patient care and end-of-life care. A lot of what she addresses relates to patient-centered care for healthcare workers, and how they should interact with patients.

There's always the dilemma: keep fighting and pressing for more treatment? Or quit the expensive treatments, which could be more detrimental than ameliorating for a patient at his/her end, and focus on the quality of life and palliative care? So it's up to the physician to understand and read the patient's desires, whether he/she explicitly says it or not. Does the patient have a strong love towards life and resilience? Or does the patient feels he/she already lived a full life and just wants to be around his/her loved ones?

This book definitely made me more sensitive to the topic of dying, and a glimpse of what it is like in the elite settings of medical school and residency and doctorship which so few people can attain to.

[Peter · Rating 4 out of 5]

This is a book everyone should read. It's not easy - she deals with the difficult issues of death and with her own and our mortality. Her perspective is that of a physician dealing with dying on a daily basis. But it is also an issue that sooner or later we all deal with related to our loved ones and eventually ourselves. The vivid clinical descriptions made me stop in places to take a few deep breaths before continuing, but they served the purpose of focusing my attention and making reading a deliberate and thoughtful act rather than a subconscious scimming of the material. Getting all the way through this book is worth the work, particularly because it describes a journey through Chen's developing perspective on and relationship with life, mortality, death and dying. It will make you think.

[Frank Jude · Rating 3 out of 5]

The subtitle of this book says it all: "A Surgeon's Reflections on Mortality." Pauline Chen is a transplant surgeon with an apparently uncommon sense of reflective thinking. While reading this book, I was moved by the realization of how much suffering -- both the buried, denied suffering of medical staff, and the often confused, scared suffering of dying patients -- is caused by western medicine's framing of death as defeat!

Chen makes the case that only when doctors face their own mortality, will they be able to provide the kind of humane and human compassion and palliative care for the dying that is so desperately needed.

Perhaps a teaching on the Five Remembrances is in order?

[Robin · Rating 4 out of 5]

Pauline Chen's book takes us through her years of medical school, her internships and residences. She also gives us a look at her childhood and family. The discussion through her cases looks at the many difficulties that come with mortality and decisions around level of care. As a nurse I very much appreciated her reflections and how they helped me revisit many areas of my career.