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MAUREEN CAVANAUGH (Host): Doctors are well-known for their reluctance to criticize other doctors, at least in public. And the warm and insightful writing of my guest, Pauline Chen, is not usually what you'd think of as criticism. But Dr. Chen does pose a challenge for her colleagues. She says with all the focus on technique and technology in medicine, it may be that the value of good communication and a bit of real compassion has been overlooked. The nexus point in the struggle between cool professionalism and emotional engagement is clearest when doctors and their patients confront death. Pauline Chen's book, "The Final Exam: A Surgeon's Reflections on Mortality," is about the emotional challenges posed to doctors by terminally ill patients. Dr. Chen is a liver transplant and liver cancer surgeon. She also writes a health column "Doctor and Patient" for the New York Times online. So, welcome, Dr. Chen. Thanks for being here.
DR. PAULINE CHEN (Hepatic Surgeon/Author): Thank you. I'm thrilled to be here.
CAVANAUGH: Well, why did you want to be a doctor when you were a little girl?
DR. CHEN: Ah, you know, I think the reasons that I went into medicine are very similar to the reasons that most of my colleagues choose to do so, and that is that I really wanted to help people and I felt that by being a doctor I could do that. I wanted to help people that were struggling with illness or struggling with some kind of medical problem. What's interesting though, what has always struck me as interesting, is that I think for many of us, we go into the field wanting to help people, wanting, oftentimes passionately, to do so because, you know, to get through all of the training, you have to really want to do that very badly. But what happens, and it's actually rather sad in a way, what happens is young doctors go through this marvelous training process, marvelous in many ways because every year we end up producing doctors that are really, really well trained, that are quite competent. But at the very end of that process somehow, we doctors have gotten about as far as you can possibly get from the very people that we set out to help. We don't speak the same language. Oftentimes, patients – we don't – patients don't understand, may not understand, what we're saying. And for patients, many of them at the end of life or at critical points in their healthcare don't really want to talk to us. They'd rather talk to the nurses, to the social workers, to the chaplains, or even to their lawyers, somebody else besides their doctor. And so I think it's actually a tragedy of healthcare that the people who wanted so badly to help others, in the end, at the end of this process, actually end up quite distanced from them. You know, my belief, Maureen, is that if we began to talk about things in some way and oftentimes the most difficult things like end-of-life care, how you want to die, or even simple things, but if we begin to talk a little bit more that somehow we can begin to bridge that gap in a way.
CAVANAUGH: Well, I think, Pauline, one of the reasons that your book "Final Exam" is – has been so popular is because it really strikes a chord with patients and with some doctors about this particular difficulty. I'd like, if you would, to tell us a little bit more about what problems that doctors have specifically in dealing with terminal illness and death.
DR. CHEN: Well, I think – I'll talk a bit from my own experience and I'm most familiar, obviously, with that. I am not in any way the perfect doctor. I struggle very much with end-of-life care, with talking about dying, about terminal prognoses, because I think death, no matter how you look at it, is very difficult. For instance, I'll give you one example of sort of the influence of training and ways that perhaps we can be different. When I was going through training, one routine that often happened when patients were dying in our ICU was that at the time surrounding the actual death, the doctors would leave the patient's room or the area where the patient was dying. And they would leave the family alone with the patient so that our belief was that, you know, the families wanted privacy at the very end. And so we would scatter. And I remember doing that over and over again as a resident when my patients would die and I'd sort of convinced myself as I believe many of my peers did was that this was much better, it was better to do it this way. When, in fact, I think we did it partly because it was very uncomfortable to be there. It – Not only did we grieve for losing our patients, losing another human being, but it's very personal, I think, for a lot of doctors when they lose patients because you are so involved with how they're doing and their therapy. Anyway, this happened pretty routinely in my practice as a junior resident until about my third year of residency and I remember I was taking care of a businessman who had colon cancer that had spread to his liver and lungs. And he was initially on the regular floors and every afternoon—I'd round on him twice a day with the team—and every afternoon his wife would be there and she would greet me and she would say, Dr. Chen, can I talk to you outside of the room? And we'd go outside and she'd say, when can my husband go home? Because both she and he knew that he was going to die fairly soon and they wanted for him to die at home, and I would tell her every day, we'll get him home soon, don't worry about it. Well, as things turned out, he ended up getting sicker and ended up going to the ICU and I remember one night. I was on call, it was about three or four in the morning. And it was pretty obvious to me that he was going to die in the next – soon, within an hour or so. And so I called my attending surgeon and I called the patient's wife and she came in, they both came in. This was the middle of the night. She looked devastated, as anyone who's about to see their partner die would be. And I did what I had always done, which was I brought the patient's wife and my attending surgeon to the room and then I turned around to leave, fully expecting the attending surgeon to go with me. And when I got out of the room, I turned around and I realized that I had been the only one to leave. And so I waited outside. I waited for a few minutes, just waiting for my attending surgeon to come out because I thought this is what we usually do. But he didn't come out and after a while I thought this is strange, so I opened the curtains and I looked in and what I saw there that night, I have never forgotten. He was standing next to the wife and he pointed to the patient's chest and explained to her what the last sounds, the last breaths of the dying sound like. And then he pointed to the cardiac monitors and he said, he was explaining what the last wave forms of life look like. And finally put his hand on the patient's arm and he told her about the comfort of her presence even though her husband seemed to not be conscious. And the woman was sobbing but there seemed to be such comfort in those words and his presence. And so I waited outside of the room, as I had always done, for about a half hour. And then the surgeon stepped out and the wife stepped out and it was obvious that he – the patient had died. But about a couple of weeks after that I received a note from the patient's wife and she said, you know, although my husband didn't die at home as we had always wanted, he had the kind of dignified death that we had hoped for. And I remembered that and I remembered that every time, subsequently, that I had a patient who was dying in the ICU, and I tried to do the same. I didn't always succeed but I tried because I think that night that surgeon taught me that as doctors, we could do more than just cure and that those other things that we could do were really important.
