A lesson in dying
While medical students dream of saving lives, the University of South Florida tries to make sure those students are also equipped to deal with death.
By JOHN BARRY
Published February 4, 2007
The surgeon begins her book with her first patient. They met when the surgeon was a first-year medical student, taking her first anatomy class. The patient had been dead for a year.
"Despite all the precautions taken by my medical school, my cadaver hardly remained an impersonal corpse," Pauline Chen writes. "I remember unzipping the white bag and being surprised by her thin arms. Her fingers were long and slender, with delicate pointed tips; her nails had been filed into fine ovals and painted with coral nail polish."
A card attached to the body bag gave her age and gender. She was 72. "There was nothing else: no name, no address, no story."
Chen's newly published book, Final Exam: A Surgeon's Reflections on Mortality Knopf, $23.95, is an account of her struggle to come to terms, as a doctor and a human being, with an obvious but little acknowledged hazard of her trade: the death of a patient.
She is a liver transplant surgeon living near Boston who was trained by the best medical schools in the country, including those at Yale, Harvard and UCLA. But most of the hard lessons on death came much later, in operating rooms, at bedsides, and in hallways where grieving families waited.
"Like most of my colleagues," she writes, "I came into medicine poorly equipped to deal with terminal patients. . . . I learned from many of my teachers and colleagues to suspend or suppress any shared human feelings for my dying patients, as if doing so would make me a better doctor."
In Philadelphia on a book tour, Chen said by telephone that the response both from families and physicians has been overwhelming. "We're not encouraged to talk. Medical students have said, 'You've made it easier for us.' "
She last saw her cadaver on the afternoon of exam day. "She was covered neatly in white plastic. Through the plastic, I touched her forehead, her shoulders and her hands. . . . Thank you, I thought, feeling at that moment the strong and regular beats at the center of my own chest."
Hana Osman leads seminars on end-of-life decisions and living wills for medical students at the University of South Florida. She's a professor for the USF Department of Community & Family Health. She uses actual cases.
Patient has a living will. Says he wants to die with dignity. What's that supposed to mean? He doesn't want to be a vegetable? Or he doesn't want a temporary feeding tube? Or he doesn't even want to be incontinent?
Doctors are reluctant mind readers, Osman says. They have one priority when there's an ambiguous living will: Don't get sued. "The sick person isn't going to sue. But family members can create a lot of havoc."
Doctors get through medical school by memorizing brain-jogging jargon - words like asystole (a dead heart) - not by pondering mortality and quality of life. "Remember, these folks are scientists. When you talk about quality of life, that's almost foreign to them. Think about who goes to medical school: the brightest and the hardest working. They are not those who spent a lot of time in the arts."
USF tries to address that by exposing medical students to humanities studies, by assigning first-year students to patient care, and by inviting Osman to do seminars.
"Some are very much into it," Osman says. "But this is kind of a forced activity. You can always sense that they're thinking, 'Right after this, I have to go to lab.' "
Taking on new roles
First-year USF medical student Navid Eghbalieh has a class coming up next year where he will learn how to break bad news.
Other students will play the part of a family waiting outside an operating room. He'll come out, tell them that their loved one has died. He'll be graded on it.
Navid, 25, is half-Greek. He grew up in a culture in which funeral celebrations are part of every family's experience. In his teens, he rode in a car that was hit by a drunk driver, killing his friend in the front seat. He blamed himself, because he had given up the front seat to his friend. Before medical school, he was a paramedic for three years in Los Angeles, where many of the trauma centers had closed and ambulances had to drive around to find an emergency room that would accept their patient.
That exposure to life-and-death situations is what led him to medical school.
"You want to do more."
In the spring, Navid will pay last respects to his cadaver, one of about 30 provided to the medical school by the state. He and classmates will gather in the picnic area beside Lake Behkne and lay flowers. A professor will blow bagpipes.
Like Chen, Navid knows his cadaver's age. He doesn't know her name.
Emmanuel Zervos is Navid's mentor. He's an oncology surgeon at Tampa General Hospital. His specialty is the most mortal of all cancers: pancreatic.
His first experience with cadavers was as an attendant in a morgue. "As an adolescent, I had a fascination," he says. He's been a surgeon six years.
Sometimes a patient asks, "I have a cruise coming up in March. Should I take it now?"
Zervos answers, "You may never feel any better than now. Go while you can enjoy it. Try to get in as much living as you can. Every day is a gift."
Family doctors might be able to accept death as a natural outcome. It's harder for a surgeon. "You consider it a failure no matter what," Zervos says. "You never operate on someone anticipating he is going to die."
He says he limits his full emotional commitment only to those patients he operates on. "I don't have the emotional reserves for every patient I interact with. But surgery is the closest bond possible between patient and doctor. It allows me the privilege and right to deal with end-of-life issues."
Some patients help him more than he helps them.
"I had the privilege to take care of a gentleman who taught me a lot about the gracefulness of ending life. He ensured that his wife would be taken care of, even to the point of hanging pictures for her. He taught her how to handle things. It was an honorable way to die. I use that experience to counsel patients going in that direction.
"He was diagnosed Sept. 11, 2001, and died March 16, 2002."
In the years since, he has lost dozens more patients.
"I remember every single one of them."
John Barry can be reached at (727) 892-2258 or email@example.com.
[Last modified February 4, 2007, 20:06:55]
[an error occurred while processing this directive]