CAVANAUGH: I'm speaking with Dr. Pauline Chen. She is the author of the bestselling book "The Final Exam: A Surgeon's Reflections on Mortality." And in reading your book, I come to understand the idea that the concept in medical school for a long time has been, well, if you are technically brilliant, you are serving your patient better than being emotionally available. That, in itself, is somewhat dangerous. Just concentrate on being a brilliant surgeon and you've done your job.
DR. CHEN: You know, I think that's an interesting question and I think it's a question that comes up over and over again. The fact that technical competence is separate from compassion or for caring for your patient or bedside manner when, in fact, my belief is that they're very much intertwined, that you cannot be technically competent without really caring for those who come to ask you for your help. So, for instance, if you take the liver transplant operation, which is an operation, the operation I'm most familiar with, and you think about the most difficult part of that operation, it is the connection of the hepatic artery of the donor liver to the hepatic artery of the patient who's receiving the liver. That is the most important part of that operation because if there is even one tiny thing wrong with it, the liver, the new liver, will not function as well. I mean, it is – it's vital. Now when you think about when that occurs in the timeline of transplanting a liver, it usually occurs at about three or four in the morning because not only have you had to do the transplant operation but you have had to go and procure the donor liver. And so at four in the morning you're pretty tired, you haven't slept, you haven't – probably haven't eaten, probably haven't seen your family in a while. And – But when you're doing that connection, and I've seen countless liver transplant surgeons doing this, they will do it over and over and over again until it is absolutely perfect. And when I think about that, I think you cannot tell me that those surgeons aren't feeling a huge deal of compassion for their patients. You know, one of the most interesting things for me has been to talk to other people in my field about end-of-life care and about their experiences. And about a year ago I was at a hospital in New Jersey speaking to senior surgeons and after I talked about some of my experiences, one of the senior members of the faculty stood up and began to talk about a patient of his who had died a decade ago and it was an extraordinary retelling because he remembered details. He had remembered, I mean, exquisite details of what had happened. And then after he was done, he said at the very end, he said, I still think about this patient because I wonder could I have done something differently? Did I do the right thing? Could I have, you know, was there something I could have done differently? Well, after he was done, another senior surgeon stood up, one after another, and they were telling stories from ten years ago, 20 years or 30 years ago. And it struck me because every one of them wanted to – they asked themselves, could I have done something differently? There's a huge sense of connection and responsibility. At the very end, the chairman of the department stood up and he looked at the medical students and the residents, the young doctors, the upcoming generation, and he said, I want us to begin to talk about these things because I don't want these young people to go through their careers like I have and my colleagues have with regrets or wondering about things. And I think there is the power of conversation because not only can we improve our relationships with our patients, but we can strengthen ourselves as caregivers. I really think that there is a lot of power in the simple act – and I'll – of talking to one another.
CAVANAUGH: And my final question to you, is that a change that you see occurring in medical schools?
DR. CHEN: Yes, yes. Oh, there have been some really marvelous efforts on the parts of medical educators over the last 20 or 30 years to try to change that. And it's amazing to me because I talk to, for instance, chief residents in surgery or chief residents in medicine, and, you know, I was there about a decade ago and they are so much more articulate about their – about caring for patients, about bedside manner, about end-of-life care. Medical students are just much more aware than they were. I mean, there's still a lot of work to do but we've really come quite a ways. And, you know, there – One of the recent things that have happened, for instance, is that now in order to complete your training in general surgery or in internal medicine, you have to have exposure to palliative care. That never happened when I was going through training. And the same for medical students, there are many more things offered but we still have a ways to go. And so I'm optimistic but I think we still have work to do.
CAVANAUGH: Thank you so much for being here, Dr. Pauline Chen. She is the author of "Final Exam: A Surgeon's Reflections on Mortality."
